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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1104769-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) pushed a vulnerable adult (VA) and the VA had a bruise and scrape on his/her forearm. Date of Incident(s): January 3, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (1); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility and law enforcement records (LE); and through four interviews conducted with the VA, a facility supervisor (P1), the VA’s case manager (CM), and the SP. Facility documentation showed the VA had “good humor,” and liked being outdoors. The VA wanted to live in an apartment independently. The VA was diagnosed with schizoaffective disorder – bipolar type. The VA was not subject to guardianship. The VA received respite services from the facility in a hotel and the VA’s intensive services required 1:1 staffing. The supervision the facility staff provided included continuous situational awareness, frequent interaction, early identification of escalation cues, immediate de-escalation, redirection, and consistent limit setting. The VA’s Support Plan Addendum – Intensive Services provided the following: · The VA would remain in his/her assigned hotel room unless accompanied by staff. The VA would be supervised when outside the room. The VA was able to use technological devices to access music, calming videos, or other appropriate digital content that was identified as soothing and non-triggering. Staff persons were to remain present and actively monitor the VA’s behavior. If staff persons observed that the VA’s technology use was causing an increase in agitation, fixation, or oppositional behavior, access was to be modified or discontinued immediately. · The VA preferred interactions that were calm, direct, and non-confrontational. Staff persons were to approach the VA using respectful language, a neutral tone, and provide clear explanations of expectations. The positive support strategies were to focus on reducing power struggles and avoiding authoritative or punitive approaches, which had historically contributed to escalation. Staff persons were to provide the VA with time to process information and avoid rushing or pressuring the VA when possible. The VA’s Individual Abuse Prevention Plan (IAPP) provided the following information: · The VA was susceptible to physical abuse, and had periods of agitation and poor insight, repeated civil commitments, oppositional responses to staff, and a history of sexually inappropriate and provocative remarks toward others. Additionally, the VA had a history of incidents that brought law enforcement into contact with him/her. The VA had an impaired hazard recognition, unreliable judgment under stress, and difficulty accepting redirection. · The VA had difficulty reading verbal and nonverbal cues of most people. The behavior the VA engaged in increased the likelihood of physical harm. LE records provided the following information: · LE was contacted on January 3, 2026, at 11:02 p.m., due to a concern the VA was assaulted at a hotel. LE dispatch was informed the VA was bleeding and required LE and paramedics to respond. · While at the hotel LE reviewed surveillance video of the incident which showed the incident occurred in the hotel lobby and started at 9:14 p.m., and showed the following: o The VA was sitting at a table in the hotel lobby using a computer and the SP approached the VA. While sitting at the table the VA pushed the SP backwards, and then stood up, grabbed the SP’s jacket with two hands and pushed the SP backwards again. The SP retreated multiple steps before engaging the VA and holding his/her ground by holding onto the VA’s clothing. The SP and the VA relaxed, but the SP kept his/her left hand on the VA’s shoulder, and the VA said, “Let go.” o The SP attempted to reach back toward the table however the VA grabbed the SP again and pulled the SP back into the VA’s body. The SP and VA “struggle” as they were “pushing and grabbing” each other’s clothing. The SP disengaged the physical contact from the VA and walked back to the table. The VA responded by assuming a “fighting stance,” and moved toward the SP. As the VA moved toward the SP, the SP reached out with his/her left arm in an attempt to keep the VA away from him/her. The VA continued toward the SP, and the VA and SP again started “pushing” and “pulling” each other’s clothing. The VA lost his/her “footing” and turned toward a couch, and leaned over it. The SP disengaged, and walked over to the table. The VA moved from the couch and back toward the SP. The VA “stared [the SP] down” before sitting down at the table next to the SP. · The VA told LE s/he was playing music on a computer in the hotel lobby, and the SP went near the VA to turn off the computer. The VA said s/he grabbed the SP’s arm and then they started fighting. The VA had an approximate five-inch-long abrasion on his/her right forearm. The VA said the abrasion occurred after the SP “threw” the VA over the couch. LE did not observe any swelling, discoloration, favoritism, or limited range of motion on the VA’s right forearm. Paramedics assessed the VA and placed a dressing on the abrasion. The VA declined any further treatment. · The SP said the VA was on the computer in the hotel lobby and the VA had been “cussing” at the SP for the previous hour. The SP attempted to redirect the VA leave the hotel lobby and to go back to the room to take his/her medications. The SP was trying to pause the computer, and the VA grabbed the SP’s arm and pushed him/her. The SP said s/he grabbed the VA to prevent him/her from getting closer, and attempted to disengage from the VA, but the VA continued to approach the SP. The SP attempted to grab the VA, and push him/her away, and the VA lost his/her balance and fell onto the couch. The VA sustained the injury to his/her arm, and the SP attempted to perform first aid, but the VA took off the bandage. · LE stated the VA was the “aggressor” during the incident and the SP appeared to be defending him/herself and disengaged from the VA multiple times. · A different staff person arrived at some point and worked with the VA the remainder of the evening. This investigator reviewed the video of the incident and noted the following information: · At 9:14:18 p.m., the SP walked toward the VA and the SP reached toward the computer the VA was using. During the initial physical contact, the VA and the SP held each other by the others