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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: 1090299-H_CRS (Home and Community-Based Services-Community Residential Setting) 1072349-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon thomas.c.nixon@state.mn.us 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was slapped and hit by a staff person (SP) which was heard by another staff person (P1). Date of Incident(s): May 18, 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 July 6, 2025; from documentation and video at the facility and law enforcement (LE) records; and through nine interviews conducted with five staff persons (P2-P5 and the SP), two supervisory staff persons (P6 and P7), the VA’s guardian (G), and the VA’s case manager (CM). Attempts were made via phone, text, email, and mail to contact and interview an administrative staff person (P1), but P1 did not respond to requests. P1 provided information to LE and that information is included below. The VA was diagnosed with autism and his/her communication was very limited. Due to the VA’s disabilities, the VA was not interviewed for the investigation. The VA’s Individual Abuse Prevention Plan and Coordinated Service and Support Plan Addendum each stated the VA engaged in self-injurious behaviors and staff persons were to redirect the VA. Information from P2-P7 and the SP was consistent that the VA engaged in self-injurious behaviors. The VA hit him/herself on the nose, forehead, and/or back of his/her head and on objects, walls, floors, and on staff persons. The VA’s county Support Plan and the facility’s Coordinated Service and Supports Plan Addendum, each stated that the VA was to have awake overnight staff. P6 said there were two staff persons who worked the overnight shift. The VA often got up several times throughout the night and might urinate and/or defecate in his/her bedroom. One staff person helped shower the VA while the other staff person cleaned the bedroom. Information was consistent that on May 17, 2025, the SP and P1 worked the overnight shift and P2-P5 came in the following morning. The facility was a single level home. The VA’s bedroom was across the hall from a bathroom. There was a video camera in the upper corner of the wall that captured video in the hallway but not inside the VA’s bedroom or bathroom. The video did not have audio. P6 and P7 provided the following information: · On May 18, 2025, around 3 p.m., while P6 was outside the facility yet not working, P3 came outside and told P7 that there were “bruises” on the VA’s ears. A “couple minutes” later, P1 came outside and said that around 4 to 5 a.m., the SP woke P1 to help clean the VA’s bedroom. P1 cleaned the VA’s bedroom while the SP and the VA were in the bathroom. P1 heard “slapping noises” from the bathroom that sounded like someone was getting “hit.” P1 said s/he yelled into the bathroom and asked if everything was okay but did not hear a response. When the VA came out of the shower room, s/he was “pretty upset” and “crying.” The SP told the VA to go to his/her bedroom so the VA went back to bed. P1 followed the VA into the bedroom and assisted him/her into bed. The VA was “fine” and went to sleep. · P6 notified a supervisory staff person about the incident and then went inside the facility. P6 saw that the VA had two dark purple bruises on the upper back of his/her ear. P6 did not see any marks on the VA’s neck. P6 told the SP to “go home” for the day and did not discuss the bruises with the SP. Once the SP left the facility, P6 called 9-1-1. (Note: LE records showed LEO arrived to the facility around 4 p.m. examined the VA’s marks and interviewed P1 and P6.) · P7 stated that the marks on the VA were “not similar” to injuries s/he sustained due to his/her self-injurious behaviors. The VA did not grab him/herself around the neck or “typically” leave fingermarks. P6 and P7 were not aware of any self-injurious behaviors with the VA’s ears. · Neither P6 nor P7 had any prior concerns with how the SP interacted with the VA.
