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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: 1079313-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Samantha Wueste Suspected Maltreatment Reported: It was reported that three staff persons (SP1-SP3) engaged in physically aggressive interactions with a vulnerable adult (VA). It was also reported that SP1 “pinched” and “squeezed” the VA’s “breasts” and did not let go after the VA told SP1 to “stop.” [Note: The words “breasts,” “boobs,” or similar terminology used throughout this report were the words used by those who provided information for this report; however, such wording should not be used as an indicator of the gender and/or genitalia of the VA.] Date of Incident(s): September 3, 2025 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), clauses (1) and (2); and subdivision 2, paragraph (c); 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 use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. 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 was obtained during site visits conducted on October 1 and 6, 2025; from documentation at the facility and law enforcement records; and through eight interviews conducted with a supervisory staff person (P1), two administrative staff persons (P2 and P3), the VA’s guardian (G), the VA’s case manager (CM), a social worker from the VA’s school (SW), SP1, and SP2. Attempts were made via phone and U.S. mail to contact and interview SP3, but the attempts were not successful. However, SP3 provided information to a law enforcement officer (LEO) which was included below. Additionally, the VA was contacted and an in-person interview was scheduled in conjunction with LE but the VA was not available on the arranged date/time or during a later date/time that the interview was rescheduled for. However, the VA provided information to the LEO and to his/her care team which was included below. The facility was a multi-level home in a residential area, where the VA lived with two housemates (H1 and H2). The facility’s main level had an open floor plan with an entry/hallway directly in front of the main door that connected to a living room towards the left and a dining area with an attached kitchen straight ahead. The living room contained a couch positioned against a window that viewed the front yard of the home; a second couch positioned against a perpendicular wall; and a mounted TV, coffee table/TV stand, and oversized chair positioned along the back wall. Along the right side of the entry/hallway was access to an attached garage and two half-flight staircases leading to the upper and lower levels of the home. The upper level had two bedrooms including the VA’s bedroom, two bathrooms, and a staff office. The lower level had a family room, a bathroom, H1’s and H2’s bedrooms, and a laundry room. Due to the history and behaviors of the clients, the facility installed a day/infrared surveillance camera near the main door to help monitor the common living areas which viewed the living room and portions of the kitchen, dining area, and entry/hallway. The camera monitored this area 24/7 with live and date/time stamped video footage but did not include audio recording. The VA, H1, and H2 each had a 24-hour plan of care and supervision that included 1:1 staffing for each during the facility’s daytime hours and shared one awake overnight staff from 10 p.m. to 8 a.m. From approximately 8:15 a.m. to 2:30 p.m. on the weekdays during the school year the VA attended a transitional educational program (school) located in the community that was operated by the local intermediate school district’s Special Education program. The VA’s Support Plan, Support Plan Addendum- Intensive Services including Self-Management Assessment, and Individual Abuse Prevention Plan (IAAP) updated May 1, 2025, provided the following information: · The VA was “energetic” and enjoyed “joking around,” listening to music, dancing, and spending time with others. The VA’s diagnoses included oppositional defiant disorder, disruptive mood dysregulation disorder, major depressive disorder, and mild intellectual disability. On November 11, 2021, the VA moved into the facility seeking supports and services relating to his/her diagnoses that included health and behavior management, community integration, transportation, assistance to complete activities of daily living, and developing independent living skills. · The VA had a history of emotional dysregulation, maladaptive behaviors including verbal/physical aggression, “easily” being “drawn and pulled into” others’ conflicts, “taking on [the] frustrations” of others as his/her own, and making choices that “ignored [his/her] personal safety” without understanding the potential “dangers” or “consequences” that might result from these decisions. The VA also became “upset quickly” and “overstimulated” which made it “difficult” for the VA to “control [his/her] emotional stability” and impacted the VA’s ability to “appropriately” interact with others. Additionally, the VA had a “tendency” to escalate his/her behaviors if others tried to interact with the VA while s/he was “upset.” Therefore, staff persons were