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AMENDED 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.” NOTICE: The original Maltreatment Investigation Memorandum was amended to include the correct license numbers. The original document, dated March 12, 2026, must be destroyed.
License Number and Program Type: 1121791-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Lindsay.Arth@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) placed a vulnerable adult (VA) in a prone restraint. There were also concerns that the SP did not stop the restraint when asked by other staff persons. Date of Incident(s): December 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 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 29, 2026; from documentation at the facility; and through seven interviews conducted with the VA, three facility staff persons (the SP, P1, and P2), a supervisory staff person (P3), and the VA’s guardians (G1 and G2) who were also the VA’s family members. The facility was a two-story home and the VA was the only client who lived at the facility. Three awake staff persons were at the facility 24 hours a day. The VA was diagnosed with autism, generalized anxiety, and attention deficit hyperactivity disorder. The VA enjoyed cars and playing video games. The VA’s Positive Support Transition Plan said that the VA had a history of physical aggression towards others including hitting, kicking, punching, scratching, and/or throwing items and the VA may “target” others who set limits or boundaries. The VA also had a history of property destruction including throwing furniture and hitting/kicking windows and walls. When the VA began displaying “agitation,” staff persons were to redirect the VA to another activity or to another area to “calm.” When the VA posed a risk of harm to him/herself or others, staff persons were to implement an emergency use of manual restraint (EUMR) for “safety.” Staff persons were to use “therapeutic intervention methods” to ensure that safety was “maintained.” [Note: During interviews, persons used the words restraint and hold when referring to implementing EUMR’s.] The VA’s Self-Management Assessment said that when the VA became “aggressive,” s/he would typically “approach” the “target” and “strike” at them with his/her hands. The VA may also choke others. Staff persons were to use “appropriate therapeutic intervention skills” to deescalate the VA when “agitated.” P1, P2, P3, and the Internal Review provided the following information: · On December 23, 2025, at 4:23 p.m., P2 called P3 stating that the SP placed the VA in an “unnecessary [prone] [restraint].” P2 told P3 that someone needed to come to the facility and “help” the VA because the VA was “escalated” after the restraint and was in a “state of crisis.” P3 then notified a supervisory staff person (P4). · At approximately 4:30 p.m., P3 and P4 arrived at the facility and observed the VA crying, which P3 said was not typical for the VA. The VA “shouted” that s/he was going to “die” and that the SP was “going to kill [him/her].” The VA also said repeatedly, “Fuck you, [name of SP]” and that the SP should “leave.” Additionally, the VA was “striking [his/her] arm into [a] wall repeatedly” and was “ignoring” verbal redirection from staff persons including P4. P4 said that the VA was “more dysregulated” than s/he had “ever seen” the VA. · At some point the VA calmed and P4 spoke to the VA who said that the SP put him/her in a “hold.” However, the VA did not want to answer further questions. On December 26, 2025, P4 again spoke to the VA who stated that the SP “put [him/her] in a hold” and that the SP was “trying to kill” him/her. The VA again did not want to provide further information. On January 7, 2026, P4 again spoke to the VA about the incident who said that the SP “put me in a hold for no reason.” · P1 and P2 each said that on the afternoon of December 23, 2025, prior to the incident, the VA was talking to the SP about his/her “favorite” video game characters and that the SP told the VA that s/he was “not talking to [him/her] anymore.” P1 and P2 each said this caused the VA to become “frustrated” and “escalated” and the VA asked the SP why s/he was not talking to him/her. The SP told the VA that s/he would not talk to the VA if the VA was being “disrespectful.” P1 also tried talking to the VA and the SP told P1 that s/he “did not have to talk to [the VA].” · P1 and P2 each said that the SP then “told” the VA to go to his/her bedroom, in a “very mean” and “aggressive” tone, and that the VA went to his/her bedroom and “complied.” P2 told the SP that s/he was not supposed to tell the VA to go to his/her room and the SP told P2 not to “talk to [him/her] like that.” · The SP