clothing, the VA pushed the SP backward approximately ten feet before the SP resisted and applied force toward the VA. The SP proceeded to move the VA backwards approximately five feet, and the VA’s and the SP’s movement stalemated at 9:14:44 p.m. The SP kept his/her hand on the VA’s shirt at shoulder level. The SP attempted to move back toward the computer, but the VA re-engaged and grabbed the SP’s arm and shirt. The SP and VA held each other’s clothing, and remained in a physical stalemate until 9:15:05 p.m. · At 9:15:05 p.m., the SP disengaged from the VA, and took multiple steps backwards toward the computer. The VA moved back toward the SP, and at 9:15:08 p.m., the SP placed his/her hand on the VA’s clothing near his/her shirt. The VA responded by grabbing a hold of the SP’s clothing, and while the VA and the SP were entangled, the VA lost his/her stability and fell into a couch at 9:15:14 p.m. The SP released his/her hand from the VA’s clothing and moved away from the VA, holding out his/her arm to keep the VA at an arm’s length, and continued to move away from the VA as the VA was getting off of the couch. · At 9:15:19 p.m., the SP took multiple steps away from the VA, and there was no further physical contact. The VA said the SP tried to turn off a computer the VA was using, and the VA grabbed the SP’s hand. The VA said the SP responded by grabbing the VA’s throat and shirt, and pushed the VA backwards and into a couch. The VA said s/he sustained a “scrape” to his/her forearm from being pushed into the couch by the SP. The VA said during the incident s/he felt threatened and was “fearful for my safety.” The CM said the VA was “intrusive” to other persons and had a history of “exaggerating” incidents. P1 said s/he was not present for the incident, but reviewed the surveillance video. P1 said based on the video recording the SP did not follow his/her training, and should not have had physical contact with the VA. The facility completed an Internal Review (IR) which provided consistent information with LE records and provided the following additional information: · The SP provided 1:1 supervision to the VA prior to the incident, keeping the VA in his/her line of sight. The SP then attempted to verbally redirect the VA to close the “inappropriate” browser on the computer. The SP should have used further verbal redirection and not “physically intervened” by reaching into the VA’s “personal space” to manually power off the computer. · The SP provided consistent information to the facility as to that which the SP provided to LE, and the SP denied any aggressive actions toward the VA. The SP provided the following information: · The SP provided consistent information to that which the SP provided to LE. The SP also said, although his/her actions did not follow the facility’s trainings s/he was not trying to harm the VA during the physical contact. The SP said s/he tried to create distance from the VA multiple times after the VA initiated physical contact, and held out his arm as a form of creating distance due to the VA’s physical aggression. · The SP said during physical contact s/he tried to use minimal force and verbally prompted the VA to stop during the physical contact. P1 and the SP received training on the VA’s client specific plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: Information showed that on January 3, 2026, the VA and the SP engaged in a physical altercation in a hotel lobby. LE reviewed the surveillance video from the hotel and determined the VA was the aggressor during the incident, and the SP appeared to be defending him/herself, as well as trying to disengage from the VA multiple times during the incident. The VA and the SP provided conflicting statements to LE regarding the incident. The VA and the SP both told LE the VA was playing music on a computer in the hotel lobby when the SP approached the VA, and the VA initiated physical contact by grabbing the SP. The VA said s/he suffered a five-inch-long abrasion on his/her right forearm after the SP “threw” the VA over a couch. The SP told LE the physical contact was done to prevent the VA from getting closer to the SP, and attempted to move away from the VA, but the VA continued to approach the SP. The SP said the VA lost his/her balance and fell onto a couch, at which time the VA sustained an injury to his/her forearm. Video showed that the incident lasted approximately one minute. The VA and the SP held each other’s clothing and at one point the VA moved the SP back ten feet and then the SP moved the VA back five feet. The SP moved back from the VA and then when the VA went toward the SP again the SP held the VA’s shirt again. Then the VA fell over the couch and the incident ended shortly after. The SP said s/he tried to create distance from the VA multiple times after the VA initiated physical contact and held out his arm as a form of creating distance due to the VA’s physical aggression. The SP said during physical contact s/he tried to use minimal force while verbally prompting the VA to stop. Although the SP physically engaged with the VA, grabbed the VA’s shirt, and moved the VA backward which were in violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6), given that the video showed that the VA stumbled over the couch, that the SP attempted to back away from the VA on more than one occasion, and that the SP did not appear to intentionally cause an injury to the VA during the approximately one minute incident, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services, or whether the VA’s injury was sustained by means other than accidental. It was not determined whether neglect or physical abuse occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct; conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but were not followed. The facility completed additional staff training for all employees on crisis intervention and de-escalation to better support and protect the persons who received services. The report was similar to past events as the VA had previously been involved in another physical altercation with a staff person. The SP did not follow his/her training related to crisis intervention, de-escalation, and the facility’s Emergency Use of Manual Restraint policy. The IR stated the SP did not withdraw to a safe distance, and engaged in “reciprocal force.” The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because they took immediate corrective action.
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