to visually monitor the VA when s/he was “upset” and try to limit verbal interactions with the VA until the VA communicated with staff persons that s/he was ready to talk. Staff persons were to contact law enforcement if the VA’s behaviors became “unsafe.” · During situations when the VA was emotionally dysregulated and had maladaptive behaviors, staff persons were to provide the VA with “encouragement” to use his/her coping skills which would help the VA remove him/herself from the conflict that was “upsetting” the VA. If the VA was in a situation that became “unsafe,” staff persons were to “safeguard” the VA by verbally redirecting the VA to leave the area or to “physically remove” the VA “when necessary” to maintain the safety of the VA and/or others, while using whichever response was the least restrictive intervention. Additionally, staff persons were “permitted” to block or redirect the VA’s limbs/body without holding or limiting the VA’s movement and with less than 60 seconds of physical contact when attempting to interrupt a behavior that was potentially harmful to the VA/others. During situations when staff persons were trying to “calm or comfort” the VA, it was also “permitted” to hold the VA if there was no resistance from the VA. · According to the VA’s IAPP, the VA was considered to be “a follower” and “could be coerced into doing potentially dangerous things” to be “part of a group.” The VA also lacked an understanding of sexuality, and was “likely” to seek out/cooperate in inappropriate or abusive situations. Due to the VA’s diagnoses and history, the VA was susceptible to physical, sexual, and emotional abuse and would not be able to defend him/herself against verbally/physically aggressive persons. Staff persons were to ensure the VA’s safety and intervene in situations that were potentially harmful/unsafe to the VA. The SW stated that at an unknown time during the morning of September 9, 2025, while the VA was attending school, the VA told the SW that s/he was “upset” with a facility staff person (later determined to be SP1) because of an incident that occurred the week prior. According to the VA, s/he and SP1 were “rough housing” in a “playful” manner until SP1 “pinched and squeezed” the VA’s “boobs” which caused the VA pain but SP1 continued this behavior and did not stop at the VA’s request. However, the VA was not able to recall the date that the incident occurred, was not aware of SP1’s full name, and did not provide any additional details about the incident to the SW at that time. The VA’s Service Delivery Log and the facility’s Employee Timecards, the VA attended school on September 3, 2025, and then returned to the facility at approximately 3 p.m. with H1, H2, and three staff persons (SP1-SP3) present within the home at that time. SP2 worked at the facility from 8:02 a.m. to 10:35 p.m., SP1 worked from 2:16 to 10 p.m., and SP3 worked from 2:55 to 10 p.m. The facility’s video surveillance footage dated September 3, 2025, from 6:30 to 9:30 p.m. (three hours) was reviewed by this investigator and showed the following: · There were multiple interactions between the VA and SP1, SP2, and SP3 that were physically aggressive and inappropriate. The interactions included, but were not limited to: - Multiple incidents in which SP1 and SP2 each danced with the VA in a provocative manner. - Multiple incidents in which SP1-SP3 each pushed VA including pushing the VA onto the couches and pushing the VA to preventing the VA from standing. - Multiple incidents in which SP1-SP3 each hit the VA using open and closed hands making contact with various parts of the VA’s body including buttocks, hands, arms, legs, back, shoulders, and torso. The hits were hard enough for the VA to lose his/her balance. - Multiple incidents in which SP1-SP3 each spanked the VA buttocks. - Multiple incidents in which SP1-SP3 each kicked the VA, including kicking the VA’s buttocks, legs, arm/hand, and upper body. - Multiple incidents in which SP1-SP3 each grabbed and pulled on the VA’s arms and wrists. - Multiple times throughout the video, the VA’s behaviors and non-verbal cues including body language, facial expressions, and hand gestures, indicated that the VA was frustrated and/or upset with the situation or with SP1, SP2, and/or SP3’s conduct towards the VA. However, SP1-SP3 each were smiling and laughing while attempting to further provoke and escalate the VA’s behaviors which resulted in multiple incidents when the VA aggressively lashed out at staff persons in response while SP1-SP3 each appeared “entertained” by the VA’s emotional/physical outbursts/responses. In addition, there were multiple incidents when SP1-SP3 each responded to the VA’s aggression by using manual restraints where one to two staff persons temporarily “pinned” or held the VA down by his/her limbs and/or torso while the other staff person(s) continued to provoke the VA with physically aggressive/inappropriate behaviors that the VA was not able to respond to or retreat from and while the VA showed resistance to being restrained. - An incident in which SP3 walked up behind the VA who was sitting on one of the living room couches and placed the VA into