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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: 1060919-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Suspected Maltreatment Reported: A vulnerable adult (VA) fell from a changing table from a height of three feet causing a head wound. A staff person (SP) did not ensure that the siderails of the changing table were up before assisting the VA. Date of Incident(s): November 20, 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 17, paragraph (a): 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 December 17, 2025; from documentation at the facility; and through six interviews conducted with four facility staff persons (P1-P3, SP), the VA’s guardian (G), and the VA. The facility’s Bathing Guidelines Procedure stated that staff persons, “do not assist individuals with a bath or shower with only one staff in the house”. Staff persons were to “use the side rail and safety straps when using the changing table.” The facility’s Program Abuse Prevention Plan showed that the house was staffed 24 hours a day with one awake overnight staff person. The preferred staff person ratio during awake hours was one staff person for every two individuals or one staff person for every three individuals. A minimum of one staff person for every four individuals must be maintained during awake hours. The VA enjoyed going to his/her day program, visiting with family members, and watching TV. The VA attended a day program five days a week for up to seven hours per day. The VA was diagnosed with cerebral palsy and encephalitis. Due to the VA’s diagnoses, the VA required assistance with all areas of living and utilized a motorized wheelchair for mobility and a Hoyer lift for all transfers. Due to the VA’s limited ability to communicate, the VA provided limited information for this investigation. The Hoyer was a portable hydraulic lift with an x-shaped bracket with four connection points attached to a sling. The VA used a mesh fabric sling with four straps that hooked onto the Hoyer bracket. The bracket could be raised and lowered to lift the VA before moving the Hoyer lift to the intended destination. The bracket was then lowered, and the VA was no longer being supported by the sling and Hoyer lift. The sling was designed to allow the VA to be in a modified seated position while transferring from place to place. The VA’s Health Needs Record stated the VA had a diagnosis of encephalitis that caused muscle spasms, involuntary jerking movements, and muscle stiffness. Due to the spasms, the VA’s “provider” instructed that two staff persons assist with all cares so one staff person could remind the VA to relax while the second staff person completed the cares. The facility did not have further documentation regarding clarification of the provider’s instructions regarding two staff person’s presence during cares. The VA did not recall the date or time but recalled that the SP assisted him/her with getting ready for the day. The SP assisted the VA with showering and getting dressed. While on the changing table, the VA tried to “help” the SP and rolled off the changing table hitting his/her head. The SP provided the following information: · On November 20, 2025, the SP was working at the facility alone. The SP entered the VA’s bedroom around 6:30 a.m. and assisted the VA with getting out of bed using the Hoyer lift. The SP then brought the VA to the bathroom to shower. · Around 7:00 a.m., the SP assisted the VA with getting dressed. The SP was trained to use the Hoyer lift to get the VA onto a changing table that was about three to three and half feet off the ground. Once the VA was on the changing table, the siderails would be put up so the VA could not roll off the changing table. The SP did not put the siderails of the changing table up and assisted the VA with getting dressed. The SP did not think the VA would roll off the changing table if s/he was standing in front of the changing table. · The VA had a history of wanting to be “helpful” when staff persons were assisting with dressing, changing, showering, and during transfers. Due to the VA’s diagnosis, the VA had unpredictable jerking movements that at times, caused injury to staff persons. On November 20, 2025, the VA attempted to be helpful by lifting his/her legs when the SP was getting the VA’s shoes on, and the VA was on the changing table. · The VA rolled off the changing table, hitting his/her left shoulder and side of his/her head near the crown of his/her head. The SP was not able to recall what the injury looked like. The SP was standing near the VA’s feet when s/he fell off the changing table. The SP guided the VA’s feet to the floor after s/he had hit his/her head on the tile floor. · The SP observed that the VA’s head was bleeding and called P1 around 7:30 a.m. P1 said that s/he would arrive to the facility soon and instructed the SP to get the VA up from the floor and into his/her wheelchair. · The SP got the VA up from the floor using the Hoyer lift and put the VA in his/her wheelchair. The SP put a gauze pad on the VA’s head where it was bleeding and asked the VA if s/he was okay. The VA nodded “yes”. The SP then assisted other individuals who lived at the facility and P1 arrived at the facility around 9:00 a.m. · The SP observed P1 entering the VA’s bedroom but was not paying close attention since the SP was assisting other individuals with their daily morning routines. The SP assumed that since P1 arrived at the facility, P1 would have contacted 9-1-1 