then followed the VA to his/her room and began “yelling.” P1 and P2 each heard a “bang” or “thud,” which P2 said sounded like “two bodies hitting the ground.” P1 also said that s/he heard the VA yell, “Why am I being put in a hold?” P1 and P2 then “ran” to the VA’s bedroom and saw the VA in a “prone” position on the floor although P2 also said that the VA was “kind of” on his/her side. P1 said that the SP had his/her body in a diagonal position across the VA to “hold” the VA to the floor and that the SP also “held” his/her face against the VA’s to “further pin” the VA. The SP also used one hand to hold the VA’s “palms” behind his/her back and the SP’s other arm was under the VA’s stomach. · The SP told P1 and P2 that the VA hit his/her face or “attacked” him/her but P1 and P2 did not see that. The SP then asked for “help” but P1 and P2 told the SP, “No,” because the SP implemented the “wrong” restraint and because staff persons were supposed to do the restraint together. P1 and P2 also did not think that the VA needed to be in a restraint. P1 and P2 told the SP to “get up” and to let the VA “go” multiple times but the SP said that the VA would “attack” him/her if s/he did. The SP then asked the VA to count to 30 and that s/he would “release.” The VA did so and then the SP “released” the VA. (Note: P2 said that there was not a 30 second count but that at some point the SP let the VA go). The SP then asked the VA to explain what s/he “did wrong” and why s/he was put in a restraint but the VA stated that s/he “did not do anything wrong.” · P2 said that after the incident, the VA was “shaking” which P2 had not seen before. P2 said that the VA stated that the SP was “trying to kill” him/her and P2 said that it “seemed like [the SP] was trying to hurt [the VA].” · Following the incident, staff persons including P1 observed two bruises on the VA, including one on his/her face approximately 2.5 inches long that resembled “rug burn.” The VA also had a bruise on the left side of his/her back on his/her shoulder blade. P2 said that the VA did not have the injuries prior to the incident. P1 said that the VA received ice and ibuprofen because the VA said that his/her head “hurt” after the incident. P1 said the injuries went away after 24 hours. P1 and P2 did not see any injuries on the SP. · P1 thought that the restraint lasted approximately two minutes and lasted from 3:51 to 3:53 p.m. P2 thought the restraint was from 3:54 to 3:55 p.m. P1 and P2 did not see the VA display physical aggression towards the SP prior to the restraint or while the VA was in the restraint but said that the VA was “fighting” to get out of the restraint and was “crying.” P2 did not see the VA display any behaviors that day and described the VA as “calm” and “happy” prior to the incident. P1 said that the VA hit walls and displayed other property destruction earlier in the day but not around the time of the restraint. P1 said that the “whole day,” the SP was “very frustrated” and “irritated” with the VA and “did not want to deal with [the VA] at all.” If a staff person was frustrated, they could tell other staff persons or take a break in the office. · P1 and P2 said that staff persons were trained to do a restraint with three staff persons and that the SP did not ask P1 or P2 for help prior to implementing the restraint. P2 said that the SP asked for help after the SP had already implemented the restraint. · On December 23 and 29, 2025, P4 spoke to the SP about the incident. The SP told P4 that on the date of the incident, the “overall shift was long” and that his/her “attention span” to work with the VA was “running thin.” The VA had “very high anxiety” and seemed a “little off” earlier in the day. The VA was “really wanting to hang out” with the SP and was “beginning to escalate.” At some point, P2 was on his/her laptop and the VA attempted to talk to P2 but P2 did not “listen” to the VA which also “escalated” the VA. (Note: P1 told P4 that s/he did not “recall” any staff person being on their laptop on the date of the incident.) · The SP also told P4 that at some point, P2 “told” the VA to go to his/her bedroom and the SP “followed up” and also told the VA that s/he “needed” to go to his/her bedroom, including because the VA was “putting holes” in the walls. The VA then went to his/her bedroom and the SP followed so that s/he could talk to the VA at his/her bedroom door. The SP began talking to the VA, but the VA was “very upset” regarding something that occurred the day prior and during this, the VA punched the SP “three times” on the SP’s forehead and eye. The SP attempted to “block” the punches but then the VA also scratched the SP’s face, which left a “small scratch” on the SP. The SP then “shouted for