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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: 1071746-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) was seen “beating and punching” a vulnerable adult on the head and neck. Date of Incident(s): January 31, 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 law enforcement records; and through five interviews conducted with two facility staff persons (SP and P1), a facility supervisory staff person (P2), the VA’s guardian (G), and the VA. The VA’s diagnoses included intellectual disabilities, cerebral palsy, and aphasia. The VA required assistive devices with mobility and had a history of interfering behaviors, which included physical aggression. The VA enjoyed music, bingo, van rides, and bowling. The facility was single story residence with a finished basement in a residential neighborhood. The main floor consisted of a dining room, office area, a kitchen, a living room, three bedrooms, and a bathroom. The basement consisted of a living room, a laundry room, a utility room, a bathroom, and a bedroom. The VA’s Action Plan dated March 17, 2025, stated the VA “may hit, kick, scratch, or punch others. [The VA] will throw objects, overturn tables, slam doors, hit or kick objects, rip up paperwork, punch holes in walls, or damage window treatments.” The VA’s Risk Assessment stated the VA “would not successfully be able to retreat from physical abuse.” If physical abuse was observed, staff persons moved the VA to another location away from the abuser. The VA had limited verbal abilities and provided this investigator yes or no answers that indicated s/he was happy at the facility, s/he liked all the staff persons, had never been hit or hurt by anyone at the facility, and felt safe at the facility. P1 provided the following information: · On January 30, 2026, P1, who did not typically work at the facility, picked up a shift and worked 10 p.m. to 8 a.m. at the facility. P1 and the SP were the only staff persons working. On January 31, 2026, around 7 a.m., P1 assisted a client in the bedroom next door to the VA’s bedroom while the SP assisted the VA getting dressed in the VA’s bedroom. P1 heard a “scream” from the VA’s bedroom and went to the VA’s doorway to see what was happening. P1 saw the VA sitting in his/her wheelchair and the SP was standing next to the VA, “hitting” the VA on the “head and neck.” · P1 said the SP hit the VA with an open-handed slap and a closed fist punch and the VA was “fighting back.” P1 did not check the VA for any injuries. · P1 asked the SP why s/he “did that” and the SP said when s/he was putting an absorbent undergarment on the VA, the VA “hit [the SP] first.” The SP eyeglasses had fallen to the floor during the incident, so the SP picked them up off the floor and left the room. The VA was “crying” and threw his/her lotion bottle and shoes, before closing the bedroom door. · After the SP left the VA’s bedroom, the SP told P1 the “bosses won’t believe you” because the SP worked at the facility for many years and P1 just started at the facility. P1 was “rushing” to get to another job and “just left.” On January 31, 2026, at 10 a.m., P1 called and informed P2 of the incident. P2 said s/he would “report [the SP].” P1 asked P2 not to tell the SP that P1 was the person that reported the incident. · Approximately one week later, the SP was still working at the facility and so P1 called P2 and asked why the SP was not fired. P2 said that “wasn’t how the system works” and told P1 if s/he reported the incident late, “[P1] may lose [his/her] job.” P1 was “afraid to speak up,” and believed P2 did not want P1 to report the incident. P2 provided the following information: · On February 2, 2026, P1 called P2 and said s/he saw the SP “hitting” the VA on the morning of January 31, 2026. P1 said s/he was in a client’s bedroom next door and saw the SP hit the VA in the VA’s bedroom. P1 did not want the incident “reported.” P2 went to the facility and checked on the VA and did not see any bruises. P2 asked the VA if s/he was okay and the VA said s/he was “fine.” P2 did not report the incident right away as s/he did not think P1 was “sure what [P1] had witnessed.” · On February 3, 2026, P2 asked the SP about the incident. The SP said that s/he told the VA it was time for a shower. The VA became “agitated,” called the SP names, and “threw stuff.” The SP left the room and closed the door. The SP returned after the VA calmed down and gave the VA a shower. The SP denied hitting the VA and said s/he worked with the VA for years and “knew” the VA’s behaviors. · Two days later, P1 called P2 and said s/he wanted to “report” the incident. P2 questioned how P1 could have seen into the VA’s bedroom. P1 said s/he went to the VA’s doorway. P2 told P1 they could both get in trouble for reporting the incident “late.” · Three to four days later, P1 approached P2 and said that P2’s behavior regarding the incident was discrimination because if the SP was of the same ethnic background as P1, P2 would have fired the SP. P2 got “nervous” about the mention of discrimination and told P1 that P2 had to report the incident. · On February 12, 2026, P2 told a supervisory staff person (P3) about the alleged incident. P2 told P3 s/he had not reported the incident because s/he “wasn’t certain” and had checked the VA’s body and did not see any “bruises or anything” and “it’s not possible for [P1] to see in the room from where [P1] was.” · P2 said s/he should not have waited and should have reported the incident to P3 when P1 told him/her about it