|
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: 1120974-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that in response to a vulnerable adult (VA) engaging in property destruction, a staff person (SP) threatened to place the VA in a hold, pushed the VA onto the couch and grabbed the VA’s arm which caused bruising to the VA and a possible sprained wrist. Date of Incident(s): February 19, 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 16, 2026; from documentation at the facility, medical records; and through six interviews conducted with the VA, the VA’s guardian (G), the VA’s case manager (CM), two supervisory staff persons (P1 and P2), and the SP. Attempts were made through telephone and certified mail to interview a facility staff person (P3), however, P3 did not respond to those requests. The VA was diagnosed with mild intellectual disability, attention deficit hyperactivity disorder, Tourette syndrome, Noonan syndrome, and major depressive disorder. The VA enjoyed playing video games, spending time with family and friends, going on community outings, and attending church. The VA required 1:1 staffing during awake and overnight hours and had four hours of unsupervised time in the community. The facility’s Handle with Care (HWC) policy said that manual restraint was only permitted when an individual posed an imminent risk of physical harm to self or others, and less restrictive interventions failed. If a manual restraint was used, it was the “least restrictive method possible” and used for the “shortest time necessary.” The facility’s Emergency use of Manual Restraint policy (EUMR) said that the facility allowed certain manual restraints which staff persons could use on an “emergency basis” which included, physical escort/walking: stage one and two, arm restraint/one staff person standing: one arm and two arm, and arm restraint/one staff persons sitting: one arm and two arm. If using an arm restraint, staff persons directed one arm of the person served “forward to cross in front of the person’s body by applying slight pressure above or below their elbow.” Staff persons then “lightly gripped” the persons crossed arm, slightly above the wrist, holding the arm in a crossed position. Staff persons then slid their free arm between the persons arm and waist, to “grip” the persons forearm, with palms facing down. The VA’s Self-Management Assessment said that the VA had a history of physical and verbal aggression towards staff persons and peers, property destruction, self-harm behaviors, and leaving the facility without supervision. The VA used coping skills to problem solve without being aggressive, however, “acted without thinking” when dysregulated. The VA had difficulty upholding others personal space and boundaries and did not always provide accurate information in an attempt to get staff persons in trouble. The VA’s Support Plan Addendum (SPA) said staff persons assisted the VA with scheduling and attending preventive appointments, providing transportation, and establishing clear and consistent boundaries. The VA had a history of cutting him/herself and hitting/kicking staff persons. Staff persons followed all safety protocols to ensure the safety of the VA and staff persons. The VA often yelled, swore, and used derogatory language towards staff persons. Staff persons were to “disengage” from interactions with the VA by walking away, not making eye contact, and monitoring the VA’s body language. Staff persons could intervene when the VA returned to baseline but were trained to follow HWC techniques if a situation became unsafe. Staff persons were to be “vigilant” when they worked and be “as detailed as possible” with documentation due to the VA having a history of “extending the truth.” Staff persons were not permitted to physically intervene and/or restrain the VA but were permitted to block and/or redirect the VA’s limbs for less than sixty seconds and were allowed to withhold and/or remove objects the VA used in an unsafe manner. The VA’s Positive Support Transition Plan said that when the VA displayed threatening behaviors, such as physical aggression towards staff persons or property, staff person called 9-1-1 and documented the incident appropriately. If the VA expressed thoughts of harm towards him/herself, staff persons called crisis intervention services and documented as appropriate. The facility previously attempted EUMR in response to the VA’s behaviors, however, the VA was “strong” and “able to overpower” a majority of staff persons. The VA “believed” s/he was “justified” in defending him/herself if s/he was touched, and “will fight.” The VA had increased behaviors after a staff person shift change, if the staff person was a different race/ethnicity than the VA and in environments where there were multiple people, or staff persons were “larger” than the VA. When escalated, the VA engaged in posturing, and positioning himself in a way to intimidate others, slammed his/her hands/elbows on tables and counters, punched and kicked surfaces, threw furniture, and grabbed staff persons and attempted to throw them out of the room/facility. The VA “often succeeded” in breaking objects with his/her fist and/or head. The VA said that on an unknown date, the SP “grabbed” the VA, “twisted and pulled” the VA’s arm, and pushed the VA on the couch. When the SP twisted the VA’s arm, the VA heard a “pop” and the VA said “fuck, ouch” but the SP did not care so the VA tried to punch the SP for “self-defense.” The VA had two bruises and went to the doctor and did not want the SP to work at the facility again. The VA did not provide additional information related to the incident. Video of the incident was not time stamped but had audio and provided the following information: · P3 sat at the dining room table and the VA said, “I’m going to start breaking something, starting with this chair.” The VA then walked into the dining room, picked up a dining room chair, held it over his/her head, and threw it on the ground. The chair broke when it hit the floor, and the VA attempted to pick the chair up again, but the SP walked into the living room, pushed the VA in the back with one hand, picked up the chair and told the VA s/he was “not breaking things.” The VA then pushed the SP with two hands and the SP held out one hand to “block” the VA. The VA pushed the SP again and the SP told the VA s/he would “put [the VA] in a hold right now.” · The VA walked to the right of the SP towards another chair, and the SP blocked the VA with one hand. The VA then sat on the couch but stood up immediately and pushed the SP with two hands. The SP continued to block the SP with one outstretched arm, while the VA pushed the SP. · The VA then kicked a piece of the broken chair, picked up a fireplace grate and threw it across the room two times, attempted to pull a cabinet off the wall and walked into the kitchen. The VA forcibly pulled on the refrigerator door handles four times and the SP stepped between the VA and the refrigerator and directed the VA away. The VA then hit the SP and the SP used both hands to block the hit. The VA said, “Don’t touch me,” and the SP told the VA “One more touch and [I] will put [you] in a hold.” · The VA walked back to the living room, picked up an item from the shelf and threw it at the wall. The VA then picked up two end tables and threw each onto the floor. The SP stood away from the VA with his/her hands in his/her pockets. The VA then sat on the couch and the SP picked up items the VA threw and handed them to P3. · While the SP and P3 picked up, the VA stood up, picked up an office chair and threw it. When the VA threw the chair, it hit the SP. The SP picked up the chair and the VA moved towards the SP. The SP extended his/her arm towards the VA and the VA said, “Don’t push me,” and “lunged” towards the SP. The SP then walked away with the desk chair and told the VA “One more touch and [I’ll] put [you] in a hold.” The VA moved towards the SP, pointed in the SP’s face and yelled “Don’t touch [me]. [I’ll] punch your lights out,” while doing a punching motion, eight times, with his/her right arm, very near to the SP’s face. When the VA did this, the VA told the SP s/he would “punch [the SP’s] lights out” and called the SP “bitch ass [N word]” and “fucking [N word]” repeatedly. The SP told the VA not to do that, and the VA again made a fist with his right hand and made a punching motion towards the SP’s face. The SP stood with his/her hands in his/her pockets when the VA did this. · The VA then attempted to pull the same cabinet off the wall, walked into the kitchen, made a fist with his/her right hand, and “slammed” his/her hand on the glass stovetop four times in a row. The SP placed him/herself between the VA and the stove and pushed the VA with one hand, away from the stove. The VA then yelled at the SP multiple times “[the SP] hit me.” P3 responded and said, “[The SP] did not hit you.” The VA attempted to hit the SP, and the SP then maneuvered the VA in front of the SP, held the VA’s arms at the wrists and directed the VA to the living room. When they got to the living room, the SP pushed the VA onto the couch. The VA immediately got up and punched the SP in the chest twice, and the SP pushed the VA back onto the couch. The VA then kicked his legs repeatedly at the SP, and both the SP and P3 attempted to grab the VA’s legs and told the VA to stop. The SP then backed away, and the VA stood up, punched the SP and repeatedly called the SP racial slurs. · The VA remained on the couch, and was seen holding his/her right wrist, moving the wrist in circles. The VA did not initially complain of pain, but later said the SP “sprained” the VA’s wrist and that the VA’s wrist hurt. The VA then told the SP that the VA could break whatever s/he wanted, and the SP could not stop the VA unless the VA hurt him/herself. P1 and P2 provided the following consistent information: · On February 19, 2026, at 7:43 p.m., the VA texted P1 and asked P1 to tell the SP and P3 to turn off the lights in the VA’s bedroom. P1 did not respond to the VA’s text messages and/or calls outside of business hours because P1 got “continual” phone calls and text messages from the VA. P1 thought the VA asking the SP and P3 to turn off the VA’s bedroom lights was like the VA “asking where the bread was” because the VA’s bed was right next to the light switch, and the VA could have turned the light off with his/her foot. · At an unknown date, time, the SP texted P2 and said the VA was “escalating” because the SP told the VA “no” and that the VA was “breaking items” and “getting in staff persons faces.” The SP asked P2 to view the cameras in the facility regarding the VA’s behavior. When the SP text P2, P2 noticed s/he had “fifteen or sixteen” missed calls from the VA, as well as multiple text messages. Staff persons did not respond to the VA’s calls and text messages after hours, because s/he regularly attempted to contact staff persons for non-emergent situations. The VA’s text message asked P2 to call the SP and tell the SP to turn off the light in the VA’s bedroom, and that the VA was “going to break stuff” if the SP did not do so. · On February 20, 2026, at an unknown time, P1 and P2 reviewed video footage of the incident and saw that the SP had his/her hands on the VA’s wrists while the SP directed the VA out of the kitchen, and that the VA “fought” the redirection. The SP “shoved” the VA, and the VA “ended up on the couch on [his/her] back.” The VA and the SP “pushed and shoved each other” and P2 saw the VA hold his/her wrist in the video. · The SP told P2 s/he put his/her hands on the VA “for safety reasons” but did not provide additional information. The VA told P2 that if the SP “would have kept on” the VA would have “stomped [the SP’s] ass.” When P2 spoke with the VA, the VA showed P2 two bruises on the top of the VA’s right wrist. The bruises were oval, and the VA said it was from the SP. The VA complained of pain in his/her arm and asked to go to the emergency department, so P2 brought the VA for an x-ray, and the VA’s wrist was not broken or fractured. · P2 believed the SP put his/her hands on the VA as a “safety precaution” because the VA previously broke the stove top and attempted to cut him/herself with a piece of the glass, however, thought the SP “went overboard.” · Staff persons were trained on how to complete appropriate physical holds, however they “never” went “hands on” because the VA was very strong and could hurt him/herself or a staff person if s/he became physical, and the VA believed that s/he could “defend” him/herself however s/he felt necessary if staff persons used hands on. Staff persons were trained to verbally redirect the VA as much as they could, call 9-1-1 if unable to calm the VA, and/or remove themselves from the situation. · P2 did not have previous concern with the SP’s care of the VA and thought the SP did well “talking [the VA] down” from situations where the VA became escalated. The SP provided the following information: · On February 19, 2026, the SP and P3 worked at the facility from 3-11 p.m. Between 8-9 p.m., the VA requested his/her medication. The SP brought the medication to the VA’s bedroom, but the VA refused and said s/he would “take it when [s/he] was ready.” An unknown amount of time later, the SP went back to the VA’s room and gave the VA his/her medication, which the VA took and then “slammed” his/her bedroom door. · The VA then “called” the SP to the VA’s bedroom and told the SP to turn off the VA’s light. The SP told the VA that s/he could turn the light off by him/herself because the VA was “working towards independence.” The VA again told the SP to turn the light off and the SP told the VA “No.” and that the VA had been “very disrespectful” to staff persons and the SP would not do that for the VA. The VA then called the SP “more names” and the SP walked away from the VA. · The SP heard the VA call the G and P2 to “report” the SP for not turning off the light. The G told the SP that s/he could turn the light off on his/her own and thought P2 told the VA the same. P2 then called the SP and asked the SP why s/he would not turn off the light. The SP told P2 that the VA called staff persons names “all day long” and that the SP was “walking away” from the situation and the VA could turn off his/her light today. P2 said “Okay.” and that s/he would tell the VA to turn off his/her light. · The VA was upset that s/he did not get a response from P2 and left his/her bedroom. The SP