if the VA required further assessment by a physician. The SP was concerned that the VA should have been taken to the emergency room but was following instructions provided by P1. · The SP previously expressed concern to P1 and other supervisory facility staff persons regarding the lack of staffing in the mornings. The SP routinely worked alone and assisted four individuals with getting ready in the mornings. Three of the individuals required the use of a Hoyer lift or other assistive equipment for completing routine care. The SP was trained to provide care and assist the VA alone and the SP was aware that at times, the VA required two staff persons. · The SP did not wait for P1 or another staff person to arrive at the facility to assist with bathing and showers. P1 provided the following information: · P1 did not recall the date that the incident occurred but was able to recall that s/he received a phone call from the SP between 7 and 8 a.m. The SP told P1 that the VA fell off the changing table and hit his/her head on the floor and his/her head was bleeding. P1 told the SP to call 9-1-1 if it was an emergency and that P1 was on his/her way to the facility. · P1 arrived at the facility around 8:15 a.m. and checked the wound on the VA’s head. The SP told P1 that s/he provided first aid to the VA. P1 observed that the bleeding had stopped. P1 called his/her supervisor and contacted the G. · P1 had a concern regarding a possible head injury, but the VA was not taken to the hospital until 9:20 a.m. when P2 arrived. · P1 was aware that two staff persons should be present when getting individuals dressed and bathing. However, there were not enough staff persons available to provide two staff person coverage at all times or when the VA needed assistance with showering and getting dressed. · The VA had a history of wanting to “help” staff persons when s/he was showering or getting dressed but the VA had jerking movements that made getting the VA dressed more difficult. · P1 no longer worked at the facility following the incident on November 20, 2025, but could not recall when s/he last worked at the facility. P2 provided the following information: · P2 did not work at the facility but was responsible for taking individuals to scheduled appointments. On November 20, 2025, the VA had a dentist appointment and P2 was scheduled to pick the VA up from the facility and transport the VA to and from his/her scheduled dentist appointment. · P2 called the facility to remind staff persons that the VA had a scheduled dentist appointment. P1 informed P2 that the VA’s dentist appointment needed to be rescheduled due to the VA having a “cut” on his/her head. Since P2 was approximately ten minutes away from the facility, P2 went to the facility. · P2 arrived at the facility around 9:20 a.m. and went to the VA’s bedroom. P1 was attempting to put a sweater on the VA and P1 said the VA fell from the changing table. P2 observed the VA’s head and saw that the VA had a cut about an inch to an inch and half near the crown of his/her head and that the cut was still bleeding. P2 put a new bandage on the VA’s head. · The facility nurse was contacted by P2 who instructed P2 to call 9-1-1 or transport the VA to the hospital. P2 told the facility nurse that s/he would take the VA to the hospital. P2 got the VA into the van and transported the VA to the hospital. P2 contacted the G to let them know that s/he was taking the VA to the hospital due to a fall and cut on his/her head. · The VA received three staples in his/her head and received a CT scan of his/her right shoulder but did not sustain any injuries to his/her right shoulder and the VA did not have a concussion. · Sometime between 1:00 and 1:30 p.m. P2 transported the VA back to the facility. P2 then left the facility due to other scheduled appointments. · The VA had a history of trying to “help” staff when they were assisting the VA with getting dressed. To P2’s knowledge, the VA only required one staff person when being assisted with bathing/showering and getting dressed but P2 was not sure since s/he did not work directly with the VA or other individuals that lived at the facility. · Staff persons working at the facility were trained to call 9-1-1, then the facility nurse, the G, and then the supervisor. P2 was not sure why 9-1-1 was not contacted after the VA fell off the changing table. P3 provided the following information: · On November 20, 2025, P3 received a call from P1 “just before 9:00 a.m.” P1 informed P3 that the VA had “an accident” and hit his/her and was bleeding. P3 instructed P1 to call 9-1-1, go to the facility, and to call the facility nurse. · P3 did not know that P1 and the SP did not call 9-1-1 until P3 read the incident report on November 21, 2025. P3 did not know why P1, and the SP did not call 9-1-1 after being instructed to by P3. To P3’s knowledge, P1 and the SP did not contact the facility nurse but instead P2 contacted the facility nurse. · It was “company policy” that two staff persons were required when an individual needed full assistance with bathing/showering. P3 did not know why the SP had given the VA a shower without another staff person to assist and did not know why P1 did not arrive at the facility until 8:00 or 9:00 a.m. when P1 was scheduled to be at the facility by 8:15 a.m. · P1 did not work at the facility after December 11, 2025, due to circumstances unrelated to the incident on November 20, 2025. The G provided the following information: · On November 20, 2025, P2 contacted the G a little after 