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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: 1070562-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Beth Virden Suspected Maltreatment Reported: It was reported that one time, a staff person (SP) threw a soda can at a vulnerable adult (VA) and another time, the SP slapped the VA. Date of Incident(s): September 5 and 23, 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 subdivision2, 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 a site visit conducted on November 5, 2025; from documentation at the facility; and through six interviews conducted with the VA’s guardian (G), facility staff persons (the SP, P1, P2, and P3), and a supervisory staff person (P4). [Note: The VA told the DHS investigator that the SP shared snacks and cigarettes with him/her, but the VA declined to provide additional information or be interviewed further.] The VA’s support plans stated the following: · In 2013, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included mild intellectual disabilities and pervasive developmental disorder. · The VA had a history of swallowing non-food and non-digestible items, like pens, batteries, and coffee filters. If the VA got ahold of something that s/he might swallow, staff were to express their concern to the VA and give him/her the opportunity to return the item for safekeeping. If the VA refused to return the item, staff were to use the least restrictive method possible to retrieve and safekeep the item. · If the VA swallowed a non-food and non-digestible item, staff were to place the VA on a liquid diet until the item passed in the VA’s stool. If the VA consumed an item that was sharp or might cause harm or if the VA showed signs of constipation, abdominal pain, fever, nausea, or vomiting, staff were to seek emergency medical services. · At night, the facility provided one awake staff for the VA and the VA’s housemates. During the day, the facility provided a 1:1 staff specific to the VA. The VA could be unsupervised (without staff) inside his/her bedroom if staff checked on him/her at least every 30 minutes and routinely searched the VA’s bedroom for items that s/he might swallow. The VA’s “personal items” were stored in the basement and were accessible to the VA with 1:1 staff supervision. The VA could move freely upstairs and could be outside unsupervised if staff knew his/her whereabouts. The facility was a single-family home where the VA lived with his/her housemates. Regarding September 5, 2025: The facility’s incident reports stated the following: · On September 6, 2025, the VA told P3 that the SP was sleeping during the overnight shift; and that the VA showered and laundered the VA’s clothes without waking up the SP. [Note: The dates on the incident report were unclear, but other sources stated the VA said the SP was sleeping on September 5, 2025.] · On October 15, 2025, the VA told P4 that when the SP was sleeping on September 5, 2025, the VA grabbed the television remote out of the SP’s hand, and the SP woke up and threw a soda can, hitting the VA’s chest and spilling. P1-P4 provided the following information: · P3 said that s/he could not recall the date when s/he arrived at work in the morning to relieve the SP who worked the previous overnight. After the SP left, P3 prompted the VA to take a shower, but the VA yelled that s/he had already showered during the night when the SP was sleeping. However, P3 did not see a soiled shower towel that the VA used to take a shower and when asked, the VA told P3 that the soiled towel was “put away.” When P3 later learned that the VA said the SP threw a soda can that night, P3 said that the VA did not tell him/her anything about this, and P3 did not recall seeing a soda stain on the floor or any other indications that a soda can was thrown. · P2 said that around mid-September 2025, the VA told P2 that s/he was not being truthful when s/he said the SP was sleeping during the overnight shift. The VA said that s/he had been “mad” at the SP when s/he said this. The VA did not tell P2 anything about the SP throwing a soda can at him/her. · P3 and P4 each said that in October 2025, the VA told them, each, that the SP was sleeping during an overnight shift in September and when the VA went to wake him/her up, the SP “startled” and “jolted” awake throwing a soda can, which struck the VA’s chest and spilled. The VA said that s/he then took a shower and did his/her laundry. · P1-P4 each said that the VA independently showered and dressed, and so staff did not typically see him/her unclothed and/or notice marks or injuries. P1 said that if the VA had an injury, s/he would most likely tell staff. There was no information about the VA having any injuries consistent with being hit by a soda can in September 2025. The SP said that s/he never fell asleep on an overnight shift or threw a soda can at the VA. The SP said that the VA had a history of making “untrue” statements “all the time.” The first time the SP worked with the VA, the VA “accused” the SP of grabbing the VA’s arm outside of a Dollar store. The SP said that s/he “never” touched the VA and then about a week later, the VA told staff that the SP did not grab his/her arm. Regarding September 23, 2025: The facility’s incident report stated that on October 15, 2025, the VA told P4 that on September 23, 2025, the VA removed a latex glove from the bathroom garbage can and the SP “open-handed slapped” the right side of the VA’s chest so that s/he would drop the glove. The SP then said to the VA, “What the fuck are you doing? I am not going to hang out with you anymore. I am only going to hang out with other individuals.” P1, P3, and P4 provided the following information: · P1 said that one time, date unknown, s/he was working at the facility with the housemates while the SP was working 1:1 with the VA. P1 saw the VA go into the bathroom with the SP following. The VA was inside the bathroom, and the SP was standing in the bathroom doorway looking in. The SP then called out for P1 and when P1 arrived, s/he saw the VA with a latex glove in his/her mouth and “gagging” while trying to swallow it. The SP was talking “loud” and telling the VA not to swallow. P1 did not see the SP touch, or swear at, the VA. P1 told the VA to remove the glove from his/her mouth, or s/he might choke, but then the VA “gulped it down.” P1 did