help.” · The SP told P4 that s/he then placed the VA in a standing restraint which included using one of his/her hands to hold the VA’s palm together behind his/her back and another hand to “brace” the VA’s chest/stomach area. The SP used that “position” to “hold” the VA to him/her. While the SP did this, the VA put his/her leg out to “trip” the SP and the VA and the SP both fell to the floor. The SP “released” the VA during the fall and “stuck” his/her arm out to try and “brace” the fall and the VA fell onto the SP’s arm. The SP said that s/he fell to the “side” of the VA. · The VA then attempted to punch the SP again but “missed” and the SP told P4 that s/he again “called” P1 and P2 for help. While on the floor, the VA “alternated” between being on his/her side and on his/her stomach because the VA was moving around. The SP said that s/he had “no choice” other than to “hold” the VA’s palms together behind the VA’s back and to “sit on top” of the VA. (Note: During the SP’s second conversation with P4, the SP denied being on top of the VA and said that s/he was on the side of the VA. The SP also said that s/he had his/her head on the side of the VA’s shoulder, pushed against the VA’s head, so that the VA could not “headbutt” the SP.) · P1 and P2 then came into the room and the SP told them that they needed to get the VA on his/her “side” and the SP asked P1 and P2 for assistance. P2 told the SP, “I don’t come to work to deal with holds,” and then P1 said that if P2 was not going to do a “hold,” there was “no point” in doing it. P2 and the SP then told the VA to count to 30, which the VA did, and the SP let go of the VA’s arms and “fully released” the VA. The VA made no further attempts to “aggress.” However, the VA was crying and “upset” with the SP. The SP said that the “hold” was “not even 45 seconds long.” · The SP denied that P1 or P2 told him/her that s/he was doing the “hold” wrong or that they told the SP to “let go.” The SP said there was “some disagreement” between P1, P2, and the SP regarding the incident. · P4 asked the SP why s/he told P4 that s/he “sat on top” of the VA during the “hold” but later said s/he was on the side of the VA and the SP said that during the incident, the VA was initially “rocking back and forth” but later was in a “prone” position for the remainder of the incident. · P4 also spoke to a staff person (P6), who worked with the VA and the SP on December 23, 2025, prior to the incident. P6 told P4 that at some point, the VA began to “escalate” due to repeating the “same topic” regarding video games but staff persons “resolved” the “escalation” and there were no concerns when P6 left. P6 did not have any concerns with the SP. · A staff person (P5) also worked with the SP prior to the incident and stated that when s/he arrived, the SP told the VA, “I am going to put you down” when the VA was becoming “upset.” P5 tried to “step in” to have a conversation with the VA and to tell the SP that s/he would “take over” but the SP asked P5 to “stop speaking” to the VA. P5 said that the VA was “talking excessively” about his/her video game and the “repeated questions” seemed to give the SP a “short temper.” The SP “showed signs of being upset visibly” including his/her “tone” and “difficulty making responses” to the VA. · P3 also worked on the date of the incident until approximately 3 p.m. Prior to P3 leaving, the VA was having a “really good day” and was “completely fine.” The SP was “late” for work and said that s/he was not feeling well but that s/he took “medicine.” · P3 said that staff persons were trained not to do a prone restraint. The SP was typically an “amazing” staff person and could “deescalate” the VA. Prior to the incident, the VA “liked” the SP and asked when the SP was working next but after the incident, the VA said that the SP “took me down for no reason.” P3 described the VA was “very smart.” The VA had a history of aggressive behaviors, including giving staff persons “concussions” or pulling their hair and in December 2025, the VA had a “really bad month” regarding behaviors due to medication changes. The VA said that s/he enjoyed working with P3 and P4. The VA “did not know” if there were any staff persons that s/he did not like. The VA said that “most” of the staff persons at the facility put him/her in a “hold” and “wrestled [him/her] to the ground.” The holds were supposed to “calm” the VA, but the VA said that they “only made [him/her] more upset.” The SP was the last staff person to put the VA in a hold and the SP no longer worked at the facility because the SP put the VA in a “hold instantly.” When this investigator asked the VA why the SP put him/her in a hold, the VA said, “I do not remember but I was probably a danger to others.” The