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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: 1069170-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns/Alice Percy 651.431.6513 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) became upset and engaged in physical contact with another client (C). Two staff persons (SP1 and SP2) did not follow the VA’s Emergency Use of Mechanical Restraints protocol. The staff persons shoved the VA and performed a “leg sweep” in the hallway, which caused the VA to fall to the floor. After the incident, the VA’s shirt was torn and there was a mark on the VA’s body. Date of Incident(s): November 11, 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 November 19, 2025; from documentation at the facility and law enforcement records; and through ten interviews conducted with four facility supervisory staff persons (P1-P4), a staff person (P5), SP1, SP2, the VA, the C, and the VA’s guardian (G). The VA enjoyed doing craft projects, taking walks, watching movies, playing board games, and spending time with his/her family members. The VA’s diagnoses included mild developmental disability, disruptive mood dysregulation, generalized anxiety disorder, major depression, attention-deficit hyperactivity disorder, and autism spectrum disorder. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to physical abuse because s/he might not recognize what constitutes physical abuse. The VA might not defend him/herself from physical abuse. If the VA was in imminent danger, the staff persons were to intervene as necessary to protect the VA’s health, safety, and rights and guide the VA to a safe area and observe him/her for any signs of abuse. The VA might exhibit behaviors that could provoke abuse from others, such as being bossy, yelling, biting, hitting, and kicking. The VA did not understand boundaries or personal space. The VA’s Intensive Services Assessment stated that when the VA displayed aggressive behavior, the staff persons were to verbally direct the VA to another area or to an activity. The VA stated that on one occasion s/he and the C fought while SP1 and SP2 worked at the facility. The C “flipped off” the VA so the VA chased the C from the kitchen to his/her bedroom. The VA put dents in the C’s bedroom door when s/he kicked it and then entered the bedroom and “accidentally” hit the C in the head. SP1 ran down the hall after the VA carrying a mop and SP2 ran away from the VA so the VA did not hit him/her. The VA stated that s/he went into the C’s bedroom to protect the C from SP1. SP1 ripped the VA’s shirt when s/he pulled the VA from the C’s bedroom and dragged the VA on the floor. SP1 also put a blue mat on the floor so that they could “put [the C] down.” The VA stated that neither SP1 nor SP2 hit him/her, but s/he had a four- to five- inch mark across the middle of his/her upper back. The VA believed s/he got the mark from the C’s bedroom door. The C stated that on one occasion the VA acted out and banged the C into the door and then slammed the C’s head into the wall twice. The VA also broke the C’s bedroom door. The C fell to the floor and the VA grabbed the C’s leg and one of the staff persons pulled the VA away from the C. The C did not recall which staff persons were working that day or which staff person pulled the VA away from the C. One of the staff persons took the C to the staff office and telephoned 9-1-1. The C was taken to the hospital by ambulance and spent the night at the hospital. P1 - P5 provided the following information: · Consistent information was provided that on November 11, 2025, SP1, SP2, and P1 worked at the facility with three clients. At the time of the incident, P1 was on a community outing with one of the clients. While P1 was on the community outing, SP2 called P1 a few times because the C was upset and the VA “called the cops” on the C. SP2 told P1 that “the cops weren’t coming anymore.” SP2 called again and told P1 that after SP1 took the C to his/her bedroom to deescalate, the VA followed them and hit the C, causing the C to hit his/her head. P1 returned to the facility. P2 stated that SP1 telephoned him/her and told him/her that the VA entered the C’s bedroom, the C fell, and they called law enforcement officers (LEOs). · When P1 arrived at the facility, a LEO and an ambulance were at the facility. The LEO told P1 that the VA called them and told them that SP2 hit him/her, so the LEOs responded to the call. The C had a bump on his/her head. The paramedics told the C that s/he “looked fine,” but since s/he wanted to go to the hospital, they took him/her to the hospital in the ambulance. The paramedics assessed a scratch on the VA’s back but did not take the VA to the hospital. P2 stated that at approximately 5 p.m., P1 telephoned P2 and told him/her that s/he would accompany the C to the hospital. P4 stated that the C received a CAT scan while at the hospital and returned to the facility the following day. · P1 stated that after the incident, the VA had a scratch on his/her back. P1 described the scratch as “pretty red and pretty long.” The scratch was thin “like a pencil.” The VA told P1 that SP1 ripped his/her shirt down the front and hit him/her with a broom. · P1 stated that SP2 told P1 that the VA grabbed a broom and tried to enter the C’s bedroom. SP2 tried to keep the door closed, but the VA entered, hit the C, and knocked the C to the floor. P2 stated that s/he was told that the VA hit the C, which caused the C to trip and hit his/her head. · P2 stated that on the following day, s/he reviewed the video recordings from the facility and then had P3 watch the video. P3 told P4 to watch the video recordings and review the incident. P4 stated that s/he then watched the video. At the time SP1 