a headlock for approximately two seconds. - At approximately 6:43 p.m., it appeared that SP1 quickly pinched the VA’s upper left chest area and then did the same to SP2 who had an immediate physical response, with SP2’s facial expression and body language indicating that SP1’s actions caused SP2 pain. · At approximately 6:50 p.m., the VA left the facility with SP1 and SP2 and returned at approximately 7:45 p.m. with food and drink items. · No other facility clients were observed to be in the living room or kitchen for the duration of the video. SP1 and SP2 provided the following consistent information: · The VA had a “good relationship” with SP1, SP2, and SP3 and liked “continuous attention” from staff persons. The VA also had “tendencies” to get “mad” if staff persons did not provide this attention or engage with the VA in a manner that the VA wanted. There had also been ongoing boundary concerns with the VA “flashing” his/her intimate areas at staff persons while inside the facility that SP1 and SP2 each talked to supervisory staff persons about but were told to keep the VA “engaged” and to not “just ignore” the VA. · On September 3, 2025, SP1-SP3 worked at the facility with the VA, H1, and H2 during the evening shift. When the VA return to the facility that afternoon from school, s/he was “upset” and “sad” about his/her personal family matters so staff persons wanted to help the VA “cheer up” by “entertaining” and engaging the VA in a manner that was consistent with how staff persons were trained. Throughout the evening, SP1-SP3 each engaged in “playful” activities that the VA liked and initiated including “pretend fighting,” dancing, and going for a care ride. H1 and H2 remained on the lower level of the home for “most” of the evening because each of these clients preferred their “privacy and independence” which were then “given and respected” by staff persons. There were known interpersonal conflicts between the VA, H1, and H2, so H1 and H2 did not like to interact with the VA. · During their respective interviews, when told about the video and some of the interactions observed on the video, SP1 and SP2 each became quiet. SP1 and SP2 each said that his/her conduct was not appropriate and “apologized” for his/her behaviors and interactions with the VA during that evening. Additionally, SP1 and SP2 each stated that his/her intentions and actions were not done “maliciously” or to cause the VA harm, that the VA and staff persons were “playing” and laughing the whole time,” that “no one” was “mad or “actually fighting” during this time, that the VA was not verbalizing and/or showing any signs of emotional distress or physical pain from SP1’s-SP3’s actions, that the VA did not receive any injuries from SP1’s-SP3’s actions, and that the evening ended on “good terms” with the VA hugging staff at the end of the shift when SP1-SP3 were leaving the facility. · SP1 denied that s/he “pinched” or “squeezed” the VA’s “breast” area but stated that s/he “might” have “accidentally brushed up against [the VA’s] chest area” when they were “rough housing.” Additionally, SP2 stated that s/he did not witness an interaction like this occurring between SP1 and the VA. LE records showed that the LEO’s review of the video footage was consistent with this investigator. SP1 and SP2 each provided information to the LEO that was consistent to the information each provided to this investigator. The LEO’s report also provided the following additional information: · The LEO was “familiar” with the VA and the facility because s/he had responded to prior incidents involving the VA and spoke with the VA on a “regular basis” for the “last few years.” On September 19, 2025, the LEO arrived at the facility and talked with the VA about the incident. According to the VA, SP1 and the VA were “rough housing” in the living room “like they always do” but then SP1 “pinched” and “twisted” the VA’s right “boob,” above the VA’s “nipple” when the VA was sitting on one of the living room couches. The VA then told SP1 to stop, stood up, and went to sit on the other living room couch but SP1 approached the VA again and “did the same thing.” At an unknown time later, after the VA changed into his/her nightwear, SP1 “pinched” and “twisted” the VA’s “boob” a third time which made the VA “mad.” The VA told SP1 to stop and the VA went to his/her bedroom. SP2 and SP3 were present during these incidents with one of the staff persons approaching the VA at a later date to talk about what happened but “made it seem” like the VA was “lying.” However, the VA told the LEO that there were cameras in the living room and that s/he was not lying. · On October 17, 2025, the LEO contacted and interviewed SP3 via phone. SP3 told the LEO that s/he worked a “double shift” on September 3, 2025, and was aware of why the LEO was contacting him/her. SP3 then provided information to the LEO that was consistent with the information that SP1 and SP2 initially provided this investigator. SP3 told the LEO that this was “not a normal” night, that SP1-SP3 were trying to make the VA “happy,” that SP1-SP3 each were “playing” with the VA how the VA wanted,” that there was “never fighting” and “no