followed the VA into the living room and told him/her “We aren’t going to break things today.” The VA then picked up chairs and hit them on the wood floor. The SP grabbed one chair and gave it to P3 to put into the office. The VA then moved into the kitchen and “pulled” on the refrigerator and the SP “tried to move” the VA away. The VA then walked to the stove and “banged” his/her hand “very, very hard.” The SP moved the VA out of the kitchen to the living room because the SP did not want the VA to break the stovetop. When the SP moved the VA, the SP “stood behind” the VA, but did not remember exactly how s/he moved the VA. · The SP knew the VA previously broke the stove top and wanted to ensure the VA was “safe and healthy” by not allowing that to happen again. The SP thought that if the VA continued, the VA would hurt him/herself, and the SP thought s/he acted in “good faith” with “no malice” behind his/her actions. The SP “thought” s/he “might have” grabbed the VA’s wrist when s/he moved the VA because the VA was “throwing hands.” The day after the incident, the VA said his/her hand hurt from hitting it on the stove and the SP “moving” the VA. P2 brought the VA to the hospital for a scan, and there was no fracture. · Staff persons were trained on the use of manual restraints as well as HWC. If the VA tried to be “hands on” with staff persons, staff persons “dodged” the VA and “verbally” calmed the VA. If the VA did not calm, staff persons were trained to contact law enforcement. Medical Records showed that on February 20, 2026, the VA was brought to the emergency department for complaint of “extremity pain” after a staff person “bear hugged” the VA in an attempt to move the VA from hitting the glass stove top. The VA said s/he had right forearm, hand, and wrist pain and that it was worse with use and movement. The VA had “minimal bruising along the volar aspect of the right hand, 3rd and 4th metacarpals” and the VA’s wrist was “without tenderness” with palpation. The VA had an x-ray of his/her wrist and forearm which was negative for fracture and/or dislocation. The VA was discharged back to the facility and advised to return with any discoloration, weakness, temperature change, numbness, tingling, or severe pain in the extremity. The facility’s personnel files showed that P1-P3 and the SP were trained on all facility policies and procedures, the VA’s plans, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes Chapter 245D.04, subdivision 3, stated that a person’s protection-related rights included the right to be treated with courtesy and respect. Minnesota Rules, part 9544.0060, subpart 2, item x, stated that actions or procedures prohibited from being used as a substitute for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience, including manual restraint, except in an emergency in accordance with Minnesota Statutes, section 245D.061 Conclusion: The VA’s plans showed that the VA had a history of physical aggression towards staff persons and that staff persons were not permitted to engage in physical intervention with the VA but could block and/or redirect the VA’s limbs for less than sixty seconds and were allowed to withhold and/or remove objects the VA used in an unsafe manner.
Information including a video was consistent that on February 19, 2026, the VA became escalated at the facility and destroyed property. Although there did not seem to be an imminent risk of injury to the VA or the SP, the SP pushed the VA several times and placed the VA in a physical hold by holding the VA’s wrists while guiding the VA out of the area which was inconsistent with facility policies, the standards of a professional caregiver in a facility licensed by the Department of Human Services, and a violation of Minnesota Statutes Chapter 245D.04, subdivision 3 and Minnesota Rules, part 9544.0060, subpart 2, item x. The VA sustained bruising to his/her wrist during the incident. The SP said s/he implemented the restraint because the SP thought the VA would hurt him/herself and said that the SP “might” have grabbed the VA’s wrists. Although the VA sustained bruising on his/her wrist, the VA was demonstrating physically aggressive behaviors and the SP believed s/he was protecting the VA from injury. Therefore, there was not a preponderance of the evidence whether the VA’s bruising was a result of the SP’s action or caused 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 completed an internal review and determined that policies and procedures were adequate but not followed. The SP was placed on leave pending the outcome of the investigation, and all other staff persons were retrained on the VA’s plans. Action Taken by Department of Human Services, Office of Inspector General: On April 30, 2026, the facility was issued a Correction Order for the violations outlined in this report.
|
