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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: 1069348-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock Lisa.shock@state.mn.us 651-431-6142 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) slapped/hit a vulnerable adult (VA) on the top of the head. Date of Incident(s): February 27, 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 subdivision 2, 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 March 9, 2026; from documentation at the facility; and through six interviews conducted with the VA, two supervisory staff persons (P1 and the SP), two staff persons (P2 and P3), and two staff persons (P4 and P5) who worked with two clients (C1 and C2) at a different program operated by the same license holder. The VA’s guardian was contacted and aware of the incident but did not have any additional information to provide. The VA enjoyed smoking cigarettes, going for walks in the park, going to the Mall of America and talking to his/her significant other. The VA was diagnosed with borderline personality disorder, major neurocognitive disorder due to a traumatic brain injury, and mild cognitive impairment. The VA required 2:1 staffing at all times. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA was susceptible to physical abuse and was not able to recognize danger and/or may not be able to move away from harm independently. The VA was not able to defend him/herself from physical abuse. P1-P5, the VA and the Internal Review provided the following consistent information: · On February 27, 2026, around six p.m., P2, P3 and the VA, met P4, P5 and C1 and C2, at a movie theater. The SP, who was not working, and a friend of the SP also met P2 – P5, C1, C2 and the VA at the theater. · P2 and P3 stated that the SP purchased the movie tickets and told P2 and P3 where to sit. Because the SP was a supervisory staff, P2 and P3 sat where they were told to by the SP. The VA was sitting behind P2 and P3, next to P4, C1, and C2. · The VA, P4 and P5, each stated that as the SP walked to his/her seat past the VA, the SP open hand slapped the VA on the top of the head “hard.” · P4 and P5 each heard the VA say “ouch” and P4 asked the VA why the SP hit him/her. The VA replied that s/he did not know why the SP slapped him/her. · After a few moments the VA got up and left the theater without P2’s or P3’s knowledge and went outside to have a cigarette. The SP then text the VA asking where s/he was and the VA replied that s/he was outside. · The VA said s/he was upset and had a headache. The SP then came outside and asked the VA what was wrong. The VA said that s/he did not tell the SP what was wrong, and s/he told the SP that s/he wanted to go home. · The SP text P2 and P3 that the VA wanted to leave so P2 and P3 came out of the theater. When P2 saw the VA, the VA “looked upset” so P2 asked what was wrong, and the VA said, “I’ll tell you when we get in the car.” Once in the car, the VA told P2 and P3 that the SP had hit him/her “hard” on the top of the head and his/her head hurt. · P2 and P3 took the VA home and gave the VA an ibuprofen for his/her headache. P2 then contacted P1 and told P1 what the VA said. P1 also received a text from the VA asking for P1 to call. When P1 called the VA, the VA told P1 that the SP “hit” him/her, like a “slap” on the top of the head · P4 and P5 stated that the SP had been “acting drunk” at the theater and they saw the SP with an alcoholic beverage. The SP provided the following information: · The SP purchased three movie tickets with the company credit card and purchased his/her own ticket with his/her own money. The SP was not working at the time of the incident and was attending the movie on his/her own time. · The SP purchased an alcoholic beverage when s/he had first arrived at the movie theater and another one later that evening. · The SP stated that as s/he walked past the VA to get to his/her seat, s/he “tousled” the VA’s hair and the VA laughed. The SP denied hitting the VA on the head. The SP said the VA having his/her hair tousled, and it was their “cat and mouse” game they play with each other. · When s/he noticed the VA was not in his/her seat, the SP text the VA asking if s/he was “okay.” The VA replied that s/he was outside “smoking,” so the SP went to where the VA was. The SP asked the VA, “What’s going on?” and the VA told the SP that s/he was feeling anxious. · The SP then asked the VA if s/he wanted to go back inside to watch the movie or if s/he wanted to go home. The VA stated that s/he wanted to leave so the SP text to P2 and P3 telling them that the VA wanted to leave. · The VA then left with P2 and P3 and the SP went back into the theater and watched the remainder of the movie. · The SP denied hitting the VA with an open hand and stated that s/he only tousled the VA’s hair. The Vulnerable Adult Reporting Policy said that all clients had the right to receive services in an environment that was free of all forms of abuse, including physical abuse. Facility documentation showed that P1, P2, and the SP were trained on the VA’s plans, facility policies, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Statutes Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states that a person’s service-related rights include the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: Although the SP denied hitting the VA on the top of the head and stated s/he “tousled” the VA’s hair making the VA laugh, P4 and P5 provided consistent information that on February 27, 2026, the SP slapped the VA on the top of the head “hard” and the VA said, “Ouch.” In addition, the VA provided consistent information during his/her interview and to P1, P2, and P3 regarding the SP slapping him/her on the head, that was consistent with the information provided by P4 and P5. Afterwards, the VA told P2 and P3 that his/her head hurt and they administered the VA ibuprofen when they returned to the facility. The SP’s action of slapping the VA on the head was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Slapping a person on the head hard enough for the person to say “ouch” and causing a headache, is not accidental or therapeutic conduct. Therefore, there was a preponderance of evidence that the SP’s conduct of slapping the VA on the top of the head could reasonably be expected to produce physical pain or injury. It was determined that 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). 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 trained on the VA’s plans, facility policies, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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. The physical abuse for which the SP was responsible for did not meet the definition of “recurring” or “serious” because it was a single incident and although the VA developed a headache, the VA did not sustain a serious injury. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed once the facility became aware of the incident. There were no similar prior incidents. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP 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 the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Given that the facility took corrective action, a correction order was not issued for the violation outlined above.
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