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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: 1104982-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that while a vulnerable adult (VA) and a staff person (SP) were in the kitchen, a facility staff person (P1) heard a slap sound and the VA said, “You slapped me.” Date of Incident(s): Prior to February 16, 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 March 2, 2026; from documentation at the facility; and through four interviews conducted with P1, a facility management person (P2), a facility staff person (P3), and the SP. Although this investigator contacted another staff person (P4) and the VA’s guardian (G), they did not respond to requests to be interviewed. This investigator met the VA but the VA was unable to provide information in an interview due to his/her abilities. The facility had four bedrooms, two bathrooms, an office, a kitchen, a dining area, and a living room. The VA and three roommates lived at the facility. The VA’s Support Plan showed that the VA enjoyed playing golf, participating in activities in the community, and celebrating holidays and birthdays. The VA’s Person Summary showed that the VA had a moderate developmental disability. The VA’s Individual Support Services Assessment (ISSA) showed that the VA had “several chronic conditions,” some of which included diabetes and attention-deficit/hyperactivity-disorder (ADHD). The summary also showed that “schizophrenia causes [the VA] to experience disorganized thinking, and lack of motivation.” The VA’s Risk Assessment Detail showed that the VA engaged in self-injurious behavior (SIB), but specific information was not included in the plan in terms of what the VA engaged in. P2 said that on February 15, 2026, P1 called P2 and said that while P1 assisted a client to his/her bedroom, P1 heard a “slap sound” coming from the dining area and that the VA and the SP were the only persons in the kitchen. Prior to the incident, P2 did not have concerns related to the SP’s interactions with the VA. P1 provided the following information: · P1 did not specifically remember the date, but knew that s/he worked on a “Sunday” from 8 a.m. until 10 p.m. P1 described the day as being a “regular day” before the incident while s/he worked with the SP, P3, and P4. · Shortly after dinner, P1 assisted another client to his/her bedroom, which was next to the dining area. At the time, P3 ate in the staff office, which was also next to the dining area. The SP and the VA remained in the dining area, two other clients went to the living room, and P4 went somewhere, but P1 did not know where P4 went. · When P1 and the client s/he was working with were in the client’s bedroom, with the door closed, P1 heard a “slap sound” coming from the dining area. P1 heard the VA say, “[S/he] hit me.” The comment caught P1 “off guard.” At the time, the VA was the only client in the dining area and living room. P1 was aware that there were times that the VA hit his/her head and “bite” his/herself. P1 did not hear the SP say anything. P1 was also aware of times that the VA said something that s/he “believes true,” but was not true. P1 remembered one time in which the VA talked about recently getting a haircut, but the VA had not had his/her hair cut in months. Prior to the incident, P1 had not worked much with the SP and was not aware of any concerns related to the SP’s interactions with the VA. · About 30 minutes after the incident, P1 checked on the VA, who was in the living room, did not see any red marks and the VA seemed to be “fine.” P1 called P2 to inform him/her of the incident. When P1 was asked why there was a delay in checking on the VA or calling P2, P1 said that s/he “wasn’t sure what I heard,” but P1 thought that s/he “morally” had an obligation to call P2. P1 did not talk to the SP about what P1 heard. P3 said that the day of the incident, after the client s/he worked with finished dinner, the client went to his/her bedroom and P3 went to the office to eat his/her dinner. While P3 ate dinner, with the door open, s/he did not hear anything from the SP or the VA. P3 did not see any red marks or anything on the VA and the VA was in a “good mood” when P3 saw the VA in the living room after P3 left the office. P3 did not have any concerns related to the SP’s interactions with the VA. The SP provided the following information: · The SP did not remember the date but remembered that s/he worked with the VA on the day of the incident. At about 5 p.m., the VA and other clients began to eat dinner in the dining area. When the VA ate, the VA ate his/her food without issues. When the VA finished eating, the VA remained at the table for about ten minutes while the SP cleaned the kitchen. · When the VA left the table, s/he went to the living room and watched television with his/her roommates and other staff, but the SP did not remember who was in the living room. · The SP denied slapping the VA or any type of physical contact. The SP did not remember the VA saying anything related to being hit or slapped. The SP did not see any red marks on the VA and stated that the VA was in a “good mood” after dinner. · Prior to the incident, the SP did not see the VA demonstrate any type of behavioral issues to others, but the VA made inaccurate statements, such as that the “police are here” when that was not true. The SP also was aware that the VA “can slap” him/herself. The SP did not see the VA slap his/herself that day. The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to February 15, 2026. Conclusion: Information showed that after dinner on February 15, 2026, P1 left the dining area and went to a client’s room while the SP and the VA remained in the dining area. While P1 was in the client’s room, with the door closed, P1 heard a slap sound coming from the dining area and heard the VA say, “[S/he] hit me.” About 30 minutes later, P1 checked on the VA in the living room and the VA seemed “fine.” Then, P1 called P2 to tell P2 about the incident. P3 and P4 were also working at the time of the incident. P3 did not hear anything or see any marks on the VA. P4 did not provide information for the investigation. Given that the VA had a history of making some inaccurate statements, based on information from the SP and P1, that no one saw red marks on the VA, that the SP denied physical contact with the VA, that P3 did not hear anything from the VA or a slap sound, and that P1 questioned what s/he heard and did not witness anyone slapping the VA, there was not a preponderance of the evidence whether the SP slapped the VA. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility’s Internal Investigation showed that policies and procedures were adequate, followed, and that additional training was needed. But specific information regarding training was not provided. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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