VA then said s/he did not want to provide further information. The SP provided the following information: · On December 23, 2025, around 1 or 1:30 p.m., when s/he arrived to the facility, s/he greeted the VA with a “high five” and “fist pumps.” However, the VA was “fixated on a lot of stuff,” including an incident the prior day and stated that someone was “trying to kill me.” The SP did not know what happened the prior day. · At some point, P2 told the VA to “stop talking.” P2 was also on his/her laptop and was not talking to the VA. (Note: P1 and P2 each denied that P2 was on his/her laptop, that P2 told the VA to stop talking, and each denied that P2 was not talking to the VA.) The SP told the VA that s/he would talk to the VA if the VA did not get “worked up.” The VA and the SP began talking but the VA became “mad” and hit a wall “hard” with his/her hand. P2 then told the VA to “go to [his/her] room” and to “take a break.” (Note: P1 and P2 each denied that P2 told the VA to go to his/her bedroom.) The VA began walking towards P2 and the VA’s “body language” showed that s/he was “amping up.” The VA was trying to “intimidate” P2 and P2 “stood [his/her] ground.” (Note: P1 and P2 each denied that this occurred.) The VA was near his/her room and P2 again told the VA to go to his/her room and the VA said that s/he was not going to do so. The SP then told P2 that s/he would “take care of this” and P2 went into the nearby office. · The VA then went to his/her bedroom and the SP stood in the VA’s doorway to talk to him/her because the SP was trained to “distract” and “communicate” with the VA when the VA displayed behaviors. The VA again began talking about the prior day and told the SP that staff persons were trying to put him/her in a hold, “hurt” the VA, and/or ruin Christmas. The VA then “launched” towards the SP in a “blind rage” and punched the SP in the face three times, which the SP had never seen before. The SP asked the VA to “calm” and had his/her hands up to block the VA and then saw that the VA was trying to scratch the SP. The SP tried to implement a hold as s/he was trained by putting his/her arms underneath the VA’s but the VA’s leg “caught” the SP’s and they both fell to the floor and landed “side by side.” The VA then hit the SP in the face and the SP asked the VA if s/he was “okay.” The VA again said that staff persons tried to “kill” him/her. · The SP called for P1 and P2 to help him/her and when P1 and P2 came into the VA’s bedroom, the SP told them that the VA was able to “get up anytime” but that s/he and the VA fell because the VA “wrapped” his/her leg around the SP’s. However, around this time, the VA became more “agitated” and it “seemed” like the VA would hit the SP with his/her left arm. The SP asked P1 and P2 what they wanted him/her to do because the VA could “hurt” the SP and P2 told the SP that s/he “did not have time for this” and did not “come to work to put people in holds.” The SP told P2 that s/he “did not like putting people in holds.” The SP then asked the VA to take a “deep breath” and that after, s/he would “let [the VA] up.” The VA then got up and the SP checked the VA for injuries but the SP did not find any. The VA was “okay” and began talking about holds s/he was in the prior day. · Following the incident the SP had “lacerations” on his/her neck and chin due to the VA scratching him/her. However, the injuries were “not deep” and the SP did not require medical attention. · Staff persons were trained to have three staff persons present when implementing a hold that included one staff person for the clients legs, one staff person for the clients hands, and the other for “support.” The SP had only been a part of one other hold with the VA and the SP’s shifts with the VA were typically “smooth.” · The SP denied putting the VA in a prone restraint but said it may have looked like it due to the VA and the SP falling to the floor and the SP’s arm being under the VA. The SP said that at no time was s/he holding the VA and that the VA got up on his/her own. · The SP denied sending the VA to his/her bedroom and said that s/he was trained not to do that because it was the VA’s home. Additionally, the VA was “not a toddler.” However, the SP said that P2 told the VA to go to his/her room. · The SP denied telling the VA not to talk that day and said that s/he would “never” tell the VA that. The VA was “smart” and one of the “coolest” people that the SP knew. · The SP thought there were interpersonal conflicts between him/her and supervisory staff persons including P4, which was why there were concerns with the incident. (Note: The SP, nor any staff person, mentioned any interpersonal conflicts between the SP and P1 or P2.) The SP said that s/he