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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: 1103884-HCBS (Home and Community-Based Services) Investigator(s): Emily Kearns/Alice Percy Minnesota Department of Human Services 651.431.6513 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP) pushed a vulnerable adult (VA) to the floor and then laughed at the VA. While the VA was on the floor, the SP took a video of the VA, which s/he then showed to the VA. The VA sustained bruises from the fall. Allegation two: It was reported that the SP smoked marijuana while working at the facility and administered the VA a medication while under the influence of marijuana. Date of Incident(s): December 17 - 18, 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), 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 was obtained during a site visit conducted on January 8, 2025; from documentation at the facility; and through five interviews conducted with two facility supervisory staff persons (P1 and P2), the SP, the VA, and the VA’s guardian (G). The facility provided up to 16 hours a day of Individualized Home Supports with training to assist the VA with living independently and an additional eight hours of nighttime supervision. The VA needed assistance with meal preparation and cooking, housekeeping, laundry, shopping, community activities, medication administration, and cognitive and behavioral support. The VA lived on the lower level of the G’s home. The VA’s bedroom, living room, and workout room were located on the lower level while the main living areas of the home, including the kitchen, living room, and the G’s bedroom, were located on the main level. Due to his/her unsteadiness when walking, the VA used a “stair chair” to go up and down the stairway. A locked safe containing the VA’s medications was located in the laundry room on the main level of the home. The VA enjoyed watching movies, listening to music, going on community outings, and working on arts and crafts projects. The VA’s diagnoses included Huntington’s disease, mood disorder, attention-deficit hyperactivity disorder, and severe fetal alcohol syndrome disorder. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to physical abuse and was unable to identify potentially dangerous situations. The staff persons were to provide awake supervision during the night to ensure the VA’s safety. Due to his/her diagnoses, the VA was sometimes unsteady when walking and required occasional assistance with mobility. The VA’s Self-Management Assessment stated that the VA was at increased risk of falls and the staff persons were trained to assist the VA when s/he was moving around. The VA had a walker and used a speaker device to assist him/her with communicating with others. Facility documentation showed that the SP, P1, P2, P3, and P4 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Allegation one: It was reported that the SP pushed the VA to the floor and then laughed at the VA. While the VA was on the floor, the SP took a video of the VA, which s/he then showed to the VA. The VA sustained bruises from the fall. The VA’s progress notes provided the following information: · December 17 - 18, 2025, completed by the G: [The VA], [P1], and I arrived home from speech therapy at 5 p.m., thinking [the SP’s] shift began at 5 [p.m.]. [The SP] was in the house, having used the garage code. [The SP] had [his/her] first double shift and I assumed [s/he] knew about [the VA’s] night meds, the safe code, etc., and I was asleep at 7 p.m. · I awoke around 9 p.m. as [the VA] had yelled. [The SP] came upstairs and I was at the top of the stairs as [the SP] came up and heard [him/her] utter a foul word about [the VA’s] rage. [The SP] explained [the VA] was upset that [the SP] insisted [the VA’s] bedroom door be cracked. [The VA] wanted it shut. I opened the safe and gave [the SP] a lorazepam [as needed medication], which [s/he] gave to [the VA]. They had another fuss as [the VA] came out of [his/her] bedroom and turned the TV on to watch it. [The SP] took the remote from [the VA] by force and ordered [the VA] back to bed. It became quiet and I fell back asleep. I woke at 1 a.m. as I heard [the VA’s] chair coming up and [him/her] go into the fridge. [The VA] said [the SP] was with [him/her] and took two popsicles downstairs. [The VA] said [the SP] ate [his/her] popsicle and forcefully took [the VA’s] and ate it as well. [The VA] began to yell. Since [a supervisory staff person (P5)] had told me not to intervene but let staff handle [the VA], I stayed upstairs. [The VA’s] rage continued and I heard [him/her] call “[G’s name], help me.” The SP came upstairs for another [as needed medication]. I told [the SP] to use a lorazepam and [s/he] asked for the safe code. I gave it to [him/her] but [s/he] put it in two times incorrectly and the safe locked as [s/he] went