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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: 1083119-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) failed to remain close to a vulnerable adult (VA) and the VA fell and struck his/her face on a windowsill. The fall resulted in a laceration to the VA’s face, which required four stitches. Date of Incident(s): February 28, 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 17, paragraph (a): 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 March 10, 2026; from documentation at the facility and medical records; and through six interviews conducted with three facility staff persons (SP, P1, P2), a facility supervisory staff person (P3), and the VA’s two guardians (G1 and G2). Due to the VA’s abilities, the VA was not able to provide information for this investigation. The VA’s diagnoses included autism, severe developmental disabilities, seizure disorder, and functional quadriplegia. The VA enjoyed watching television, music, and going on walks. The facility was a one-story, single-family residence in a neighborhood with residential houses and businesses. The main floor consisted of a sensory area, a dining room, a kitchen, two bedrooms, an office, and a bathroom. The finished basement consisted of two bedrooms, a living room, a laundry room, a bathroom, and a storage room. Staff meeting notes for the VA from January 14, 2026, stated, “1-2 staff assisting [the VA] moving,” “never left alone or stepping away,” and “if [the VA’s] up, you’re up.” The VA’s Support Plan Addendum, dated October 1, 2025, to September 30, 2026, stated, “[The VA] may move quickly, drop or fall without notice.” The VA had a history of falls and staff persons “always need to be reasonably close to [the VA], which is in arms distance away and must maintain visual eyesight as well.” The VA “can pace throughout the home and backyard without direct assistance.” The VA’s Gait Belt Information, dated January of 2026, said the VA wore the gait belt for the entire day for mobility support and safety, with the exception of when the VA showered, slept, or was out in the community wearing a belted safety vest. Staff persons were instructed to use an underhand grip on the belt at either the VA’s sides or back and walk with the VA from behind or on either side. “A gait belt is an assistive device secured around [the VA’s] waist that allows staff to safely support [the VA] during transfers, lifting, and walking around the house. The gait belt is not intended for staff to bear all of [the VA’s] weight, nor does it mean [the VA] should not be encouraged to move independently.” The gait belt provided added stability, prevented falls, improved balance and control for the VA and staff persons, and reduced injuries for staff persons. The facility reviewed video footage from the incident and documented the following: · On February 28, 2026, at 1:36 p.m., the SP walked the VA to a red chair and said, “You got this.” The SP was in front of the VA, and held the VA’s elbows as they walked sideways and backwards towards the chair. The VA sat down and immediately started to stand up again. The SP saw this and then turned away from the VA. The VA got to his/her feet and the SP remained with his/her back to the VA. The SP appeared to be doing paperwork at the dining room table. Four seconds after the VA stood up, the VA started to lean towards the kitchen counter (to the left). The VA reached out and attempted to catch him/herself but fell over and rolled onto his/her back. The SP “rushed” over to the VA, the VA reached for the SP, and the SP stood over the VA and said, “You need to stop,” and waved his/her hand. The SP left the VA on the floor and walked back to the dining room table and wrote something down. The VA rolled over and crawled toward the tall kitchen countertop. The VA reached to grab onto the top of the countertop, which was approximately four and a half feet tall, and struggled to pull him/herself up to a standing position. The SP verbally encouraged the VA to pull him/herself up. The SP walked over to the VA but did not offer any assistance, which the VA “obviously needed.” The SP again walked away from the VA and left him/her standing alone near the tall kitchen counter, which was “not following [the VA’s] safety plan.” · At 1:52 p.m., the VA stood with his/her back against the wall near the kitchen gate attached to the counter. The SP sat on the fireplace ledge on his/her cellphone. After 24 seconds, the VA walked toward the SP. The VA used the kitchen counter ledge as a guide as s/he walked and held onto the counter for an additional 35 seconds before the VA let go and walked toward the SP. The VA started to lean to the right and his/her “legs couldn’t get underneath him/herself fast enough.” “[The VA] appeared to know [s/he] was going to fall as [s/he] dove towards [his/her] red chair.” The SP stood up quickly and put his/her arms out in an attempt to catch the VA. Once the VA “hit the chair, [s/he] misjudged the distance” and hit his/her face on the windowsill. A loud “thud” was heard and the SP said, “Shit! What the fuck [the VA]? Oh my God [the VA]!” The SP brought an ottoman over and propped the VA’s feet up and went to get a paper towel to tend to the VA’s face. P2 