arguments,” and that the VA knew how to get SP1 and SP2 “to play” with him/her while getting SP3’s attention. Additionally, SP3 “overheard” the VA say that SP1 “pinched [the VA’s] breast” but SP1 “apologized” to the VA and told the VA that s/he was not aware that this happened and did not “mean to.” · Later that day, after the LEO had reviewed the video footage, the LEO talked with the VA for a second time. The VA provided information that was consistent to the information s/he provided previously to the LEO. The VA also told the LEO that it was “kind of a normal night and kind of not” because SP1 “pinched [his/her] breasts” which was “different” than how SP1 “normally” interacted with the VA. The VA also told SP3 about this that night but SP3 told the VA, “Yeah, I know but she was just playing.” However, the VA said that SP1 tried to make the VA “mad” on “purpose” and that SP1 acted “extra,” “hyper,” and “different” around SP2. The VA told the LEO that s/he was not “upset” with the physical aggression that SP1-SP3 each displayed towards the VA that evening but was only mad at SP1 for “pinching” him/her. · The information was submitted to the county attorney for review of potential charges for SP1-SP3 which was pending at that completion of this investigation. P1-P3, the G, and the facility’s Incident Report/Internal Review dated September 26, 2025, provided the following information: · On September 17, 2025, via an email with the Department of Human Services, P3 was made aware of the incident who shortly thereafter notified P1 and P2. Prior to the email, supervisory and administrative staff persons were not aware that an incident occurred. On September 18, 2025, P1 spoke with the VA at the facility who provided information that was consistent to the information that the VA provided to the SW. After talking with the VA, P1 told P2, P3, and the G what the VA said. Approximately a week later, P2 began to review video footage from the facility from early September 2025. · On September 19, 2025, the G talked to the VA about the incident and the VA provided information to the G that was consistent with the information that the VA had provided to the SW and P1. · P2 reviewed the video footage for September 1- 3, 2025, and saw interactions on September 3, 2025, that were consistent with the interactions as outlined above and that was consistent with the information the VA provided to the SW, P1, and the G. · The G had no additional concerns with the care and services provided to the VA. The CM was aware of the incident but did not have any additional information to provide. The facility’s Program Abuse Prevention Plan stated that staff persons were to assist clients in developing positive skills while decreasing maladaptive behaviors by using a person-centered behavioral approach that encouraged positive/socially appropriate behaviors and helped clients develop the daily living skills, independence, and self-confidence. According to the facility’s Employee Code of Ethics, “all” staff persons were to maintain professionalism and conduct themselves in a manner that was respectful and reflected the best interest of each client. Additionally, staff persons were “prohibited” from having “social relationships” with the clients and were “never” to engage in “any form” of harassment, including sexual harassment. According to the facility’s policy on the Rights of a Person Served, the clients had the right to be free from maltreatment and to be free from restraint, time out, seclusion, restrictive intervention or other prohibited procedures, except in the case of emergency use of manual restraint to protect the resident from imminent danger to him/herself or others. Additionally, clients were to have services and supports provided to them that were identified in their plans in a manner that respected clients as individuals and took into consideration the person’s preferences. Clients were to be treated with courtesy and respect. Facility documentation showed that SP1-SP3 each received training on the VA’s care plans; the facility’s policies and procedures, including the Program Abuse Prevention Plan, Employee Code of Ethics and the Rights of Person Served; and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Minnesota Statutes and Rules: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), state in part that a person’s protection-related rights include the right to be treated with courtesy and respect. Minnesota Statutes, section 245D.061, subdivision 2, states that an emergency use of manual restraint must meet the following conditions: immediate intervention is needed to protect the person or others from imminent risk of physical harm and the type of manual restraint must be the least restrictive intervention needed to eliminate the immediate risk of harm and effectively achieve safety. Conclusion: A. Maltreatment: The VA’s plans provided information that the VA had a history of maladaptive behaviors as well as strategies for staff persons to use to support the VA. The VA became “upset quickly” and “overstimulated” which made it “difficult” for the VA to “control [his/her] emotional stability” and impacted the VA’s ability