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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: 1097996-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) used blocking pads (referred to as “blockers” in remainder of report) incorrectly which caused a vulnerable adult (VA) to fall backwards and hit his/her head and back. Date of Incident(s): January 28, 2026 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 February 10, 2026; from documentation at the facility, law enforcement records, and medical records; and through seven interviews conducted with the VA’s guardian (G), the VA’s case manager (CM), a supervisory staff person (P1), two facility staff persons (P2 and P3), and SP1 and SP2. The VA was unable to provide information due to his/her diagnosis. The VA was diagnosed with severe range intellectual disability, autism, attention deficit hyperactivity disorder, had a history of seizures, and was non-verbal. The VA required twenty-four-hour supervision and assistance with bathing, grooming, meal preparation, medication assistance, transportation and communication. The VA enjoyed riding his/her bicycle, going for rides in the vehicle, swimming, and visiting friends and family. The VA’s Support Plan Addendum said that the VA had a history of property destruction and physical aggression towards staff persons. Staff persons were provided blockers to use if/when the VA displayed aggressive behaviors. The blockers were used “during episodes of physical [aggression]” and if the VA threw objects at and/or charged at staff persons. Staff persons held the blockers, moving them “up and down/side to side,” and were trained to keep their arms at a ninety-degree angle not extending their arms outward. The VA’s Individual Abuse Prevention Plan said the VA was unable to defend him/herself from physical aggression, unable to identify potentially dangerous situations, and was verbally and physically abusive to others. Staff persons ensured the VA’s safety by guiding him/her from unsafe situations and redirecting the VA to do something positive that s/he enjoyed. The VA engaged in self-injurious behaviors, lacked “self-preservation skills,” and relied on staff persons to complete all activities of daily living. The VA’s Behavior Support Plan said the VA had a history of physical aggression towards others, including hitting, kicking, biting, charging at staff persons, grabbing, and scratching. Staff persons used blockers when the VA threw objects and/or charged at staff persons and discontinued the use of blockers immediately when the behavior ended. Staff persons also utilized the blockers by placing them on the floor when the VA banged his/her head. When the VA had “dead/absent stares” it typically meant the VA was having a seizure. The incident occurred on the main floor of the facility, in the living room, dining room, and kitchen areas. Each room was separated by walls, but adjoined through open doorways, which allowed the VA to “run” around the facility in a circular pattern. The living room had a large brick fireplace, with gold metal doors and grate. The fireplace had a brick hearth, which was low to the floor and stuck out from the wall. There was a piano located in the dining room. The facility had wood floors throughout. P2 provided the following consistent information during an interview with this investigator and law enforcement: · On January 28, 2026, P2 worked with SP1 and SP2 at the facility and at an unknown time, P2, SP1, and SP2 brought the VA on a van ride. Shortly after leaving, the VA became upset that SP1 and SP2 would not let the VA sit in the middle seat of the van. The VA unbuckled and became “unsafe,” so they returned to the facility. At this time, P1 was also at the facility and in the staff office. · When the VA entered the facility, s/he “instantly” charged at SP1 and SP2. The VA “chased” SP2 around the house, and SP2 went into the bathroom and shut the door. The VA “banged” on the bathroom door and P1 came out of the office and “reminded” P2, SP1, and SP2 to use the blockers if the VA was aggressive and then returned to the office and shut the door. · After SP2 went into the bathroom, the VA “went towards” SP1. SP1 used the blocker to block the VA when s/he “charged” and also used the blockers to “pin” the VA to the wall. The VA “clawed” SP1 so SP1 released the VA from the wall and P2 attempted to verbally redirect the VA but the VA “wasn’t listening or hearing anything” and charged at SP1 again. · SP1 used the blockers and “extended” his/her arms with “really good force.” When the VA hit the blockers, s/he fell backwards and hit his/her head on the bottom of the piano. When the VA fell, s/he cried and “refused” to get up. P1 then came out of the office and asked the VA if s/he wanted to get up and the VA said, “No.” P1 told the VA to let staff persons know when s/he was ready, and they would help him/her up. P1 then returned to the staff person office. · An unknown amount of time later, when the VA calmed and got up, SP2 left the bathroom. As soon as the VA saw SP2, the VA “charged” at him/her and SP2 blocked the VA with blockers. The VA grabbed the blockers, and when s/he let go, SP2 used the pad to “shove” the VA. The VA fell backwards into the fireplace hitting his/her head on the metal part of the fireplace and his/her back on the hearth of the fireplace. The mark on the VA’s back looked like a heat rash, or that it had been scraped on concrete and did not bleed. P2 thought the mark was on the VA’s right side and that it was the length of a bottle of water, and slightly wider than it was long. · The VA cried “hysterically” and “called out” for the G. After the VA fell, P2 saw a large mark on the VA’s back, but the VA would not allow P2 to care for it. The VA then got up, went into the kitchen, opened the refrigerator and cabinets, and “threw everything” at SP1 and SP2. · After the VA threw items in the kitchen, P1 came out of the office again and asked if everything was “okay.” P2 showed P1 the scratch on the VA’s back and P1 asked what happened. SP1 and SP2 told P1 the VA “fell.” At that time, P2 did not tell P1 that the VA hit his/her head because P2 needed to “process” what happened. Later that evening, at an unknown time, P2 text P1 and said that SP1 and SP2 were “scared” of the VA and should not work with him/her. · On January 29, 2026, at an unknown time, P2 called P1 and told P1 what P2 witnessed the previous day, which was consistent with the information P2 provided above. P1 was “shocked” and asked P2 not to talk to staff persons about what happened. · On January 29, 2026, at an unknown time, P2 brought the VA a medical appointment. The medical professional recommended ointment for the scratches on the VA’s back and advised staff persons to monitor the VA for new or worsening symptoms. · On January 31, 2026, P2 and P3 brought the VA to a medical appointment (as follow up from the fall on January 28, 2026) for a computed tomography (CT) scan, and the VA was diagnosed with a concussion. · P2 was trained to use blockers as a “defensive tool” and not an “offensive weapon.” Blockers were meant to block being hit by the VA or hit by objects, but never to “restrict, hold, or pin.” P2 had never seen SP1 or SP2 use the blockers incorrectly prior to this incident and did not believe the VA lost consciousness during the incident. P1 provided the following information during an interview with this investigator and law enforcement: · On an unknown date in January 2026, P1 worked at the facility and was in the office. P2, SP1, and SP2 were also working, and at an unknown time, took the VA on a van ride. Shortly after leaving the facility, they returned. P1 could not remember which staff person told him/her, but they returned because the VA had “behaviors” in the van that were not safe. · When P1 was in the office s/he heard sounds like items being thrown. P1 left the office to see what happened and saw the microwave as well as food items from the refrigerator and freezer on the floor. The VA was lying on the floor near the piano and P1 asked the VA if s/he was “okay.” The VA shook his/her head “yes” so P1 picked up some items off of the floor, reminded P2, SP1, and SP2 to use blockers if the VA was aggressive and returned to the office. At that time, P1 was unaware of any injuries to the VA but knew there was “big behaviors” happening due to the number of items on the floor. · On January 29, 2026, at an unknown time, P2 called P1 and told him/her that the VA had a “scratch” on his/her back. P1 asked P2 to send him/her a photo. P1 viewed the photo and thought it was five to six inches wide as well as long and looked like a “scrape.” It was red, but there was no blood coming out, and P2 thought it was on the VA’s right side of his/her back. · When P1 spoke with P2, P2 did not mention the VA hitting his/her head and P1 was not aware that the VA hit his/her head until later that morning when s/he reviewed the incident report completed by P2 the morning after the incident. The VA had a previously scheduled medical appointment on January 29, 2026, so P1 called the staff person working and told him/her to ask the medical professional to check the VA’s head. P1 did not remember who brought the VA to the appointment. · After the appointment, P1 was told that the medical professional checked the VA’s head and “didn’t see anything concerning,” and said if the facility wanted more information, they could bring the VA for a CT scan. · On January 30, 2026, P1 and P3 brought the VA to “multiple” medical facilities to have a CT scan done but they were unable to find somewhere that was able to do it. The VA became agitated and started having behaviors, so P1, P3, and the VA returned to the facility. · On January 31, 2026, P3 and P2 brought the VA to a medical professional to have a CT scan. P1 reviewed the after-visit summary which said the VA had a concussion. · Staff persons were trained to use blockers when the VA was aggressive towards staff persons to “protect” themselves. Staff persons held the blockers on their body and moved with the pad in the direction the VA came from. The blockers were never to be used “offensively.” · P1 did not have prior concern with SP1’s and/or SP2’s care of the VA and had no information that the VA lost consciousness during the incident. P3 provided the following information: · On an unknown date, at 4 p.m., P3 worked at the facility with P2 and at some point, they brought the VA on a drive. During that time, P2 told P3 that s/he saw SP1 and SP2 “push” the VA with the blockers, and that the VA was injured by the fireplace and hit his/her head on the piano. P2 talked about the incident “most of the night” and told P3 that SP1 and SP2 were “definitely getting fired.” When P3 worked, the VA was in “good spirits” but kept pointing to his/her head and P3 saw scratches on the VA’s back that were “almost a palm width, going horizontally down [his/her] back.” · On January 31, 2026, P3 and P2 brought the VA to have a CT scan. Medical professionals told P3 that the CT scan came back “negative.” There was no bleeding but some slight bruising near the surface of the VA’s skull and the VA likely had a concussion. · The VA was normally “unstable” and “off