provided the following information: · On February 28, 2026, the SP worked upstairs with the VA and P2 worked downstairs with another client. P2 heard “ruckus” upstairs and texted the SP to see if s/he needed help. About two minutes later, the SP yelled for P2 to come upstairs. The SP told P2 that the VA fell and P2 saw a “gash” on the VA’s face. P2 then called P1 to inform him/her of the injury. · P1 told P2 that the VA needed stitches and s/he would try to get an appointment. P1 scheduled a time for the VA to be seen at urgent care (UC) a short time later. P3 was called to come in early and assist with taking the VA to UC. · P2 asked the SP how the VA fell, and the SP said the VA tried to walk to his/her chair and fell while trying to sit in the chair. The SP told P2 that the VA had fallen twice but did not give details of the first fall. · The SP asked P2 if s/he stood near the VA when the VA stood by the kitchen gate. P2 told the SP that staff persons were supposed to be “up” whenever the VA was “up.” P2 said the VA was “always on [his/her] feet,” even though s/he was “very unsteady.” Staff persons were told that when the “VA moves,” staff persons were to move with him/her and that staff persons were to be “right next to” the VA when s/he was moving. When the VA sat down, staff persons had to be “in arms reach” of the VA. The VA had a history of seizures, was a fall risk, and was “very wobbly” on his/her feet. If staff persons were not next to the VA and the VA got up and started to walk, “you aren’t going to make it in time,” and the VA “is going to fall.” · When P3 arrived at the facility, the SP only mentioned the VA fell once that day to P3. P1 provided the following information: · On February 28, 2026, P1 received a video call from P2. P2 told P1 that the VA fell and P1 wanted guidance on if the VA should go to UC. P1 saw the cut on the VA’s face and told P2 to take the VA to UC to be assessed for stitches. The VA was taken to UC and received four stitches on his/her face. · P2 said the SP was the VA’s 1:1 staff and P2 was unsure of how the VA fell. · The SP called P1 and said the VA was walking, attempted to sit in his/her chair, and “missed” the chair hitting his/her face on the window. P1 said if the VA was wearing his/her gait belt and the SP was near the VA, the VA should not have fallen. · On March 2, 2026, P1 reviewed video footage from the facility and saw the VA had fallen twice. The SP only reported one fall. The SP did not assist the VA when s/he fell the first time and “ignored” that the VA was on the floor. The VA reached for the SP and the SP walked away. Staff persons were expected to help the VA up when s/he fell. Staff persons were supposed to be near the VA and assist him/her walking. The SP let the VA “struggle” for too long to pull him/herself up. About 10-20 minutes later, SP was sitting on the fireplace ledge on his/her phone and the VA was standing in the same spot s/he had pulled him/herself up to after the first fall. The VA started walking and the SP did not assist the VA. The VA went to sit in his/her chair and missed. The VA struck his/her face on the windowsill. · If the SP had followed the VA’s plans, “that type of fall should not happen.” The SP did not document the first fall or tell P1 about it. P1 was not aware the first fall occurred until the video was reviewed. P3 provided the following information: · On February 28, 2026, around 2:10 p.m., P3 was contacted by P1 and asked to come in early for his/her shift and assist with taking the VA to UC. · P3 arrived at the facility and asked the SP what happened to the VA. The SP told P3 that the VA was standing over by the kitchen, walked to sit down in the chair, lost his/her footing, and fell into the window. The SP did not say where s/he was at the time of the incident. P3 said the SP was “always” sitting by the fireplace. · P3 accompanied the VA and the SP to UC and the VA received four stitches. · The VA always wore the gait belt or a belted safety vest unless the VA was sleeping or showering. Staff persons were supposed to be within “arm’s length” of the VA and when the VA moved, staff persons were to be “right next to [the VA].” When the VA was unstable, staff persons had a hand on the gait belt. · When the VA was in the chair, “[the VA] can’t fall out,” but s/he can “get out” of the chair. Staff persons stayed next to the VA to make sure s/he did not fall if s/he tried to get up. Staff persons “should always be next to [the VA].” G1 and G2 said the VA needed 24-hour care and had limited mobility. The VA’s mobility and balance had declined over the past year. The VA was “unsteady” on his/her feet and staff persons were to be “right next to” the VA “all the time.” The gait belt was used for staff persons to assist the VA in moving around and to “catch” the VA if s/he fell. G1 and G2 were “extremely concerned” over the SP’s actions in the video and did not have any previous concerns about the staff persons or facility. The SP provided the following information: · The SP worked as the VA’s 1:1 staff person one to two days per week and had worked with the VA for the past four months. The VA had a history of falls and was unsteady when s/he walked. Staff persons were “supposed to move around with [the VA]” when the VA was