to the safe. I went downstairs and [the VA] was crying, told me [the SP] had pushed [the VA] down, laughed, and took a video of [the VA] on the floor, showed it to [him/her], and laughed. [The SP] did not help [the VA] up. [The VA] told me [the SP] had not given [his/her] night meds and I went up and got them. It was about 1:30 a.m. I heard [the VA] call the SP [the “N” word”]. [The SP] retorted and angrily and called [the VA] a “bitch.” · I took the pills down myself. . . I asked [the SP] to stay upstairs and [s/he] did so. . . [The VA] told me about [the SP] pushing [the VA] down and laughing and [the SP] had shown [him/her] the video. As [the VA] fell asleep, I came upstairs and asked [the SP] to send me the video. [The SP] said [s/he] did not have one. I told [him/her] [s/he] could go home now, but [s/he] did not want to disturb [his/her family members] so s/he slept on the couch upstairs. Early morning I texted [P1] to ask [the SP] about the night’s events. [The SP] did not share the above facts or write them in [his/her] report. [The VA] told [P1] the above story that morning and showed us a new bruise on [his/her] leg shin and [his/her] palm. The G provided the following information in addition to the information provided in the above progress notes: · The SP began working with the VA the week prior to the incident and worked two overnight shifts from 10 p.m. to 6 a.m. The VA was sleeping during those shifts. · Each evening between 7 and 8 p.m., the VA was administered five medications prior to going to bed. The VA had two additional medications that could be administered to him/her when s/he experienced anxiety. All the medications were locked in a safe in the laundry room on the main level of the home and the G and the staff persons had the code to the safe. On the night of the incident, the SP told the G that s/he did not know the code and had not administered medications to the VA. At 1:30 a.m., the G administered the VA’s evening medications to the VA. · After the incident, the VA had a round three-inch bruise on his/her left shin and a bruise and a small cut on the top of his/her right hand. The cut “bled profusely.” The bruises and cut were still visible several days after the incident. The G stated that the VA was an accurate reporter of events and “does not lie.” The VA stated on the night of the incident, s/he went upstairs to get ice cream and the SP followed the VA. When the VA asked the SP what s/he was doing, the SP told the VA that s/he had to follow the VA wherever s/he went. When they returned to the lower level, the VA used the remote control to turn off the television in the living room and the SP called the VA a “bitch” and told the VA to turn the television on again. The VA ate one of the ice creams and the SP asked him/her why s/he had two and then took one and ate it. The SP took the television remote from the VA and pushed the VA’s shoulders. VA fell on the floor and called the SP the “N word.” The SP laughed at the VA and used his/her cell phone to make a video of the VA on the floor. The SP then showed the video to the VA. The VA bruised his/her left shin when s/he fell. In addition, the SP did not administer the VA’s medications to the VA before s/he went to bed. The VA stated that the SP was a “mean” person and took the remote control from the VA’s bedroom. P1 and P2 provided the following information: · P2 stated that the SP typically worked as an overnight staff person for the hours of 12 to 8 a.m. On one occasion, the SP was a “fill in” staff person and began his/her work shift at 4 p.m. P2 stated that P1 was to train the SP on working with the VA and “everything that needed to be done” while working with the VA. P1 stated that prior to the incident, the SP worked with the VA “a couple of times.” P1 did not meet the SP until the day of the incident. · After the incident, the VA told P1 that the SP pushed the VA to the floor, videotaped the VA while s/he was on the floor, and laughed at the VA as s/he showed the video to the VA. The SP also took the remote control to the VA’s DVD player in his/her bedroom and the staff persons were unable to find it. · After the incident, when P1 arrived at the home, the VA’s hand was “swollen and reddish” and beginning to bruise. The VA was afraid of the SP and was “adamant” that the SP not work with him/her in the future. · P2 stated that after the incident, s/he talked to the SP, who “walked [P2] through” what occurred during his/her work shift, which appeared to be “nothing out of the ordinary.” The VA swore at the SP, called him/her names, and “swung at” the SP, which was not uncommon for the VA. The SP told P2 that when the VA tried to hit him/her, s/he held a “blocking pad” in front of him/her and the VA fell when s/he attempted to hit the SP. The VA stood and again attempted to hit the SP as s/he continued to yell at the SP. The