and SP2 implemented the manual restraint on the VA, the VA was aggressive towards the C and P4 believed the C was in “imminent danger.” · P1 and P5 each stated that when the clients became upset, the staff persons were trained to deescalate them by separating them and talking to them. P1 stated that on a previous occasion when the VA and the C became upset with each other, P1 took the C to the lower level of the facility and SP2 took the VA outside, but the VA returned to the facility and pulled P1’s hair. · P2 stated that the VA “can be accurate” at reporting events but might exaggerate. P2 stated that the C might not always be an accurate reporter of events, depending on his/her “mood.” · P2 stated that all staff persons received training at orientation and again annually on the emergency use of manual restraints, de-escalation techniques, and documentation of incidents. Consistent information was provided that when staff persons were trained on implementing manual restraints, they were taught to use A, B, C, and D holds, which were increasingly restrictive. There were blue mats in the facility that staff persons were to use when implementing manual restraints that included moving the client to the floor. SP1 and SP2 provided the following information: · SP1 stated that when the facility was understaffed, the VA was more likely to “cause trouble.” Typically there were four staff persons working at the facility. When there were only one or two staff persons working, there was “trouble.” At the time of the incident, only SP1 and SP2 were at the facility. The C often yelled at the staff persons or hit them. When any of the clients had behaviors, the staff persons were to try to deescalate the situation and ask the clients to go to another area, watch television, or talk to the staff persons. · SP1 stated that on the day of the incident, the C began shouting and walking around the facility, which upset the VA, who began to yell at the C. When they began to escalate, SP1 and SP2 asked the C to go to his/her bedroom and the C asked SP2 to walk with him/her to the bedroom, which SP2 did. The VA became more agitated, threw various items, and hit SP1 with a broom. SP2 stated that SP1 took the broom from the VA. SP1 went outside through one door and then entered through another door. The C opened his/her bedroom door “to peek out” and the VA ran to the C’s bedroom, forced it open, and slapped the C. SP2 heard the sound of the slap. · SP2 stated that s/he and SP1 separated the VA and the C, but the VA ran back to the C’s bedroom and tried to lock the door. SP1 stated that s/he and the VA each pushed against the door. The VA yelled that s/he was going to kill the C, break the C’s leg, and choke him/her, but was unable to do so because s/he was trying to keep SP1 from entering the bedroom. SP1 then pushed open the door and entered the C’s bedroom. The VA tried to hit SP1 with a broomstick while SP1 attempted to calm the VA. Prior to following the VA to the C’s bedroom, SP1 had been cleaning and still had the broom when s/he entered the bedroom. SP1 did not hit the VA with his/her broom, but the VA attempted to hit SP1 with his/her broom, bit SP1’s hand, and slapped SP1’s face. The VA hit the C on the chin. At some point, SP1 held the VA’s shirt and the shirt was torn. · SP1 stated that during the incident, s/he was “very anxious” because s/he thought the VA would hurt him/her. SP1 did not recall moving the VA to the floor. SP1 stated that when the VA became very agitated, SP1 was unable to “physically restrict” the VA because the VA was physically bigger and stronger than SP1. SP1 did not believe that s/he “put” the VA on the floor, but the VA might have fallen. SP2 did not recall much of the incident and did not recall knocking the VA to the floor. · After the incident, SP1 called 9-1-1. Paramedics and the LEO arrived at the facility and the C was taken to the hospital. SP2 stated that the C had a “goose egg” on his/her head. SP1 went to urgent care because of his/her injuries. SP2 completed the incident report but did not complete an EUMR form because they did not implement a restraint. · SP1 stated that s/he did not hit, kick, or slap the VA. SP1 was unable to move the blue mat down the hallway because s/he was attempting to keep the VA from hurting the C. SP2 stated that s/he did not hit, kick, or punch the VA. The G stated that the VA was “pretty accurate” at providing information about events. The VA was “strong and forceful” and “challenging.” The VA told the G that the C “went after” the VA and the VA then “went after” the C and chased the C into his/her bedroom. One of the staff persons grabbed the VA, ripped his/her shirt, scratched his/her back, and pulled the VA to the floor. P2 told the G that s/he did not believe the staff persons implemented a manual restraint correctly. P2 also told the G that the VA bit one of the staff persons. The LEO’s Incident Report stated that on November 11, 2025, at approximately 4:15 p.m., the LEO arrived at the facility. The VA told the LEO that s/he was “minding [his/her] own business” when the staff persons “attacked” him/her. The VA provided inconsistent information about what occurred, including that s/he was in his/her closet when a staff person ripped his/her shirt and that s/he was in bed sleeping when a staff person ripped his/her shirt. The VA also told the LEO that a staff person hit the VA with a broom. The staff persons told the LEO that prior to the incident, the C was yelling and agitating the VA. The C went to his/her bedroom and the VA followed the C and began to hit him/her. The staff persons “pulled [the VA] off [the C]” and the C fell. The VA hit the staff persons with a broom. Two video cameras were located at each end of a long