9:00 a.m. and P2 discussed with the G that P2 was taking the VA to the hospital due to a fall from the changing table. · P2 sent photos via text message to the G of the VA’s injury on his/her head. P2 was in constant communication with the G while P2 was in the hospital with the VA. · The G was concerned that the standard of care that the VA received declined around August 2025, when numerous staff persons resigned from the facility. The facility’s Incident Response, Reporting and Review Policy provided the following information: · A serious injury of a person was identified as a head injury with loss of consciousness or potential for a closed head injury or concussion without loss of consciousness requiring a medical assessment by a health care professional, whether or not further medical attention was sought. · Response procedures for a serious injury included providing first aid/CPR, asking for assistance from additional staff persons, if immediately available and seeking medical attention including 9-1-1 for emergency medical care as soon as possible. Facility training records showed that all staff persons interviewed each received training on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. Relevant Rules and/or Statutes: Minnesota Statues, section 245D.05 subdivision 1, paragraphs (a) and (b) stated that the license holder is responsible for meeting health service needs assigned in the support plan or support plan addendum, consistent with the person’s health needs and must maintain documentation on how the person’s health needs will be met, including a description of the procedures the license holder will follow. Conclusion: Information showed that the SP worked at the facility on November 20, 2025, in the morning alone until P1 arrived at the facility around 9:00 a.m. The SP assisted the VA with showering and getting dressed between 7:00 and 7:30 a.m., when no other staff person was present at the facility. The SP acknowledged that s/he did not put up the siderails on the changing table and when the VA attempted to “help” the SP, s/he rolled off the changing table from a height of three feet, hitting his/her shoulder and head on the ground. Conflicting information was provided regarding whether P1 instructed the SP to contact 9-1-1 or wait until P1 arrived at the facility. When P1 arrived at the facility, s/he observed the VA’s cut on his/her head and said that it was not bleeding at that time. When P2 arrived at the facility, P2 said that the cut was still bleeding and transported the VA to hospital. Information was consistent between the SP, P1, and P2 that staff persons at the facility provided bathing/showering assistance to the VA and other individuals in the facility alone on multiple occasions, and the VA’s Health Needs Record identified the VA had a diagnosis of encephalitis that could cause muscle spasms, involuntary jerking movements, and muscle stiffness. Due to the spasms, the VA’s “provider” instructed that the VA have two staff persons for all cares or have one staff person to acknowledge, thank, and remind the VA to relax when staff persons completed cares. This information was contradictory to the facilities Bathing Guidelines Procedure which stated, “do not assist individuals with a bath or shower with only one staff in the house,”. However, the SP did not put the siderails of the changing table up which could have prevented the VA from falling from the changing table and assisted the VA without another staff person which were in violation of Minnesota Statues, section 245D.05 subdivision 1a, paragraphs (a) and (b). The SP did not contact 9-1-1, but provided first aid to the VA. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (5), states, a vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (iv) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (v) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. The SP’s actions of not ensuring that the side rail was up while the VA was on the changing table constituted an error in the provision of therapeutic conduct for the following reasons: (i) medical care was obtained for the VA in a timely manner. (ii) the VA suffered a cut that required staples as a result of the fall but healed and the VA returned to his/her preexisting health status. (iii) there were no past similar incidents with the SP. (iv) the SP recognized that s/he should have secured the side rail on the bed before completing cares for the VA. The SP received retraining on First-Aid and CPR and skills. (v) the incident was reported by the facility and sufficiently documented. This error in the provision of therapeutic conduct to the VA by the SP was not maltreatment. It was determined that neglect did not occur (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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed because 9-1-1 was not contacted in a prompt manner and the SP did not use the railings on the changing table. The SP was given a final warning from the facility and received retraining on skills and First-Aid and CPR. Action Taken by Department of Human Services, Office of Inspector General: The SP was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which the SP was responsible met the criteria to be determined an error. The SP was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which the SP is responsible might not be considered an error. On April 7, 2026, the facility was issued a Correction Order for the violations outlined in this report.
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