P2-P5 provided the following information: · Throughout the morning on May 18, 2025, P2-P5 each saw red marks on both of the VA’s ears that were approximately the size of a nickel. P3 saw the VA also had a “scratch” on his/her face. P3 worked the previous day and did not recall seeing any similar marks on the VA at that time. P2-P5 did not recall and were not aware that the VA ever self-injured his/her ears or that the VA had bruises there prior. · Around 3 p.m., the SP, P1, and P6 arrived at the facility. P1 told P2 that the previous night, the SP was “hitting and being aggressive” with the VA. P1 said s/he heard the VA “crying” and sounds of the VA “getting beaten.” P1 did not contact P2 at the time because s/he “panicked.” P2 asked P1 if s/he was okay, and P1 said s/he “need[ed] to talk to [P6].” When P6 arrived at the facility, P1 “ran outside” to talk with him/her and was “crying.” P3 also went outside to tell P2 about the marks on the VA. P6 then went inside and looked at the marks on the VA. Photos taken on May 18, 2025, showed the VA’s right ear with bruising on the upper curve of the helix to the side that ranged from red to purple and a small scratch mark on the neck near the lobe. On the VA’s left ear there was a similar red and purple mark on lower curve of the helix. P1 provided the following information to LE: · On May 17, 2025, P1 worked an overnight shift with the SP. Around 3:40 a.m., the SP came to P1 “angry” because the VA had a bowel movement in his/her bedroom. P1 cleaned the VA’s bedroom while the SP took the VA into the bathroom to get him/her cleaned. P1 heard the SP’s “slurred speech” that “sounded very angry” with the VA. P1 also heard “slapping and then hitting” noises from the shower room so thought the SP slapped and hit the VA. · When the SP and the VA left the bathroom, the VA appeared “very scared and was crying” and the SP looked “angry.” P1 did not see bruises on the VA prior to the incident with the SP. P1’s Log Notes for the VA stated: · On May 18, 2025, the VA slept until 3 a.m. The SP woke P1 to help clean the VA’s bedroom while the SP assisted the VA with a shower. P1 “heard slapping noises” from the bathroom that sounded like “hitting” sounds. P1 asked if “everything was okay,” but did not get a response. P1 heard more “hitting noises” and again asked if everything was okay. (Note: Video footage did not show P1 approach or speak towards the bathroom door.) · The VA and the SP came out of the bathroom. The VA “was upset” and the SP “yelled” at the VA to go back into his/her bedroom so the VA ran into his/her bedroom. When the VA came out of his/her bedroom, P1 saw “marks on [the VA’s] neck” and the VA’s “ears were bruised.” Video footage from the facility showed the following: · 4:08 a.m., the VA left his/her bedroom with bedding, went into the living room where the SP was on the couch, and placed the bedding on the floor. The SP got off the couch and walked with the VA back into his/her bedroom. The SP left the VA’s bedroom, knocked on the staff room door, and then walked around to the staff bathroom, shower room, and kitchen area. · 4:12 a.m., P1 and the VA walked into the hallway, P1 opened the shower room door, and the VA walked into the shower room. (Note: The camera does show into the shower room and information was consistent that the VA liked to take long showers.) The SP and P1 talk in the hallway, walked in and out of the VA’s bedroom, living room, kitchen, staff bedroom, and a supply closet for what appeared to be gathering cleaning items. During this time, both the SP and P1 each appear to check in on the VA in the shower room. · 4:16 a.m., the SP walked into the shower room with the VA and closed the door. From 4:17 a.m. to 4:33 a.m., P1 spent time in the VA’s bedroom, the hallway, kitchen and bathroom. At 4:22 a.m., from the bathroom doorway, P1 looked towards the shower door twice before s/he walked into the VA’s bedroom. · 4:40 a.m., the SP opened the shower door, walked into the VA’s bedroom where P1 was, returned to the shower room, and closed the door. At 4:43 a.m., the SP opened the shower door, went into the VA’s bedroom where P1 was, and then returned to the shower room and left the door open. At 4:44 a.m., P1 left the VA’s bedroom and walked to the bathroom. P1 did not look toward the shower room where the VA was as s/he crossed the hallway. · (Note: From 4:16 a.m. when the SP walked into the shower room with the VA until 4:44 a.m. when P1 left the VA’s bedroom, at no time was P1 near the shower doorway or appear to speak towards the shower door. The closest P1 got to the shower door was from the VA’s bedroom doorway, which was approximately nine to ten feet away.) · 4:45 a.m., the SP left the shower room and went into the VA’s bedroom. P1 possibly looked towards the open shower doorway as s/he went to the living room and kitchen area. As P1 walked back down the hallway and into the VA’s bedroom, s/he appeared to look toward the open shower doorway. · 4:47 a.m., P1 left the VA’s bedroom and walked towards the shower doorway. Thirty-five minutes after the VA entered the shower room, the VA exited and stood next to P1 in the hallway wearing different