hallway running from the main living areas to the four client bedrooms. The C’s bedroom was located at the end of the hallway, opposite the main living area. Eighteen video recordings that did not include audio were provided to this investigator. A review of the video recordings dated November 11, 2025, from 3:48 to 4:30 p.m. showed the VA aggressing toward the C several times, including chasing the C and forcing his/her way into the C’s bedroom multiple times. SP1 and SP2 intervened continuously by attempting to redirect the VA, block him/her from entering the C’s bedroom, and moving the VA out of the C’s bedroom after s/he forced his/her way in. To get the VA away from the C’s door, SP1 pulled the VA by the VA’s shirt causing the shirt to rip. At one point, the C left his/her bedroom rubbing his/her head. The VA hit SP1 with his/her hand and a broomstick, bit SP1’s hand, hit SP2, and threatened SP1 and SP2 with a broom. After the VA bit SP1, SP1 pulled the VA out of the C’s bedroom and SP2 pulled on the VA’s left leg, causing the VA to fall onto the floor in a seated position. SP1 attempted to hold the VA on the floor while SP2 tried to take away a mop that the VA held. The VA kicked SP2 in the chest and SP2 placed his/her right foot on the VA’s lower leg for approximately four seconds while lifting his/her left leg off the ground placing his/her weight on the VA’s leg until the VA reached for SP2’s foot. SP2’s foot slid forward off the VA’s leg. SP2 grabbed the VA’s hand and stepped back. SP1 and SP2 separated the VA from the C and both the VA and the C went to separate areas to calm. The facility’s Emergency Use of Manual Restraint Policy and Procedure stated that a manual restraint should only be used if immediate intervention was needed to protect the client or others from imminent risk of physical harm, the type of manual restraint must be the least restrictive intervention, and the manual restraint must end when the threat of harm ended. Prior to implementing a manual restraint, the staff persons were to use positive support strategies and techniques to attempt to de-escalate the client’s behaviors. After implementing a manual restraint, the staff person were to complete an emergency use of manual restraint report, an incident report, and a behavior intervention report form.
Facility documentation showed that SP1, SP2, P1, P2, P3, P4, and P5 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. Conclusion: A. Maltreatment: Regarding neglect: On the afternoon of November 11, 2025, SP1 and SP2 worked at the facility with the VA and the C. At approximately 3:45 p.m., the C began shouting and walking around the facility, which upset the VA, who yelled at the C. When they each began to escalate, SP1 and SP2 asked the C to go to his/her bedroom and SP2 walked with the C to his/her bedroom. The VA became more agitated, threw various items, and hit SP1 with a broom. SP1 took the broom from the VA. The C opened his/her bedroom door “to peek out” and the VA ran to the C’s bedroom, forced it open, and slapped the C. The C fell and injured his/her head. Video recordings showed that after that SP1 and SP2 intervened continuously by attempting to redirect the VA, block him/her from entering the C’s bedroom, and moving the VA out of the C’s bedroom after s/he forced his/her way in. The VA hit SP1 with his/her hand and a broom, bit SP1’s hand, hit SP2, and threatened SP1 and SP2 with a broom. While SP1 and SP2 were unable to follow the facility’s manual restraint protocol and the VA had a mark on his/her back, given the VA’s aggressive behaviors toward the C and the SPs and the VA’s repeated attempts to enter the C’s bedroom, that SP1 and SP2 attempted verbal redirection and took out the blue mat to show they were going to attempt to follow the protocol, and that the VA provided consistent information regarding how the mark on his/her back occurred, there was not a preponderance of the evidence as to whether SP1 and SP2 failed to supply the VA with care and supervision which was reasonable and necessary to maintain the VA’s physical or mental health or 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). Regarding physical abuse: At the time of the incident, SP1 and SP2 attempted to keep the VA away from the C and prevent the VA from harming the C. The VA had a mark on his/her back but provided inconsistent information regarding how that occurred including that it was caused by a door and that it was caused by a staff therefore it was not able to be determined whether the mark was caused by means other than accidental. However, while the majority of SP1’s and SP2’s actions were warranted given the VA’s aggressive behaviors, there was a preponderance of the evidence that SP2 standing on the VA’s leg with his/her foot while the other foot was off the ground for approximately four seconds could reasonably be expected to produce physical pain or emotional distress to the VA and was not accidental. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Facility documentation showed that SP2 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. SP2 was 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 abuse for which SP2 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident during which the VA did not sustain an injury. 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 staff persons. After the incident, all staff persons received retraining on the facility’s policies, including the Emergency Use of Manual Restraint policy.
Action Taken by Department of Human Services, Office of Inspector General: SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP2. The determination that SP2 was responsible for maltreatment is subject to appeal.
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