SP told P2 that s/he “never touched” the VA. When the VA calmed, they went upstairs and the VA got popsicles, which s/he ate. The SP was unable to administer any medications to the VA because s/he was unable to open the safe in which they were stored. The SP later sent a video to the facility which showed the VA swearing at the SP, trying to hit the SP, and falling on the floor. · P2 stated that each staff person was given a training packet for the VA and the staff persons received training on documentation, “med stuff,” and “anything they would need to know” for each work shift. P1 stated that “there was really no medications training” at the facility. P1 had medications training approximately a year earlier and was also trained to fill the medications bins since the facility’s health care professional left his/her job. P1 stated that P2 trained the staff persons on medication administration. · P2 stated that s/he told P1 that when the SP arrived at the VA’s home, s/he was to show the SP where the VA’s medications were stored because s/he would need that information when administering the VA’s 8 a.m. medications. P2 stated that P1 did not follow through with P2’s instructions. P1 stated that P2 “claimed” that P2 told P1 to train the SP, but P1 “had no recollection” of that. P1 stated that s/he “assumed” the SP “knew what [s/he] was doing.” The SP provided the following information: · The SP worked with the VA on December 17 and 18, 2025, from 4 p.m. to 8 a.m. The SP typically worked the overnight shift from 12 to 8 a.m. and did not have contact with the VA, but the facility needed extra staffing, so on that day the SP started working at 4 p.m. The SP did not get the typical training on the VA from P1, which would include what cares the client required, medication times, and a “rundown” of the client’s day. The SP had a “booklet” that went over “most of [the VA’s] things,” but it was “thick” and “a lot of info to process.” The SP did not receive training on administering medications to the VA, but did not need to administer medications to the VA on his/her previous work shifts. · On December 17, 2025, the SP was at the VA’s home when the VA and the G returned from an outing. The SP and the VA “hung out” on the lower level of the facility. At approximately 7 p.m., the VA ate a sandwich and later in the evening, s/he asked the SP to get tea from the kitchen on the main level. When the SP returned to the lower level with the tea, the VA was in his/her bedroom. The VA took the remote control from the living room to his/her bedroom. The VA remained in his/her bedroom watching television until approximately 12:45 a.m. and then told the SP that s/he wanted to get ice cream from the upstairs kitchen. The SP offered to get the ice cream for the VA, since the VA was not supposed to go to the main level without supervision. The VA became upset, but they both went to the main level. When they returned to the lower level, the VA repeatedly tried to hit the SP. The VA also threw one of the ice creams at the SP. When s/he tried to hit the SP, the VA “overextended” him/herself, causing him/her to “spin” before falling to the floor. The VA became very upset and yelled and slammed the door and woke the G. The SP did not know about the VA’s medications and the G told him/her the code to the safe, but the SP was “locked out” of the safe. The G told the SP to go to the main level of the home and the G remained with the VA. The following morning when the SP left the home, the VA was sleeping. · The SP stated that s/he did not hit or push the VA and “did not lay a hand on” the VA. The VA called the SP names, but the SP did not call the VA any names. The SP recorded the VA after s/he fell because s/he wanted it to be documented that the VA fell on his/her own. A review of two photographs taken of the VA showed a bruise and a small cut on the VA’s hand and a faint bruise on the VA’s leg. A review of two videos taken of the VA by the SP on December 18, 2025, at 1:06 a.m., showed the VA running toward the SP and attempting to take the SP’s cell phone as s/he recorded the VA. The VA picked up a chair before telling the SP that s/he would break the SP’s cell phone and swinging his/her arms at the SP. The second video showed the VA lying on the floor briefly before standing and walking away from the SP. Conclusion for allegation one: The VA provided consistent information that the SP pushed the VA to the floor, videotaped the VA while s/he was on the floor, and laughed at the VA. The G heard some of the interactions between the VA and the SP but did not see any of the interactions. The SP’s videos of the VA showed the VA swinging at the SP, attempting to take the SP’s cell phone, and lying on the floor. The videos did not show how the VA fell to the floor. The SP denied hitting or pushing the VA. On the day after the incident, the VA had a bruise on his/her leg and a bruise and small cut on his/her hand. However, given that the VA fell to the floor, was swinging his/her arms around, and was grabbing items such as a chair, it was unclear how or when the injuries occurred. Although the VA stated that the SP pushed the VA to the floor, given the conflicting information provided by the VA and the SP about the incident and that there were no witnesses to the incident to confirm or dispute either account, there was not a preponderance of the evidence whether any of the SP’s actions could reasonably be expected to produce physical pain or emotional distress to the VA. 