|
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: 1072149-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jamie Randall/Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) poured water on a vulnerable adult (VA) and banged pots and pans together to wake him/her up from sleeping. Date of Incident(s): October 4, 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 subdivision 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): 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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 19, 2025; from documentation at the facility; and through seven interviews conducted with the VA, the VA’s case manager (CM), facility staff persons (the SP, P1, P2, and P3), and a supervisory staff person (P4). Attempts by telephone and mail were made to interview the VA’s guardian (G), but s/he did not respond by the completion of this investigation. The VA’s support plans, including Individual Abuse Prevention Plan, provided the following information: · The VA enjoyed being social, doing puzzles, and baking and cooking. · In early 2025, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included intellectual disabilities and borderline personality disorder. · The facility provided at least one staff person 24 hours a day to help the VA stay safe by minimizing his/her harmful behaviors (e.g., aggression towards others and self-injurious behaviors). Staff were to monitor the VA’s behaviors and mental health and provide redirection and support as needed. Staff were to intervene in potentially harmful situations and report concerns on the VA’s behalf. · The VA was sometimes “triggered” when s/he believed others were not listening to him/her; and when this occurred, the VA might isolate or decline to talk. Staff were to listen and talk to the VA and encourage the VA’s coping skills, which included playing with his/her animals and coloring. · On a typical day, the VA preferred to wake up around 8 a.m. and go to bed around 9 p.m. On October 9, 2025, P4 emailed the following to the G and the CM: Hey everyone, just an update on [the VA] … The other day (unspecified date/time), [the VA] was asleep in [his/her] room and not answering when staff was checking on [him/her]. They said [s/he] was breathing but not saying anything. (which [s/he] does) they poured cold water on [him/her], and were banging pots trying to wake [him/her] up, [s/he] wasn’t waking up. So, they called 9-1-1 to be safe. [S/he] got up when [the paramedics arrived] and told everyone to get the [fuck] out of [her/her] room. According to [the VA] [s/he] was awake and ignoring [staff]. [The VA] stated that [P1] should have known [the VA] didn’t want to be bothered … [The VA] refused to be checked by [paramedics]. The VA said that on the day of the incident, s/he was “passed out … sleeping” when the SP and P1 were trying to wake him/her up. The SP and P1 yelled (unspecified) at the VA to try to wake him/her up and pushed the VA’s bed. The SP and/or P1 also “sprinkled water” on the VA’s head for about ten seconds. The VA was “half asleep” when this happened but said that his/her pillow was wet when s/he woke up and that the wet spot was “a little bigger” than the VA’s head. The VA did not remember anyone banging anything (making noise) to wake him/her up. The VA said that s/he was moving his/her body around, which should have signaled to the SP and P1 that the VA was okay and to leave him/her alone, but they did not stop and continued to try to wake the VA up. The VA did not say anything to the SP and P1, including any statements that s/he was awake or okay but wanted to be left alone. The SP and/or P1 called 9-1-1 and when the paramedics arrived, the VA was awake and told everyone that s/he was “fine.” The CM said that the VA might “shutdown” and “ignore” staff but that pouring water on the VA and banging pots and pans to wake the VA up was “not appropriate.” The VA did not have a history of intentionally providing inaccurate information when recalling events, but the VA’s accuracy might be dependent on the situation. The SP, P1-P4, and P4’s cellphone text screenshots provided the following information: · The SP said that one day (October 4, 2025), it was about 10 or 11 a.m. and the VA was still in bed sleeping. The SP and P1 repeatedly tried waking the VA up, but s/he was not responding or opening his/her eyes. The VA was breathing and had a pulse. · P1 said that they tried to wake the VA up for about 45 minutes to an hour without success. The SP placed a washcloth soaked in “cool water” on the VA’s forehead and banged on a wall or a window frame, but the VA did not open his/her eyes or respond and so P1 called 9-1-1. P1 did not see the SP banging pots and pans together. P1 did not have concerns with the incident and believed that his/her and the SP’s actions to wake the VA up were consistent with their training. P1 said that the VA was a “deep sleeper.” · The SP said that during the incident, s/he was talking to the VA as though the VA could hear him/her. The SP told the VA that if s/he did not open his/her eyes, the SP would pour water on the VA. The VA did not respond to this and so the SP “sprinkled water” on the VA’s face and neck. “It was just a little bit” or “droplets” and it was done “very gently.” The SP dipped