was the “scapegoat” and that s/he was “painted a villain.” · The VA also had a recent medication change which could cause the VA to be “aggressive.” G1 and G2 said that on December 23, 2025, P4 notified them of the incident. At some point following the incident, the VA said “over and over again” that s/he was “afraid” due to the incident, which G1 and G2 said was not typical for the VA to say. The VA also said that the SP was “trying to kill” him/her during the incident. The VA also typically gave reasons why s/he was put in a “hold” but for the incident with the SP, the VA did not know why the SP put him in a hold. On December 24, 2025, G1 and G2 saw the VA and said that the VA had a “couple scrapes” that looked like “abrasions” on the side of his/her face and a “little scratch” on the side of his/her neck. The VA also had a “bruise” on his/her back. G1 and G2 did not have any concerns with the facility. The Policy and Procedures on Emergency Use of Manual Restraint said that EUMR was defined as using a manual restraint when a person posed an imminent risk of physical harm to self or others and was the least restrictive intervention that would achieve safety. Property damage, very aggression, or a persons refusal to participate in treatment or programming did not constitute an emergency. Staff persons were to attempt to deescalate a clients behavior. Prohibited procedures included a prone restraint which placed a person in a face down position and staff persons were not to apply back or chest pressure while a person was in a prone position. The restraint must end when the threat of harm ended. Personnel files showed that the SP, P1, P2, and P3 received training on the VA’s plans; therapeutic intervention which included de-escalation methods, holds, positional asphyxia, and side lying position; and on the Reporting of Maltreatment of Vulnerable Adults. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.02, subdivision 34a, states that time out means “removing a person involuntarily from an ongoing activity to a room, either locked or unlocked, or otherwise separating a person from others in a way that prevents social contact and prevents the person from leaving the situation if the person chooses.” Minnesota Statutes, section 245D.06, subdivision 6, paragraph (b), clauses (7) and (8), states that emergency use of manual restraint procedures must not use prone restraint. Prone restraint means use of manual restraint that places a person in a face-down position. This does not include a brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, and the person is restored to a standing, sitting, or side-lying position as quickly as possible. Applying back or chest pressure while a person is in the prone or supine position or face-up is prohibited. Minnesota Statutes, section 245D.061, subdivision 2, states that an emergency use of manual restraint but meet the following conditions: immediate interventions must be needed to protect the person or others from imminent risk of physical harm; and the type of manual restraint used must be the least restrictive intervention to eliminate the immediate risk of harm and effectively achieve safety. The manual restraint must end when the threat of harm ends. Conclusion: A. Maltreatment: According to the VA’s plans, the VA had a history of hitting, kicking, punching, or scratching others. When this occurred, staff persons were to redirect the VA to another activity or area to calm. When the VA posed a risk of harm to him/herself or others, staff persons were to implement an EUMR for “safety.” P1’s and P2’s descriptions of the incident on December 3, 2025, were consistent with one another and similar to the VA’s. The SP’s account conflicted with P1’s and P2’s description and the SP had reason to minimize his/her actions for fear of repercussions. In addition, although the SP said s/he had interpersonal conflicts with supervisory staff persons including P4, there was no information the interpersonal conflicts included conflicts with P1 and/or P2. Therefore, it was more likely that the incident occurred as described by P1, P2, and the VA. On December 23, 2025, P2 called P3 stating that the VA was placed in a “prone” hold. P3 and P4 then went to the facility and when they arrived, P4 said that the VA was “more dysregulated” than s/he had “ever seen” the VA. P1 and P2 each said that prior to the incident, the VA attempted to talk to the SP about his/her “favorite” video game characters but that the SP told the VA that s/he was not going to talk to him/her. P1 and P2 said this caused the VA to become “frustrated” and “escalated.” Although the SP denied sending the VA to his/her bedroom, P1 and P2 each said that the SP then told the VA to go to his/her