mobile. · The SP was trained on the VA’s plans and the use of the VA’s gait belt. The VA’s gait belt was used to “help [the VA] stay stable” when the VA walked. Staff persons were trained to have two fingers under the gait belt when the VA walked around. The SP said s/he did not grab onto the gait belt and felt s/he had “more control if [the SP] wrap[ed] my arms around [the VA’s] waist.” · The SP acknowledged staff persons should have physical contact with the VA when s/he walked around and that the SP did not have physical contact with the VA on the day s/he fell and was injured. · Prior to the first fall, the SP “went to sit [the VA] on the chair because [the SP] noticed [the VA] was unstable.” When the VA fell the first time, the SP did not help the VA get up and said, “I let [him/her] get back up because I know [s/he] can.” · The VA stood against the wall unattended for “ten minutes” before the VA walked toward his/her chair and struck his/her head on the windowsill. The SP said the chair was “just a few feet” from the VA and the SP “didn’t think anything would happen” as the VA had walked from the kitchen area to the chair multiple times before without any issues. · The SP said when the VA was standing, staff persons had to be in the same room as the VA, and the SP was unsure if there was a distance requirement of how close staff persons needed to be to the VA. · The SP “forgot” to document the VA’s first fall. The SP said s/he checked the VA over and did not see any injuries from that fall. · When this investigator asked the SP if s/he did anything wrong that day, the SP said s/he “should’ve been more close” to the VA. The SP, P1, P2, and P3 were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Conclusion: A. Maltreatment: Information showed that on February 28, 2026, the SP worked as the VA’s 1:1 staff. The SP noticed the VA was “unstable” and led the VA to his/her chair to sit down. The SP walked away from the VA to go to the dining table. The SP appeared to see the VA get up from the chair and did not assist the VA. The VA took a few steps and fell. The SP walked over to the VA but did not help the VA up to his/her feet. The SP then walked back over to the table. The VA pulled him/herself up and stood alone by the kitchen gate for more than ten minutes. The SP sat on the fireplace while the VA walked toward the chair. The SP did not get up to offer assistance to the VA or hold onto the VA’s gait belt as trained. The VA attempted to sit in the chair and struck his/her face on the windowsill next to the chair. The facial injury required four stitches at UC. P2 and P3 said staff persons were to be within “arm’s reach/length” of the VA and were to move with the VA when the VA moved. The VA’s plans stated the VA wore the gait belt the entire day for mobility support and safety. Staff persons were instructed to use an underhand grip on the belt at either the VA’s sides or back and walk with the VA from behind or on either side. The gait belt provided added stability, prevented falls, and improved balance and control for the VA and staff persons. The VA’s plans stated, “[The VA] may move quickly, drop or fall without notice.” The VA had a history of falls and staff persons “always need to be reasonably close to [the VA], which is in arms distance away and must maintain visual eyesight as well.” The SP said staff persons were supposed to move around with the VA and have physical contact when the VA was mobile. The SP did not assist the VA after the first fall and stated, “I let [him/her] get back up because I know [s/he] can.” The SP left the VA standing unattended next to the wall for “ten minutes” and “didn’t think anything would happen” when the VA attempted to walk to the chair unassisted. Given that the SP was trained on the VA’s plans and using the gait belt, that the SP was aware of the need to stay close to the VA given the VA’s history of falls, that the SP stated the VA was “unstable” prior to both falls yet the SP did not remain in close proximity of the VA or maintain physical contact with the VA while the VA walked, that the SP did not use the gait belt as trained, that the SP did not assist the VA get up off the floor after the first fall, and that the VA sustained an injury from the second fall, there was a preponderance of the evidence that the SP failed to supply the VA with reasonable and necessary care or services, including supervision and mobility assistance. It was determined that 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). 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 the VA’s plans and use of the gait belt, therefore, 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 neglect for which the SP was responsible was not “recurring” maltreatment as it was a single incident but was “serious” maltreatment because the VA’s injuries required care of a physician and the VA received four stitches to his/her face. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that company policies and procedures were adequate but not followed, and there was a need for additional staff training. Staff persons were updated each time changes occurred to the VA’s plans or programming. 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.
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