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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: 1116641-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a staff person (SP) called a vulnerable adult (VA1) derogatory names, included retarded (referred to as the “r-word” throughout the remainder of this report). Date of Incident(s): Unknown 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 2, paragraph (b), clause (2): 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: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 17, 2026; from documentation at the facility and law enforcement records; and through ten interviews conducted with two supervisory staff persons (P1 and P2), two facility staff persons (P3 and the SP), VA1, VA2, VA1’s and VA2’s respective case managers (CM1 and CM2), VA1’s and VA2’s respective guardians (G1 and G2). Attempts were made by law enforcement and this investigator via telephone to contact and interview another staff person (P5) but P5 did not respond. The initial allegation included concerns that the SP called VA2 derogatory names. There was no information provided in documentation or interviews to corroborate this information so it will not be included in this report. VA1 and VA2 each lived in their own separate facility on the same property as P1’s office and each had 1:1 staffing. P1, who worked with VA1 for over 20 years, was on vacation during the time of the incidents and P2 was filling in. VA1 was diagnosed with a pervasive developmental disorder and a mild developmental disability. According to VA1’s plans, if VA1 became “upset or “frustrated” it was “important” use a “calm tone” when talking to VA1. Interventions staff persons used when VA1 was escalated included identifying “concrete things” to do, problem solving with VA1 and improve his/her situation; monitoring VA1 for an increase in agitation; and moving VA1 to a less stimulating environment. Staff persons were to avoid power struggles, confrontation, and pressured interventions. Staff persons gave VA1 space and let VA1 know they were available to listen to his/her concerns. VA1’s Individual Abuse Prevention Plan stated that VA1 may not “comprehend” emotional or verbal abuse and may not be able to defend him/herself. At times, VA1 verbally provoked other persons by being verbally aggressive. Staff persons “immediately” intervened to ensure VA1’s safety and the safety of other persons. VA1 had “psychiatric symptoms” that possibly interfered with his/her ability to relay an incident “truthfully.” VA1 made statements about seeing and hearing things that other persons did not. Any accusations or incidents were reported according to facility policy. VA1 stated that on an unknown date, at approximately 3 p.m., s/he was in his/her bedroom and walked out to the living room. The SP was making dinner and VA1 told the SP that s/he did not eat dinner until 5 p.m. The SP “argue[d]” with VA1 and called VA1 the “[r-word].” VA1 was “very upset” because previously a family member called VA1 that name and it was painful. VA1 notified P3 who gave VA1 medication to calm. VA1 did not have previous concerns with the SP prior to the incident. P1-P3 provided the following information: · On an unknown date, VA1 told P3 that the SP was confrontational with VA1 inside VA1’s bedroom and called VA1 the “[r-word].” The SP then left and VA1 shut his/her bedroom door and locked it. P3 filled out an incident report and notified P2. P2 then spoke to VA1 who provided information that was consistent with the information the VA told this investigator. · On March 2, 2026, P1 returned to work at the facility and P2 told P1 about the incident. P1 then spoke to VA1 about the incident. VA1 said that during the incident, the SP came into VA1’s bedroom, and when VA1 asked the SP to leave his/her bedroom, the SP refused and then called VA1 the “[r-word].” VA1 was “mad” and told P3 about the incident. On March 4, 2026, P1 spoke to the SP who denied calling VA1 inappropriate names. · P1 did not know the SP “that well” but prior to this incident, the SP had been in “power struggles” with other staff persons and clients. P3 worked with the SP in the past and had concerns about his/her interactions with VA1 including one previous occasion, VA1 told the SP how to cook his/her dinner and the SP told VA1 to “go to your room.” P3 was trained to suggest activities instead of telling clients what to do. · P1 stated that VA1 had a history of providing inaccurate information but was generally honest with P1 and refused to say s/he was dishonest about the above incident s. P2 stated when s/he discussed the allegations with VA1, s/he seemed “genuine” and VA1 did not exaggerate so P2 believed VA1. P3 stated s/he believed VA1 about the allegations. The SP provided the following information: · On February 19, 2026, at approximately 3 p.m., the SP began preparing dinner. VA1 started “screaming” at and calling the SP names so the SP put away the food and asked if VA1 wanted to do an activity. The SP then went to VA2’s facility and told P5 that VA1 was yelling and angry with the SP. P5 came and talked to VA1 and gave VA1 medication to calm and then left. · VA1 stayed in his/her bedroom the rest of the night except on one occasion when s/he walked to the bathroom and called the SP names. The SP did not engage with VA1 and continued logging notes on the computer. The SP denied calling VA1 any names, including the “[r-word].” The SP said it was possible VA1 “made up” the allegations so VA1 would not get in trouble for a previous incident that occurred between the SP and VA1 on February 14, 2026, where VA1 inappropriately grabbed the SP in a sexual manner. · On February 21, 2026, VA1 called the SP who was at VA2’s facility. VA1 asked the SP if s/he would come back and work with VA1. The SP told VA1 that s/he needed to see an improvement in his/her behavior before returning to work with VA1. G1 stated that VA1 was not always reliable with information especially if s/he did not like a particular staff person. G1 did not have any concerns with the facility. CM1 stated that VA1 was accurate about incidents but possibly “exaggerate[d]” timing and details. Facility documentation showed that all staff persons interviewed for the investigation, including the SP, were trained on VA1’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes:
Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), stated that a client’s protection-related right included being treated with courtesy and respect. Conclusion: A. Maltreatment: VA1 provided consistent information to this investigator and P1-P3 that on an unknown date, the SP called VA1 the “[r-word].” Although the SP denied calling VA1 the “[r-word],” for the following reasons it was more likely than not that the SP did so as described by VA1: · VA1 provided consistent information on different dates to P1, P2, P3, and this investigator. · P2 and P3 believed what VA1 said about the incident. P1 said that although VA1 had a history of providing inaccurate information, VA1 was generally honest with P1 and VA1 refused to say s/he was dishonest about the incident. · P1 and P3 had previous concerns with the SP’s interactions with other clients and staff persons. · The SP had reason to minimize his/her actions for fear of repercussions. The SP calling VA1 the “[r-word]” was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). The nature of the “[r-word]” is generally considered to be derogatory and was particularly egregious given the VA’s diagnoses of developmental disability. Therefore, there was a preponderance of the evidence that the SP’s single use of calling the VA the “[r-word]” could produce or reasonably be expected to produce emotional distress. It was determined that emotional 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: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). 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. The SP was trained on VA1’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for maltreatment of VA1. 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 emotional abuse for which the SP was responsible did not meet the definition of serious and it was not determined to be recurring maltreatment because it was a single statement by the SP. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP was suspended pending the internal investigation and if s/he returned to the facility s/he would required to be retrained on vulnerable adult maltreatment. 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. On April 21, 2026, the facility was issued a Correction Order for the violation outlined in this report.
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