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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: 1072140-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) called a vulnerable adult (VA) and the VA’s family members derogatory names and slammed a door on the VA’s knee resulting in a scrape and bruising. Date of Incident(s): March 22, 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 subdivision 2, paragraph (b), clauses (1) and (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: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · 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 30, 2026; from documentation at the facility and medical records; and through seven interviews conducted with the VA, two supervisory staff persons (P1 and P4), a staff persons (P2), the VA’s case manager (CM), the VA’s guardian (G), and a housemate (HM) of the VA. Attempts were made via telephone, text, email, regular mail and certified mail to contact and interview the SP, but the SP did not respond to the requests. The VA enjoyed being busy and helpful. The VA loved to go shopping and his/her personal appearance was important to him/her. The VA was independent with his/her personal care and liked to dress attractively. Although the VA used drugs/substances in the past, (two decades ago) s/he continued to talk about drugs as if s/he was currently using them. The VA’s diagnoses included traumatic brain injury, bipolar disorder, borderline personality disorder, substance use disorder, and type II diabetes. The Program Abuse Prevention Plan showed that the facility provided services to individuals with mental health and chemical use issues. The facility had two stories and the VA’s bedroom was located upstairs. An office area for staff persons was on the main floor, beyond a kitchen. The VA’s Crisis Prevention and Management Form stated that when the VA experienced symptoms of decompensation, s/he “might say some things that people think are mean,” s/he will demand actions from others, and this was followed with preservation. The VA was “usually able to calm [him/herself] if given time.” It was best for staff persons to remind the VA that they will talk to him/her when s/he was calm and respectful and then “wait for [the VA] to be in that state, even if it takes a while.” It was important for staff persons to “listen and remain calm.” The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA was susceptible to verbal and physical abuse from others. The VA engaged in verbally inappropriate interactions with others placing him/her at risk of abuse from the other person. Staff persons were trained in non-violent de-escalation techniques. An Incident Report Form written by a management person (P4) who was not present during the incident, stated that the VA said that on March 22, 2026, around 6 p.m., the SP called the VA names such as “ho,” “crackhead,” and “ugly.” The SP also made insults about the VA’s family members. The VA’s knee was injured when the SP closed a door on the VA’s knee. A daily log note showed that on March 23, 2026, in the morning, the VA told a staff person (P5), that the SP called the VA and the VA’s family members derogatory names. The VA provided the following information: · The VA said that s/he had a job cleaning at a store, and s/he liked to clean the facility. However, prior to March 22, 2026, the SP wanted the VA to clean “all the time” and put the VA’s dishes aside for the VA to clean. · On March 22, 2026, the SP was working alone because another staff person (P6) did not show up for work. The VA and the HM were the only residents at the facility that day. The VA did not want to clean, and the SP got “mad” at the VA. Around 5 p.m., tension between the VA and SP “escalated” and the SP called the VA a “crackhead,” “nasty ass bitch,” and made derogatory comments about the VA’s teeth and the VA’s family members. (Several of the comments referred to the VA’s history of substance use.) The VA responded by calling the SP a racial slur. The SP yelled these insults from inside the office and when the VA went “after [the SP], [the SP] shut the door” hitting the VA’s knee with the door. The SP told the VA that if the VA was not at the facility, the SP would “kick [the VA’s] ass.” The VA then went outside to calm. When the VA returned inside, the VA continued yelling and swearing at the SP. The VA said, “Do it again bitch!” to the SP who responded by yelling insults