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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: 1071755-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) slapped a vulnerable adult (VA) and tried to make the VA fall by pushing the VA and taking his/her walker from the VA while s/he was using it. Date of Incident(s): December 22, 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 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 January 9, 2026; from documentation at the facility; and through five interviews conducted with a facility staff person (P1), two supervisory staff persons (P2 and P3), a client (C), and the VA. Attempts were made by telephone and mail to contact and interview the SP, but the SP did not respond to the requests. The VA enjoyed watching movies, going on community outings, listening to music, and going out to eat. The VA’s diagnoses included schizophrenia, major depressive disorder, panic disorder, anxiety disorder, moderate intellectual disabilities, dementia, and Parkinson’s disease. The VA was not subject to guardianship. The VA’s Individual Service and Support Advocacy Assessment Detail stated that the VA understood that it was important that s/he used a walker to maintain his/her balance when going to his/her day program or into the community. The staff persons were to verbally remind the VA to take his/her time when walking and were to encourage the VA to let them know if s/he needed assistance walking. The VA’s Risk Assessment Detail stated that the VA might not be able to defend him/herself from physical abuse and might not be aware of how to report physical abuse. The VA’s Health Needs Record stated that the VA had a high fall risk due to his/her diagnoses. The VA was to use a walker at all times when s/he was ambulatory. The staff persons were to remind the VA to use his/her walker if the VA attempted to walk without the walker. The facility was located in a rambler-style building, with main living areas, including a kitchen, a living room, a dining room, and client bedrooms located on the main level. The dining room was located at the end of the kitchen and opened into both the living room and kitchen. A hallway to the client bedrooms was located on the opposite end of the kitchen and living room from the dining room. The VA stated that at the time of the incident, s/he yelled at the SP and when s/he walked from the kitchen to his/her bedroom, the SP took the VA’s walker from the VA. The SP also slapped the VA. The VA became upset and yelled at the SP. The VA was not injured during the incident. The VA believed the C was in the living room at the time of the incident. The C stated that on the day of the incident, s/he was in the living room. The VA left the living room and was in the hallway when the SP pushed the VA, slapped the VA, and attempted to take the VA’s walker from the VA, causing the VA to fall on the floor. The C believed the VA fell on his/her back, but did not appear to be in pain. The C helped the VA stand. After the incident, the VA and the C told P2 about the incident. P1 stated that on the day of the incident, the SP and P1 worked at the facility. The SP told the VA to clean the bathroom, which was dirty, but the VA refused because s/he did not cause the mess. P1 told the SP that s/he would clean the bathroom. That afternoon, while P1 was cooking dinner, the VA entered the kitchen because s/he wanted a snack. The SP began arguing with the VA and told him/her that s/he could not have snacks. The VA told the SP to move out of his/her way so s/he could get a snack, but the SP refused to move. The VA attempted to hit the SP with his/her walker, so the SP moved the VA’s walker. P1 stated that the VA was “about to fall down” when P1 stepped in and kept the VA from falling. P1 believed the VA would have fallen if P1 had not assisted him/her. P1 told the SP to “leave [the clients] alone” and the SP told P1 to leave him/her alone and that s/he could do “whatever I want.” Later that day, the VA told P1 that the SP was “mean.” When P1 told the SP that his/her actions were “not okay,” the SP went outside and sat in his/her car. P1 telephoned P2 and told him/her about the incident. P2 provided the following information: · P2 stated that on December 23, 2025, s/he talked to the staff persons, who told him/her that the previous night, the clients stayed in their bedrooms and did not eat dinner. Later, a staff person called P2 to tell him/her that the C told the staff person that the clients remained in their bedroom because the SP had slapped the VA. · When P2 talked to P1, P1 told him/her that s/he was in the kitchen and “had no idea” that the SP slapped the VA. P1 told P2 that the SP tried to make the C clean the bathroom even though it was up to the staff persons to clean. P1 told P2 that the SP was “evil” and s/he no longer wanted to work with the SP, but did not say anything about the SP slapping the VA. P1 also told P2 that s/he was in the kitchen and did not see any incident and the clients did not mention the incident to P1. · P2 stated that when s/he talked to the VA and the C on the day after the incident, they told P2 that the SP slapped the VA on the face, causing a red mark. The SP then tried to remove the VA’s walker so that the VA would trip and fall. They also told P2 that P1 was in the room and saw the incident. P2 stated that when s/he saw the VA the day after the incident, the VA appeared to be “very flushed” and his/her face appeared to be “tender and red.” P3 stated that at the time of the incident s/he was on vacation. When s/he returned to the facility, P1 told P3 that when s/he tried to intervene when the SP told the C to clean the bathroom, the SP told P1 that s/he “knew how to deal with these types of people.” P3 was told that after the incident, the VA had a red mark on his/her face and was given an ice pack, but did not require additional care. The facility’s Internal Investigation provided the following information: · The VA provided information that the SP tried to take the VA’s walker so that the VA would fall and also slapped the VA’s face. The VA did not know why the SP acted that way. The incident happened in the living room and was witnessed by P1. · P1 provided information that s/he heard yelling in the VA’s bedroom. When P1 entered the bedroom, the VA told P1 that the SP took the VA’s walker, pushed the VA, hit the VA, and tried to make the VA fall. The SP told P1 that the VA hit him/her. P1 believed the VA’s account of events. · The SP provided information that while s/he was sitting at the kitchen table, the VA ran his/her walker into the SP’s leg and attempted to grab snacks from the table. The SP told the VA not to eat too many cookies. When the SP asked the C to clean the bathroom, the C began to yell, which upset the VA. The SP denied hitting or pushing the VA. Facility documentation showed that the SP, P1, P2, and P3 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights include the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: On December 22, 2025, the SP and P1 worked at the facility with the VA and the C. The VA stated when s/he walked from the kitchen to his/her bedroom, the SP took the VA’s walker from the VA and slapped the VA’s face. The C stated that when the VA left the living room, the SP pushed the VA, slapped the VA, and attempted to take the VA’s walker from the VA, causing the VA to fall on the floor. The C helped the VA stand. P1 stated that when the VA attempted to hit the SP with his/her walker in the kitchen, the SP moved the VA’s walker, causing the VA to lose his/her balance, but P1 stepped in and kept the VA from falling. P1 believed the VA would have fallen if P1 had not assisted him/her. P1 did not provide information that s/he saw the SP hit or push the VA, but provided information for the internal review that s/he believed the VA’s account of events. P2 stated that when s/he saw the VA after the incident, the VA appeared to be “very flushed” and his/her face appeared to be “tender and red.” The SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section245D.04, subdivision 3, paragraph (a), clause (6), and were not accidental or therapeutic conduct. Although the SP did not provide information for this report, given that the VA and the C provided consistent information that the SP hit the VA on the face, pushed the VA, and tried to take the VA’s walker so that the VA would fall, there was a preponderance of the evidence that the SP’s actions could reasonably be expected to produce physical pain or injury or emotional distress to the VA. It was determined that 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. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. 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 for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and it was not determined what caused the redness on the VA’s face. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. After the incident, all staff persons were retrained on the facility’s reporting policies. 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 immediate corrective action, a Correction Order was not issued for the violation outlined above.
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