balance” and did not always watch where s/he was going. The VA had a history of falls, but P3 was not aware of the VA hitting his/her head prior to this incident. P3 said that if the VA hit his/her head, s/he would contact a supervisory staff person immediately, and have the VA evaluated by emergency medical services. P3 thought the VA had “enormous strength” and if the VA ran into the blockers, it was possible that the VA propelled him/herself backwards. · Staff persons were trained to block physical aggression from the VA. The blockers were held in front of staff persons and they “maneuvered” themselves to block the VA. P3 never used blockers with the VA because the VA was not aggressive with P3. · P3 was “confused” and did not think SP2 would “ever do this type of incident.” SP2 was attentive to the needs of the VA and was “sociable.” SP1 “seemed scared” of the VA. P3 never saw SP1 and/or SP2 use the blockers and thought P2 had a “very strong opinion” about others and often complained to other staff persons about SP1 and SP2. SP2 provided the following information: · On an unknown date, SP2, SP1, P2, and P1 worked at the facility and at an unknown time, SP2, SP1, and P2 brought the VA for a van ride. SP2 drove the van, SP1 was in the passenger seat, P2 was in the middle seat, and the VA was in the back seat of the van. SP2 drove for “not even a minute” before the VA started having behaviors in the van. The VA tried to “grab” SP2 from behind, so P2 tried to keep the VA away from SP2. SP2 then turned around and drove back to the facility. · When they returned to the facility, the VA “chased” SP2 and SP1 around the facility. SP2 went into the bathroom and closed the door, and P2 told SP2 to stay inside the bathroom. When SP2 left the bathroom, the VA “threw” items from the refrigerator at SP2 and “chased” SP2 around the kitchen and living room. While in the living room, SP2 picked up the blockers. The VA then came towards SP2, “swinging [his/her] hands and legs” and SP2 used the blockers to block the VA. At one point, the VA “grabbed” SP2’s hands and tried to hit SP2, and the VA lost his/her balance and “fell” on the fireplace scraping the left side of his/her lower back on the fireplace brick. SP2 denied seeing the VA hit his/her head on the fireplace, and said had the VA done so, SP2 would have called emergency medical services to evaluate the VA. · P1 came out of the office when the VA was “calm and relaxed” and SP2 showed P1 the VA’s injury and told P1 what happened. P1 then talked to the VA, and SP2 documented what happened. · Staff persons were trained to use blockers to follow the direction of the VA. Staff persons held the blocker close to their body and did not “push” or use “force.” · SP2 denied s/he pushed the VA, denied extending his/her arms when s/he used the blockers, and stated the VA was “unstable” and often fell at the facility. SP2 was in the bathroom and did not see SP1 use the blockers with the VA. SP1 provided the following information: · On an unknown date, SP1 worked with SP2 and P2 at the facility. P1 was also at the facility in the office. The VA asked to go on a van ride and while in the van, the VA tried to hit SP1 and SP2 and then removed his/her seatbelt. SP1 told SP2 and P2 that they could not continue without the VA having his/her seatbelt on, so they returned to the facility. · When they returned, the VA escalated and was “very super aggressive.” The VA hit staff persons and threw items from the refrigerator and cabinets around the facility. SP1, SP2, and P2 tried to redirect the VA, but those attempts were unsuccessful. SP1 grabbed a blocker and told SP2 and P2 they needed to “follow protocol” and also use the blockers. P2 declined a blocker which made SP1 “uncomfortable.” · When the VA was aggressive, s/he was “powerful” and used his/her hands and legs “like crazy.” SP1 saw the VA go towards SP2, and SP2 used the blocker by bringing it towards him/herself to block the VA. The VA was not stable and when s/he hit the blocker, the VA “fell back” into the fireplace causing “bruises” on his/her back. At one point, P1 came out of the office and SP2 notified P1 of the injury on the VA’s back. P1 told SP1, SP2, and P2 to “clean up.” SP1 denied seeing SP2 extend his/her arms and denied seeing the VA hit his/her head on the fireplace. · The VA continued to have behaviors, and SP1 used the blockers to “redirect” the VA. At one point, the VA came towards SP1 and hit the blocker. The VA fell and “lay” his/her head near the piano. P2 tried to get the VA to stand, but could not do it alone, so SP1 helped get the VA up. SP1 denied pushing the VA with the blockers, denied seeing the VA hit his/her head on the piano, and denied holding the VA against the wall. · Staff persons were provided blockers for when the VA became aggressive. Staff persons were trained to hold the blocker and pull it towards themselves to “maintain stability” for the VA but “never” push a resident or extend their arms. Because the VA was unstable, it was the responsibility of the staff persons to hold the blocker to help provide stability for the VA. The G was aware of the allegation but thought information provided by the facility was “unclear” and the G did not understand exactly what occurred. The VA’s verbal skills were “very limited”, and the VA could not provide information to the G. The VA was “clumsy” when s/he walked and if someone bumped into the VA, s/he would “stumble and go down.” The G thought that if staff persons used the blockers as the VA’s plans said, which was to protect themselves, the VA would either run into the staff person, or “bounce