on February 2, 2026. The G provided the following information: · On February 12, 2026, the G received an email from P2 that there was a report of abuse toward the VA that occurred on January 30, 2026. The VA was “checked” and no bruises were found. · The VA had limited verbal abilities and communicated mostly through body language, making it hard to communicate with him/her. · The G was “surprised” by the allegations and did not have any other similar concerns with the facility. The SP provided the following information: · On an unknown date, the SP assisted the VA with a shower. Once back in the VA’s room, the VA picked out a lightweight shirt to wear. The SP told the VA to pick out a thicker shirt due to the weather. The VA got upset, yelled at the SP to “go home,” and threw the shirt on the floor. The SP bent over to pick the shirt up and the VA told the SP to “go home.” The VA started hitting the SP and the SP blocked the VA’s hands with his/her hands and by “turning.” The VA hit the SP twice and the SP’s glasses got knocked to the floor. · P1 was also working at the time of the incident. P1 did not go to check what was happening and did not speak to the SP about the incident. · The SP left the VA’s bedroom and the VA calmed down. The SP told the staff person that relieved him/her that the VA needed to get dressed and the SP left at the end of the shift. · The SP denied hitting the VA and believed a staff person may have made those allegations to get the SP’s scheduled hours. · The SP worked with the VA since the VA moved to the facility and knew the VA “very well” and was familiar with the VA’s behaviors. The VA’s Behavior Worksheets indicated that on January 31, 2026, and February 1, 2026, the VA exhibited physical aggression throughout the day from 8 a.m. to 10 p.m. The VA’s shift notes written by the SP for January 30, 2026, 10 p.m. to January 31, 2026, 8 a.m. stated, “No concerns observed during this shift.” The facility’s Internal Review said that P2’s phone log from January 31, 2026, to February 7, 2026, was reviewed which showed “multiple calls” from P1, including some on January 31, 2026, around 11 a.m. P2 said the allegation “wasn’t communicated to [him/her]” during that phone call. Due to the amount of time that had passed from when the incident allegedly occurred to when it was reported, the VA was not interviewed and the VA “would not recall details” after that amount of time had passed. P1 said s/he did not give P2 details of the incident when it was reported on January 31, 2026, and only reported that the SP “beat” the VA and the VA cried for an hour. The SP, P1, P2, and P3 were trained on the Reporting of Maltreatment of Vulnerable Adults Act. The SP and P1 did not sign off or acknowledge training on the VA’s updated plans. Conclusion: Information showed that on January 30, 2026, the SP and P1 worked the overnight shift from 10 p.m. to 8 a.m. on January 31, 2026. On January 31, 2026, around 7 a.m., the SP assisted the VA while getting dressed. The VA got upset and started hitting and throwing things at the SP. P1 heard a scream from the VA’s bedroom and went to the VA’s doorway to see what was happening. P1 stated s/he saw the SP hit the VA on the neck and head with a closed fist and open-handed slap while the VA was seated in his/her wheelchair. The VA was crying and “fighting back.” The SP’s glasses were knocked off his/her face during the incident. P1 did not check the VA for injuries. P1 asked the SP why s/he “did that” and the SP said the VA “hit [the SP] first.” The SP said the VA got upset over being told s/he needed to wear a thicker shirt and started hitting the SP. The SP “blocked” the VA’s arms when s/he tried to hit the SP. The SP was hit two times, which resulted in his/her glasses falling to the floor. The SP left the bedroom and gave the VA time to calm down. The SP denied hitting or punching the VA. P2 said that on February 2, 2026, P1 said that on January 31, 2026, s/he saw the SP hit the VA. P2 went to the facility to check on the VA. P2 did not see any bruises and the VA was “fine.” Although P1 said the SP hit and/or slapped the VA, given that the SP denied hitting the VA; that the SP blocked hits from the VA and may have made physical contact with the VA while blocking the hits; that P1 was new to the facility and had not been trained on the VA’s plans and therefore was not familiar with the VA’s behaviors and techniques to deal with the VA’s physical behaviors; that the VA was not able to provide details of the incident but said s/he felt safe at the facility and that no one had hit or hurt him/her; that the VA was not injured; and that there was no further information to corroborate or refute P1’s or the SP’s account of the incident, there was not a preponderance of the evidence whether the SP hit and or slapped the VA or whether the SP’s actions were not accidental and could cause pain or injury to 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 completed an internal review and determined policies and procedures were adequate, but the VA’s support plan/addendum was not followed. The SP and P1 no longer worked at the facility. P2 received corrective action and retraining regarding timely maltreatment reporting. Action Taken by Department of Human Services, Office of Inspector General: On April 13, 2026, the facility was issued a Correction Order for failure to report alleged maltreatment within 24 hours and for not having documentation that a staff person was trained on the VA’s updated plans.
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