not remember what happened next but believed s/he returned to helping the other housemates while the SP monitored the VA and wrote in the progress notes to initiate a liquid diet until the VA passed the glove. P1 said that an unknown number of days later, the VA told him/her that when s/he grabbed the glove out of the garage, the SP pushed and hit him/her. The VA demonstrated to P1 by hitting the VA’s shoulder with an open hand. The VA did not demonstrate the push or hit in a forceful manner. · P3 said that in October 2025, the VA told him/her that when the VA took the glove out of the bathroom garbage can, the SP shoved him/her in his/her chest. The VA said the SP poked him/her in his/her chest and demonstrated to P3 by using two or three fingers and poking the VA’s sternum. P3 asked the VA if the SP hit him/her and the VA said, “No.” The VA told P3 that the SP yelled something at the VA like, “What the fuck are you doing? This is stupid.” · P4 said that the VA did not have a prior history of swallowing gloves from the garbage can. P1 and P3 each said that swallowing gloves was “a new thing” or “a new behavior” for the VA, and that since that time, the garbage cans were removed and no longer accessible to the VA. The SP provided the following information: · In October 2025, the SP was watching the VA in the bathroom. The VA was going to wash his/her hands but instead reached into the garbage can and pulled out a latex glove. The VA immediately put the glove into his/her mouth and swallowed. The SP ran towards the VA but could not recall what s/he was saying to the VA. The SP did not try to pull the glove away because it was already in the VA’s mouth. The SP did not jab his/her fingers into the VA, slap the VA’s chest, or swear at the VA. “That never happened.” · The SP remembered that prior to the incident, the VA was not showing signs of distress. “Everything was normal. [There were] no signs of anything.” The SP said that the VA had a pattern of swallowing non-food items, which did not need any provocation; it was always a possibility. Regarding the VA’s care and supervision: P1-P4 provided the following information: · P1 and P2 each said that the VA’s incidents of swallowing non-food items were sometimes triggered when the VA was “upset” and sometimes “out of the blue.” The VA sometimes told staff after s/he swallowed something but not always. · P1, P3, and P4 each said that if the VA appeared to be getting upset, staff were to remind the VA not to swallow anything that was not food, offer the VA chipped ice to chew on, or take the VA for a walk. · P2 and P4 each said that if the VA was holding something that if swallowed might cause severe harm, staff could use a one- or two-person hold to grab the item out of the VA’s hand. · P3 said that s/he had not been told by any supervisory staff persons to place the VA in a hold if s/he tried to swallow something. P3 said that if staff saw the VA about to swallow something, there was no protocol to grab it out of his/her hands. · P1 said that s/he was not aware of times when staff physically intervened to stop the VA from swallowing something. · P1, P2, and P3 each said that the VA had a “love-hate” relationship with the SP. P3 said that the VA was “fixated” on the SP and either wanted to spend all of his/her time with the SP or hated the SP. The SP was “kind” but had “terrible boundaries.” The SP had “good intentions” but wanted people to like him/her and wanted to be friends with the clients rather than a staff person. The SP needed to be “more stern.” · P1-P4 each said that the VA had a history of not always providing accurate information, which was typically about things that were said by others. P2 said that the VA had a history of making “false reports” specifically about the SP, like stating that the SP grabbed a cigarette out of the VA’s hand, or that the SP was sleeping but then the VA later told staff that these things were not true. The G said that the VA sometimes experienced “attention seeking” behaviors and might swallow non-food items. The VA was “really aware of opportunities” and “quick” to sneak items that s/he could swallow. The VA might not always provide accurate information, which was typically about things that were said by others. The SP said that s/he was trained to watch the VA and observe and document. If the VA appeared “upset,” the SP was trained to listen and try to calm him/her and offer alternative activities, like playing a card game. The SP reminded the VA not to swallow anything that was not food and to hand the non-food item to the SP. If the VA swallowed a non-food item, the SP followed the VA’s liquid diet protocol. The SP said that staff “rarely” put their hands-on the VA to prevent him/her from swallowing something. Staff might hold the VA if s/he was about to hurt him/herself, like jump in front of a car, but this only occurred in “unique circumstances.” If the VA was holding a non-food item, staff did not typically physically intervene. Facility documentation stated that the SP and P1-P4 received training on the VA’s support plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: It was reported that on September 5, 2025, the SP threw a soda can at the VA striking the VA’s chest and spilling, and that on September 23, 2025, the SP slapped or poked the VA’s chest when the VA was about to swallow a latex glove. Although the allegations were concerning, the VA did not immediately tell anyone about the incidents until about one month later and information was provided that the VA had a history of not always providing accurate information and “fixating” on the SP with “false reports.” Given this, and that no one had relevant concerns with the SP’s conduct or saw the SP throw anything or hit or swear at the VA, and there were no signs of injury to the VA or, in the case of the thrown soda can, a soda stain on the floor or used shower towel, there was not a preponderance of the evidence whether the SP threw a can of soda hitting the VA and/or slapped the VA on the chest. 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. The facility provided additional training to the SP and continued to evaluate if the SP always followed policies and procedures. The SP and the VA did not have a history of similar incidents. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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