off, stumble, and fall down.” The CM was aware of the allegation and did not have previous concern with the facility. A photo provided by the facility showed a large scrape on the VA’s back, however the photo does not show which side the scrape is on. The scrape appeared to go from the VA’s lower back to his/her ribcage and appeared approximately a hand width in size. Medical records provided the following information: · On January 29, 2026, the VA attended a medical appointment with his/her primary medical provider for reasons unrelated to the incident and was not assessed for any injury to his/her head or back. · On January 30, 2026, the VA was seen by a medical professional for complaint of a “head injury” and “hip injury” after a behavioral episode where the VA hit his/her head on a piano. The VA denied having a headache or vision changes. The VA’s head “appeared normal” with “no erythema, edema or bruising” on his/her scalp and “no lump palpated.” Staff persons requested the VA have a CT completed, but the medical facility was not equipped to do so. It was recommended the VA follow up with his/her primary medical provider if his/her symptoms worsened. There was no information regarding an injury to the VA’s back. · On January 31, 2026, the VA was seen in the emergency department and had a CT of his/her head and spine. The CT showed “no evidence of acute intracranial abnormality” but a “right posterior scalp contusion” with no underlying fracture. Staff persons informed medical professionals that the VA hit his/her head on the corner of a fireplace, and “lost consciousness” for an undetermined amount of time. The after-visit summary said the VA “likely” had a concussion, and it was recommended that staff persons monitor the VA, and that the VA return to the emergency department with new or worsening symptoms. There was no information regarding an injury to the VA’s back. The facility’s personnel files showed that P1-P3, SP1 and SP2 were trained on the VA’s plans, the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: P2 said s/he saw SP2 “push” the VA with the blockers, which resulted in the VA falling and hitting his/her head and back on the fireplace which caused a scrape on his/her back. P2 also said s/he saw SP1 push the VA with the blockers which resulted in the VA falling and hitting his/her head on the piano. P2 told P3 about the incident that evening but did not tell P1 (the supervisory staff person) about the injury until the following morning because s/he needed to “process” what happened. SP1 said s/he used blockers during the incident. At one point the VA hit the blockers and fell back near the piano. SP1 and P2 helped the VA up. SP2 also used blockers during the incident by bringing the blockers in towards him/herself. The VA hit the blockers and fell back toward the fireplace, injuring his/her back. SP1 did not see the VA hit his/her head at any point during the incident. SP2 said s/he used blockers during the incident and the VA grabbed at SP2 and fell scraping his/her back on the fireplace. SP2 did not see the VA fall near the piano because s/he was not in the room at that time. SP2 did not see the VA hit his/her head at any point during the incident. During the incident, P1 was in the staff office and said s/he came out on one occasion and saw the VA on the floor and that the VA said s/he was ok. P1 was unaware of any injuries to the VA at that time. The following day P2 told P1 that the VA had a scrape on his/her back from the injury. Later that morning when P1 reviewed the incident report completed by P2, it noted that the VA also hit/her head during the incident. Staff persons took the VA to get evaluated by a medical professional. SP1, SP2, P3, and the G provided consistent information that the VA was “unsteady” when s/he walked and fell easily and each thought that when the VA was aggressive, s/he could easily fall backwards after running into the blockers. Medical records showed that on January 31, 2026, the VA had a CT scan which did not show abnormal findings, and although the VA was diagnosed with a “likely concussion,” the VA was not verbal, and information provided to medical professionals was from P2 and P3. Additionally, these medical records showed that an unidentified staff person told the medical professional that the VA hit his/her head on the corner of the fireplace, and “lost consciousness” for an undetermined amount of time, but there was no additional information provided that the VA lost consciousness. SP1 and SP2 each denied pushing the VA with the blockers and said they were trained not to do so. SP1 and SP2 each said they told P1 that the VA injured his/her back when it occurred. Neither SP1 nor SP2 saw the VA hit his/her head on the piano or the fireplace. Although P2 said that both SP1 and SP2 pushed the VA with blockers resulting in the VA falling back and hitting his/her back on the fireplace and his/her head on the piano, given that the VA was unsteady on his/her feet, that SP1 and SP2 each denied pushing the VA with the blockers, that P2 had interpersonal conflicts with SP1 and SP2, that P2 delayed reporting the incident, and that there was no further witnesses to corroborate the events of the incident, there was not a preponderance of the evidence whether the VA fell by any means other than accidental or whether SP1 and SP2 engaged in conduct that produced or could reasonably be expected to produce physical pain or injury. 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 but not followed. SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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