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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: 1070576-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Anna.Parkin@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at and hit a vulnerable adult (VA) and the VA sustained a bruise on his/her left arm. Date of Incident(s): January 4, 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): 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. Summary of Findings: Pertinent information was obtained during site visits conducted on January 14 and 16, 2026; from documentation at the facility; and through nine interviews conducted with a supervisory staff person (P1), six facility staff persons (P2-P6 and the SP), the VA, and the VA’s guardian (G). The VA was diagnosed with a moderate developmental disability. According to the VA’s Individual Abuse Prevention Plan, the VA was unable to identify potentially dangerous situations or respond appropriately. The VA unintentionally put him/herself at risk by engaging with persons or going places that put him/her at risk for potential harm. Staff persons proactively guided the VA away from persons or situations that posed possible harm and explained their interventions using “clear, simple language.” Staff persons also worked with the VA to build awareness of warning signs and safe behaviors through education and role modeling. P2 provided the following information: · On January 8, 2026, at approximately 7 p.m., the VA was “visibly emotional” and told P2 that on January 4, 2026, before dinner, the SP yelled at and hit the VA. The VA showed P2 his/her upper left arm and P2 saw a “light” bruise approximately the size of a fingertip. P2 did not document or take pictures of the bruise. · The VA had “pretty good” memory retention of recent events and was sometimes accurate providing information. P2 felt that the VA was truthful about the incident. Some staff persons may not provide accurate information because there were “allegiances” between staff persons. According to the staff schedule, in the evening of January 4, 2026, P3 and the SP worked with the VA and another client. P3 provided the following information: · On January 4, 2026, at approximately 4 p.m., P3 washed laundry while the SP cooked dinner. The VA came to the door of the laundry room and spoke to P3. The SP “yelled loudly” that the VA was not supposed to be in the laundry room and to go back into his/her bedroom. The VA went out into the hallway and P3 heard noises from the hallway. As P3 walked into the hallway, s/he saw the VA “lurch forward” like s/he was “wounded.” The SP was standing in front of the VA and the VA was “yelling” at the SP. P3 did not see the SP physically touch the VA. P3 de-escalated the VA and then assisted him/her to the bathroom. · When the VA and P3 walked out of the bathroom, the SP yelled at P3 to stop interfering with the VA. P3 went to assist another client (the C) and saw the VA walk down the hallway towards the SP yelling that s/he “did not like” the SP and hit the SP twice. P3 went over and assisted the VA to another room. · P3 did not see a bruise on the VA’s upper left arm after the incident. The VA was able to provide accurate information about recent incidents but had a history of giving inaccurate information when asked questions. P1 was not aware of the January 4, 2026, incident between the VA and the SP until the investigation. On January 24, 2026, the VA told P1 that the SP “hit me again.” The VA said that the prior evening (January 23, 2026), the SP hit the VA’s upper left arm and buttocks. P1 checked and did not see any injuries to either area. The VA’s ability to provide accurate information was “50/50.” There were interpersonal conflicts between staff persons and P1 did not have concerns with the SP’s interactions with the clients prior to the incidents. The VA stated that the SP “hit” the VA on his/her upper left arm. When this investigator met the VA a second time, the VA said that the SP “hit” him/her on his/her upper left arm and buttocks. When asked if it was the same time as the previous incident or another time, the VA responded it was the same incident. This investigator did not see an injury on the VA’s upper left arm on both occasions and the VA’s buttocks were not observed. P4 and P5 each stated that the VA told them that the SP hit him/her, showed them his/her upper left arm, and they did not see any injury. P4 and P6 each stated that they heard P2 repeatedly “coached” the VA to say that the SP hit him/her. P4-P6 did not have previous concerns with the SP’s physical interactions with the VA. The SP stated in the afternoon of January 4, 2026, P3 and the VA were in the bathroom and the VA was “agitated” with P3 so the SP went into the bathroom and said s/he can finish with the VA because s/he had been working with the VA throughout the day. Once the SP left the bathroom, P3 “immediately” yelled at the SP. The SP denied hitting the VA and denied that the VA was upset and tried to hit the SP. The G stated that the VA was not always able to provide accurate information. The G did not have previous concerns with the facility. According to the Employee Code of Conduct and Conduct Between Staff and Individuals Receiving Supports policies, a “safe and effective” setting required all staff persons to demonstrate a “high level of personal and professional conduct,” including but not limited to: using a person-centered approach with each client; treating everyone with curtesy, professionalism, dignity, and respect; and providing a safe and therapeutic environment. Facility documentation showed that staff persons, including the SP, were trained on the VA’s plans, the Employee Code of Conduct, Conduct Between Staff and Individuals Receiving Supports, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: On January 8, 2026, the VA told P2 that the SP hit the VA on his/her upper left arm. On January 24, 2026, the VA told P1 that the SP hit the VA “again” on his/her upper left arm and buttocks.
Although it was concerning that the VA told multiple staff persons that the SP hit him/her; given that there was no documentation or pictures of the injuries, that P1 and P3-P5 each said they did not see any injuries on the VA, that P4 and P6 each stated that they heard P2 repeatedly “coached” the VA to say that the SP hit him/her, that there was conflicting information if the VA was able to provide reliable information about incidents, and that there were interpersonal conflicts between staff persons; there was not a preponderance of the evidence that the SP hit the VA’s upper left arm or buttocks. It was not determined whether physical abuse occurred (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 policies and procedures were adequate but possibly not followed. The facility was looking into updating the VA’s annual plans to include information about his/her ability to provide accurate information. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
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