to “appropriately” interact with others. Information from all sources was consistent that on September 3, 2025, SP1-SP3 worked at the facility with the VA during the evening shift. The VA provided consistent information to the SW, the G, P1, and the LEO that during this time, SP1-SP3 each engaged in “playful” “rough housing” with the VA which the VA considered to be “normal” behavior between him/herself and SP1-SP3. However, SP1 “pinched and twisted” the VA’s “breast” three times during this evening which made the VA “mad” because SP1’s actions caused the VA physical pain and the VA told SP1 to stop. The information provided by the VA was also consistent with the LEO’s and this investigator’s review of the facility’s video footage of the incidents. The three-hour video footage dated September 3, 2025, showed that SP1-SP3 each engaged in multiple and ongoing physically and sexually aggressive interactions with the VA throughout the evening that included but were not limited to hitting, pushing, kicking, grabbing, spanking, and holding/pinning the VA down. Although the video footage did not contain audio recording, multiple times, the VA’s behaviors and non-verbal cues indicated that the VA was upset or frustrated with the situation and/or the actions of SP1, SP2, and/or SP3, yet SP1-SP3 continued to interact with the VA in an aggressive manner that provoked and escalated the situation and the VA’s behaviors. SP1’s, SP2’s, and SP3’s actions were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6); and section 245D.061, subdivision 2. SP1-SP3 each provided consistent information during their interviews and/or to law enforcement that they were trying to make the VA “happy” and that SP1’s-SP3’s actions towards the VA were “playful. However, the video showed that the information SP1-SP3 each provided to the LEO and/or this investigator was inconsistent with what was seen on video. SP1 denied that s/he “pinched” or intentionally touched the VA’s “breasts.” However, the video showed that SP1 quickly pinched the VA’s upper left chest area and then did the same to SP2 who had an immediate physical response, with SP2’s facial expression and body language indicating that SP1’s actions caused SP2 pain. The video also showed multiple incidents in which SP1-SP3 each spanked the VA buttocks. Although the VA stated that s/he and SP1-SP3 each engaged in “playful” “rough housing” which s/he considered “normal” behavior between him/herself and SP1-SP3, given SP1’s-SP3’s actions as observed on the video were not accidental or therapeutic conduct; that multiple times throughout the video, the VA’s behaviors and non-verbal cues including body language, facial expressions, and hand gestures, indicated that the VA was frustrated and/or upset with the situation or with SP1, SP2, and/or SP3’s conduct towards the VA; that SP1 pinched the VA’s breast/chest which the VA told the SW caused him/her pain; that SP1-SP3 each spanked the VA’s buttocks on multiple occasions; and that neither SP1, SP2, nor SP3 made any attempt at any point to intervene and/or stop the others interactions with the VA, there was a preponderance of the evidence that SP1’s-SP3’s conduct could reasonably be expected to produce physical pain or injury and emotional distress to the VA; was the intentional touching of the VA’s buttocks and breast with aggressive intent; and was a failure to supply the VA with care or services which were reasonable and necessary to obtain or maintain the VA’s physical or mental health or safety. It was determined that physical, emotional, and sexual abuse, and neglect 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; and/or the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. 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). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. At the time of the incident, SP1-SP3 were responsible for the care of the VA. SP1-SP3 each received training on the VA’s plans; the facility’s policies and procedures that included the Program Abuse Prevention Plan, the Employee Code of Ethics, and the Rights of Person Served; and the Reporting of Maltreatment of Vulnerable Adults Act. SP1-SP3 were each responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated physical, emotional, and sexual abuse, and neglect for which SP1-SP3 were each responsible did not meet statutory criteria to be determined as recurring because SP1’s, SP2’s, and SP3’s conduct was a pattern of behavior that occurred on a single day. However, it was serious maltreatment because SP1-SP3 were each responsible for sexual abuse of the VA. SP1, SP2, and SP3 were each disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and found their policies and procedures adequate but not followed by SP1-SP3. SP1-SP3 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were each disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that SP1, SP2, and SP3 were responsible for maltreatment and the disqualification of SP1, SP2, and SP3 are each subject to appeal. Given that the facility took immediate corrective action a correction order was not issued for the violations outlined above.
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