bedroom, which was a violation of Minnesota Statutes, section 245D.02, subdivision 34a, and that the SP’s tone was “mean” and “aggressive.” The SP then followed the VA to his/her room. Although the SP told P1, P2, P4, and this investigator that the VA hit, punched, or “attacked” him/her and that s/he had lacerations on his/her neck and chin, P1 and P2 did not see this and did not see any injuries to the SP. Additionally, the VA, who was described as “smart,” told G1, G2, P3, and P4 that the SP put him/her in a hold for “no reason” and the VA told this investigator that the SP put him/her in a hold “instantly.” Although the SP told this investigator that s/he did not place the VA in a prone hold, P1 and P2 each said that the VA was in a prone hold and P1 also said that the SP had his/her body across the VA’s to “hold” the VA to the floor. The SP also initially told P4 that s/he sat on “top” of the VA. Therefore, there was a preponderance of the evidence that the SP had the VA in a prone position and also sat on the VA which were a violation of Minnesota Statutes, section 245D.06, subdivision 6, paragraph (b), clauses (7) and (8), and Minnesota Statutes, section 245D.061, subdivision 2. P1 and P2 each said that they told the SP multiple times to let the VA “go” but that the SP initially did not do so until s/he had the VA count to 30. The SP also denied that P1 or P2 told him/her to stop the hold. Following the incident, G1, G2, and staff persons including P1 observed two bruises on the VA, including one on his/her face approximately 2.5 inches long that resembled “rug burn.” G1 and G2 described this as an “abrasion.” The VA also had a bruise on the left side of his/her back on his/her shoulder blade. P2 said that the VA did not have the injuries prior to the incident. P1 said that the VA received ice and ibuprofen because the VA said that his/her head “hurt” after. According to P1, the injuries went away after 24 hours. P1, P2, and P5 also described the SP on the date of the incident as “aggressive,” “short tempered,” “very frustrated,” and “irritated.” The SP also told P4 that his/her “attention span” to work with the VA was “running thin.” Additionally, P5 said that at some point prior to the incident, the SP told the VA, “I am going to take you down.” Given that the SP did not follow the VA’s plans including redirecting the VA to another activity and instead told the VA to stop talking and to go to his/her room; that after the VA went to his/her bedroom, the SP followed the VA into the VA’s bedroom; that the SP did not follow his/her training and did an unapproved manual restraint including placing the VA in a prone restraint placed the VA’s safety at risk; that when the VA was no longer posing an immediate risk of harm the SP did not end the restraint; and that as a result of the restraint, the VA sustained injuries, there was a preponderance of the evidence that the SP’s actions were not accidental or therapeutic conduct and produced or reasonable be expected to produce physical pain or injury or emotional distress to the VA and represented a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA’s physical or mental health or safety. It was determined that physical 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. 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 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. The SP was responsible for the care and supervision of the VA at the time of the incident. The SP was trained on the VA plans; on therapeutic intervention which included de-escalation methods, holds, positional asphyxia, and side lying position; and on the Reporting of Maltreatment of Vulnerable Adults Act. Therefore, the SP 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 and neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring because it was a single incident that met two definitions of maltreatment. However, it met statutory criteria to be determined as serious maltreatment because the VA sustained injuries/tissue damage. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP was trained that staff persons were to “never” implement a restraint “alone.” The SP also implemented a prone restraint which staff persons were trained was a “prohibited restraint.” P1 and P2 also repeatedly told the SP to “let go” but the SP did not “listen” and continued the restraint. Staff persons were retrained on things that “should have been done in that situation.” The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was 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 the SP was responsible for maltreatment and the disqualification of the SP 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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