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). Allegation two: It was reported that the SP smoked marijuana while working at the facility and administered the VA a medication while under the influence of marijuana. The VA’s progress notes provided the following information: · December 17 - 18, 2025, completed by the G: Shortly after [the SP] left, [P1] asked me to go to the sewing room downstairs, on which the door was closed. I smelled marijuana very strongly. · December 20, 2025 addition: Both [a staff person (P3)] and [a staff person (P4)] reported they smelled marijuana both in the house. [P3] also said [s/he] smelled it on [the SP] in our driveway, as well. The G provided the following information in addition to the information provided in the above progress notes: · On December 17 – 18, 2025, the SP worked at the VA’s home. On December 18, 2025, after the SP left the home, the G found ashes from a marijuana cigarette on a cotton pillow in a closet next to the VA’s bedroom. The G stated that the SP might have caused a fire when s/he placed the ashes on the pillow. · On December 18, 2025, P1 told the G that s/he smelled marijuana in the home “all week.” P1 told the G to go to the sewing room, which the G did. The room “smelled like marijuana.” P1 and P2 provided the following information: · P1 stated that on the day of the incident, when the SP walked in the front door, it was “very strong smelling” of marijuana. When P1 mentioned the smell, the SP told P1 that s/he did not smoke. The following day, when P1 arrived at the home, s/he went to the lower level and “it was reeking” of the smell of marijuana. When P1 checked the closet, there were ashes all over a pillow on the floor. P1 believed the SP smoked marijuana in the closet. P1 told the G and P2 what s/he found. · P2 stated that s/he was not told about the smell of marijuana in the VA’s home until several days after it occurred. When P2 talked to the other staff persons about whether they smelled marijuana at the VA’s home, they provided inconsistent information. The SP told P2 that s/he did not smoke marijuana at the facility. There were no previous concerns about the SP smoking marijuana while working with clients. The SP stated that s/he did not smoke marijuana at any time and did not smoke it at the VA’s home. The SP was not under the influence of any substance when s/he worked with the VA. A review of a photograph taken at the VA’s home showed ashes on a black cushion. The facility’s Policy and Procedure on Alcohol and Drug Use stated that it was not permissible for staff persons to be on duty or transporting a client when under the influence of alcohol or illegal drugs or impaired by any chemicals or prescription/legal drugs. Any staff person, while directly responsible for clients, are prohibited from abusing any prescription/legal drugs, or being in any manner under the influence of a chemical that impairs the individual’s ability to provide services or care including alcohol, prescription/legal drugs, or illegal drugs. Conclusion for allegation two: P1 and the G each stated that they smelled marijuana in the VA’s home after the SP’s work shift. P1 also smelled marijuana when s/he walked near the SP. In addition, they both saw ashes on a cushion inside a closet on the lower level of the home where the SP had worked. The SP stated that s/he did not smoke marijuana in the VA’s home and did not smoke at any time. Although P1 and the G provided information that they smelled marijuana, given that the SP stated that s/he did not smoke marijuana, that no additional information was provided that the SP smoked marijuana at the home, and that it was unclear if anyone else would have the opportunity to smoke in the home, there was not a preponderance of the evidence as to whether there was a failure by the SP to supply the VA with care or services which were reasonable and necessary to maintain the VA’s physical health and safety. It was not determined whether neglect 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. After the incident, the SP was retrained on the facility’s policies. The SP no longer worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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