and slamming the office door on the VA “four to five times.” The SP told the VA that the VA broke the office door. (The VA showed this investigator that the side jamb on the office door was loose on the side where the door latched as a result of the incident.) · Around 6 or 6:30 p.m., the VA called the CM and the G and left each of them a message regarding the incident. · After the incident, a staff person (P3) from another facility operated by the same license holder arrived and took the VA to a local hospital because the VA did not feel safe at the facility. The VA told the hospital personnel about his/her knee although it “did not hurt” at that time. Later that evening, the VA returned to the facility after s/he knew the SP was gone. The VA said his/her knee started hurting after s/he returned to the facility. P1 was not working at the time of the incident but received phone calls and/or text messages from the VA and the SP that day. Between 6:32 and 6:58 p.m., the SP called P1 four times and left messages stating the VA was “losing [his/her] shit” and was throwing things like food and dishes and was “waving a pair of scissors.” The SP said that s/he needed to “get out” of the facility. Then either the VA or the SP called P3 who was working at another facility and asked P3 to come to the facility. When P3 arrived at the facility, the VA said s/he wanted to go to the hospital so P3 transported the VA to an emergency room but did not remain with the VA due to the VA’s level of independence. The VA was later the VA discharged and P3 returned and transported the VA back to the facility. Prior to the VA returning, P1 asked P5, who was scheduled to work the overnight shift, to come to the facility early so that the SP could leave before the VA returned from the hospital and P5 did so. P1 did not return to work until March 30, 2026, and at that time the VA told P1 about his/her knee. Regarding the VA’s ability to accurately report events, P1 said that the VA “will tell you what [s/he] believes is accurate.” Although in the past the VA made allegations about staff persons’ behavior, P1 was not aware that the VA ever said a staff person physically injured him/her. P2 was not working at the time of the incident and typically worked at the facility once or twice a month. P2 also worked with the VA for seven or eight years when the VA resided at a different residential facility. P2 said that the VA liked to “get people in trouble if [s/he] did not like them.” When asked about the VA’s ability to accurately report events, P2 said that it depended on the VA’s current mental health, the VA could “exaggerate” but was “also honest and knows what is going on.” P2 was not aware of the VA alleging staff persons physically injured the VA prior to the incident. P4 provided the following information during his/her interview and/or in the facility’s internal review: · After the incident P4 spoke to multiple individuals. P1 told P4 that during the incident on March 22, 2026, the SP told P1 over the phone that the VA threw things at the SP, called the SP names, and the SP wanted to leave the facility. The SP said that the VA was angry at the SP about the previous night. A daily note written by the SP showed that the SP worked the previous day, March 21, 2026, from 9 a.m. to 9 p.m. The VA was in his/her room listening to music when the SP arrived. The VA then talked to the SP, took a shower, left the facility at 1:30 p.m., and returned to the facility at 3:30 p.m. The VA made food, washed his/her clothes, watched TV, cleaned up his/her room and relaxed. (Note: There was no note and/or information documented regarding a reason the VA would have been angry at the SP.) · The VA told P4 that the SP called the VA insulting names such as “ho, crackhead and ugly” and made disparaging comments about the VA’s family members. During the incident, the VA’s knee was injured when the SP closed a door on the VA’s knee. P1 did not clarify with the VA what door. · The SP told P4 that the VA was “targeting” the SP, making racial slurs, and struck the SP in his/her side. The SP also told P1 that the VA was throwing things at him/her and called the SP names. (There was no information that the SP was asked about calling the VA derogatory names or slamming the door on the VA.) · P4 said that the VA had the “ability” to accurately report events; however, the VA experienced “delusions and intentionally misleads at times.”