clothes. (Note: It was unclear if the VA was crying And P1 did not appear to check the VA for any injuries or marks.) The VA went into the living room followed by P1 and then the SP. The SP placed a hand behind the VA and guided him/her back to his/her bedroom as P1 followed. From 4:48 a.m. to 4:56 a.m., the VA and the SP remain in the VA’s bedroom while P1 walked in and out of the room to grab various items and returning to the VA’s bedroom. · 4:56 a.m., the SP and P1 leave the VA’s bedroom leaving the door open. The SP brought items to the living room and kitchen area. P1 went into the shower room, came out, and looked into the VA’s bedroom before s/he walked into the staff room. At 4:57 a.m. the SP walked in and out of the kitchen area appearing to return items used for cleaning. At 5:06 a.m., video footage ended. The SP stated on May 18, 2025, around 3:40 a.m., s/he was in the living room on the couch when s/he saw that the VA was awake and out of his/her room. The SP “guided” the VA back towards his/her bedroom and at the door smelled feces so the SP knocked on the staff room and told P1 to clean the VA’s bedroom while the SP assisted the VA with a shower. The SP brought the VA to the bathroom and while in the shower the VA hit him/herself on the forehead which was something the VA did during showers. The shower “went well” and there were “no issues.” The VA did not hit him/herself anywhere else. The SP did not see bruises on the VA and denied slapping or hitting the VA. The CM stated at a previous facility, the VA was physically assaulted by another client which caused the VA to become “more aggressive” with others. The VA had a history of “slam[ming]” his/her head on walls but did not hit his/her own ears. The G had no concerns about the facility prior to the incident. Facility documentation showed that P1–P7 and the SP each received training on the Reporting of Maltreatment of Vulnerable Adults Act and on the facility’s policies. Facility documentation showed that the SP, P2, and P5, each received training on the VA’s plans prior to the incident. The facility was not able to produce documentation that P1, P3, P4, P6, and P7 were trained on the VA’s plans prior to the incidents which was a violation of Minnesota Statutes, section 245D.095, subdivision 5 which states in part that the license holder must maintain a personnel record of each employee to document and verify orientation and training. Conclusion: On May 18, 2025, P2-P5 saw injuries on the VA’s ears and neck and P1 said that s/he believed they were the result of the SP slapping and hitting the VA. However, P1 provided the following inconsistent information to law enforcement, P2, and in the VA’s Log Notes: · P1 told others s/he heard hitting and slapping noises come from the bathroom when s/he was in the VA’s bedroom, which was around nine to ten feet away. At this time, the bathroom door closed and water in the shower was running. P1 said that s/he “yelled” into the bathroom to see if everything was okay, but did not get a response. However, the video footage does not show P1 at any time yelling into the bathroom. · P1 documented s/he twice tried to ask if everything was okay while the VA and the SP were in the bathroom but, the video footage showed that at no time did P1 approach the bathroom door or speak towards it. · P1 told LE that the VA returned to his/her bedroom on his/her own which was unusual for the VA. P1 documented that the VA did not go back to his/her room right away and that the SP yelled at the VA to get back and the VA ran to his/her bedroom. However, the video footage showed the VA go into the living room and grabbed an item, then the SP guided the VA back to his/her bedroom. The video did not show that the VA ran back to his/her room. · P1 said s/he did not leave VA alone with the SP after the incident and told the SP to “go.” The video footage showed after the VA showered and was in his/her bedroom with P1 and the SP, P1 left the bedroom several times leaving them alone. The video footage showed that the SP was never in the VA’s bedroom alone with him/her after the incident occurred. Although the VA had bruising on his/her ears and a scratch on his/her neck, given that P1 provided information that conflicted with the video of the night; that the VA had a history of self-injurious behaviors although not on his/her neck and ears; that the SP denied hitting or injuring the VA; and there was no additional information to support or refute either P1’s or the SP’s accounts, there was not a preponderance of the evidence whether the SP hit the VA resulting in injury to the VA or whether the VA sustained the injuries by any means other than accidental. 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 review stated that while the policies and procedures were adequate, they were not followed. On June 1, 2025, the facility held an all-staff persons meeting to review what was and was not allowed for placing hands on the VA. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On April 15, 2026, the facility was issued a Correction Order for the violation outlined in this report.
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