his/her fingers into a cup of “warm water” and then dripped the water off his/her fingertips onto the VA. The SP then immediately wiped the water off the VA. Next, the SP tried rubbing the VA’s arms and legs to get them to move; however, the VA still did not respond. The SP told the VA that s/he was going to “get pots and pans” and when the VA did not open his/her eyes, the SP got pots and pans and stood in the VA’s doorway and “put them together to make some noise.” The SP said that s/he and P1 tried to wake the VA up for about 20 minutes without success, at which point, P1 called 9-1-1. When the paramedics arrived, the VA immediately woke up and told them all to “get the fuck out” of his/her bedroom. The SP did not know how long the VA had been in his/her bed prior to staff trying to wake him/her. · The SP said that s/he never saw other staff “sprinkle water” on a client’s face to wake them up, but it was something the SP “thought of in the moment.” The SP’s actions to wake the VA were not intended to hurt him/her but rather an attempt to ensure the VA was “alive.” The SP had never sprinkled water on a client before or banged pots and pans before; this was the sole time. · P4 provided screenshots of a text exchange s/he had with P1 on October 4, 2025, starting at 1:35 p.m., regarding the VA not waking up. P4 told P1 that the VA typically stayed in bed and did not respond to staff when s/he was feeling “overwhelmed.” P1 said that the SP “[dumped] freezing water” on the VA and shook and rubbed the VA to no avail. P1 said that they were calling 9-1-1 because “pots and pans aren’t even waking [him/her].” P4 responded, “Keep me posted.” · P2 and P3 were not working at the time of the incident and did not provide additional information. The facility’s policies and procedures stated that if a client experienced a medical emergency, unexpected serious illness, or significant unexpected change in an illness or medical condition, staff were to assess if the person required 9-1-1, physician treatment, and/or hospitalization. Staff must respond to all incidents that occur in a timely and effective manner to protect the client’s health and safety and minimize the risk of harm. Facility documentation stated that the SP and P1-P4 received training on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act and that the SP and P2-P4 received training on the VA’s support plans. The failure to document P1’s training on the VA’s support plans 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 orientation and training. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.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. Minnesota Statutes section 245D.06, subdivision 1, states, in part, the license holder must respond to incidents under section 245D.02, subdivision 11, that occur while providing services to protect the health and safety of and minimize risk of harm to the person. Conclusion: Regarding emotional abuse: The conduct of pouring water on the VA’s head and banging pots and pans nearby to wake the VA up 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). However, given that the VA said that s/he was “fine” immediately afterwards and did not react in the moment or appear aware of anyone banging pots and pans together, and that it was a single incident that had not occurred prior, there was not a preponderance of the evidence whether the conduct produced or could reasonably be expected to produce emotional distress for the VA and which included treatment that was not an accident or therapeutic and would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. It was not determined whether 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). Regarding neglect: The SP and P1 each said that the VA was not responding to their attempts to wake him/her up for between 20 to 60 minutes before P1 called 9-1-1. Although the VA was unharmed, the delay in responding in a timely and effective manner to protect the VA’s health and safety and to minimize the risk of harm was inconsistent with the facility’s policies and procedures and a violation of Minnesota Statutes section 245D.06, subdivision 1. However, although the SP’s actions of pouring water on the VA and banging pots and pans likely escalated the situation, given that there was no information the SP’s actions were intended to cause, or caused, harm to the VA; that the conduct was something the SP “thought of in the moment” and had not done previously; and that the VA did not require medical attention and said that s/he was “fine” immediately afterwards, there was not a preponderance of the evidence whether the SP’s and P1’s delay in calling 9-1-1 were a failure to supply the VA with care or services, which is reasonable and necessary for the VA’s physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: Facility documentation stated that policies and procedures were adequate but not followed. Staff must only use permitted procedures, which “Do not include putting a wet cloth on [the VA] or making noise unless specifically indicated as a permitted procedure in [the VA’s] support plan.” The facility provided additional training for staff on the use of permitted procedures and the expected response to medical emergencies. 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.
|