Although the HM was present at time of the incident, due to his/her diagnoses, s/he did not provide any pertinent information regarding the incident. The G said that s/he worked with the VA for approximately two years. The VA told the G that the SP called the VA names such as “bitch, dirty ho, and ugly,” called the VA’s family members derogatory names, and “threatened to beat [the VA’s] ass” if the SP saw the VA in the community. On Monday, March 23, 2026, the VA took pictures of his/her knee and sent them to the G. The VA said that the knee injury occurred on March 22, 2026, when the SP opened the office door, taunted the VA, then slammed the door into the VA’s knee. The G believed the VA’s account of the incident and said the VA was “really good at giving the truth but might be missing pieces.” The G said that the VA remained consistent with the information s/he provided to the G and the facility about the incident. On March 25, 2026, the VA’s knee was still sore, and s/he went to urgent care where s/he was diagnosed with a “contusion” on his/her right knee and a “sprain.” The VA was advised to take Motrin for pain and wear a knee brace. The CM worked with the VA for over 20 years and said the VA “targeted” a staff person no matter where s/he lived or worked. The CM was aware that “for a while” the VA had “issues” with the SP. On March 22, 2026, the VA left the CM “at least six messages” and the CM could hear that the VA’s mental health was decompensating with each message as the day went on. The VA said that s/he and the SP “got into it” verbally and during the last call the VA was crying and said the SP “slammed the door” on the VA. The CM did not believe the VA was always an accurate reporter of events; however, in the VA’s mind, the VA “100% believes what [s/he] says.” The CM believed “something happened” with the SP but “not to the level” of what the VA said happened. The VA’s medical records provided the following information: · On March 22, 2026, around 7:38 p.m., the VA arrived at the emergency department. The VA was “tearful” and reported that a staff person called him/her a “crackhead” and other names. The VA stated that s/he did not feel safe at the facility because of the SP’s name calling. The VA said when s/he “went after” the SP, the SP “slammed a door on [the VA’s] knee.” An abrasion was visible on the VA’s right knee, and s/he rated his/her pain seven out of ten. The VA was discharged at 8:54 p.m. · On March 25, 2026, three days after the incident, the VA was seen at an urgent care clinic regarding a right knee injury. The VA was diagnosed with “right knee sprain-contusion (bruise) of right knee.” Follow up instructions included over-the-counter Motrin as needed for pain, lidocaine patches once daily as needed for pain, and s/he was to wear a knee brace during the day. The VA took photos of his/her right knee March 23, 2026; and sent them to the G on the same day. The photos showed a vertical scratch/abrasion over the top of the VA’s kneecap approximately two inches long. The SP was trained regarding incident response and reporting, daily resident documentation, redirection techniques, the VA’s program plans, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights included the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: The VA provided consistent information to P1, P4, the G, the CM, hospital personnel, and this investigator that on March 22, 2026, the SP called the VA derogatory names, made disparaging comments about the VA’s family members, and slammed the office door resulting in an injury to the VA’s knee. Medical records documented an injury to the VA’s right knee shortly after the incident and a second appointment three days later showed the VA was diagnosed with a knee sprain and contusion. Although the SP did not provide information to this investigator and there were no other witnesses, the VA provided consistent information to multiple persons on multiple dates regarding the SP’s disparaging comments made on March 22, 2026, that included references to the VA’s history and diagnoses of substance use disorder. The VA also acknowledged that s/he yelled and swore at the SP. In addition, the VA’s knee injury was in a location that matched damage to the office door; therefore it was determined that the VA’s account of the incident was credible. The SP’s actions were inconsistent with the VA’s support plans; inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; and were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). The SP’s actions were not accidental or therapeutic conduct. Given the VA’s history of substance use disorder, the SP’s use of derogatory terms related to the VA’s diagnoses was considered malicious. Therefore, although it was a single incident, there was a preponderance of the evidence that the SP engaged in malicious language toward the VA including references to the VA’s history and diagnoses of substance use disorder that would be considered to be disparaging, derogatory, humiliating, or threatening and could reasonably be expected to produce emotional distress and slammed a door on the VA’s knee causing pain and injury. It was determined that physical and 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 hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; and 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 received training regarding incident response and reporting, daily resident documentation, redirection techniques, the VA’s program plans, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of the VA. 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 and physical abuse for which the SP was responsible was not recurring. It was a single incident that met two definitions of maltreatment. However, it met the statutory criteria to be determined a “serious” because the substantiated physical abuse for which the SP was responsible resulted in the VA sustaining a scratch (tissue damage) and contusion (bruise) to his/her right knee. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed because the SP did not complete documentation regarding the incident. All staff persons were trained regarding documentation. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined above.
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