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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: 1069675-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) punched a vulnerable adult (VA) in the face. Date of Incident(s): March 31, 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 April 14, 2026; from documentation at the facility and law enforcement (LE) records; and through ten interviews conducted with four facility staff persons (SP, P1, P2, and P6), four facility supervisory staff persons (P3, P4, P5, and P7), the VA’s case manager (CM), and the VA’s guardian (G). The VA was not able to provide information due to his/her diagnoses. The facility was a single-family residence in a residential neighborhood. The main floor consisted of a front porch, a dining room, a family room, a staff room, an office, a kitchen, a living room, a bathroom, and two bedrooms. The upper level consisted of five bedrooms and a bathroom. The basement was unfinished and used for storage. The kitchen had an island that was positioned between the dishwasher and a wall of cabinets along which was the entryway to the hallway leading to the bathroom. The VA’s diagnoses included autism, developmental dysphasia communication disorder, and mild intellectual disability. The VA enjoyed using a tablet, going to work, being outside, going to McDonald’s, and shopping for snacks. The VA’s plans stated the VA exhibited physical aggression when the VA “did not get what [s/he] wants when [s/he] wants it” such as slapping, pinching, pushing, biting, pushing his/her chin into other’s body and/or hitting others. The VA had a history of “pinching others on their arms” and it was typically interpreted as playful and not meant to cause harm. When the VA was agitated, s/he displayed loud vocalizations, hand clapping, foot stomping, slamming doors, banging on walls or objects, throwing his/herself on the floor, and self-injurious behaviors. “Verbal redirection and physical assistance as needed” were used as intervention methods. LE records showed on March 31, 2026, an officer responded to the facility and spoke to P1. P1 said the VA grabbed onto the SP’s hand, which was “normal behavior” for the VA. The SP pulled his/her right hand back and then punched the VA in the left side of the face with a closed fist. P1 told LE that the right side of the VA’s face was red and that the VA did not receive any medical attention. LE did not observe any marks on the VA’s face. On April 1, 2026, LE spoke to the SP and the SP said s/he told the VA to put dishes in the dishwasher and the VA grabbed the SP’s arm. Both of the SP’s and the VA’s arms “started moving,” which caused the VA to let go. The SP twisted to avoid the open dishwasher door and the SP’s right shoulder made contact with the VA’s sternum or chin. The SP denied striking the VA with a closed fist. The facility’s Internal Review stated that during the incident, the SP was at the kitchen sink, to the right of the dishwasher with the door open and the top dishwasher rack pulled out. P1 was behind the SP, by the bathroom door, about 15 feet away. P1 said s/he had a clear view of the VA while the SP was standing at the sink, but potentially the view “could have been obstructed” if the SP leaned over or stepped to the side. “P1 would not have a clear view of what was happening directly in front of [the SP].” P1 provided the following information: · On March 31, 2026, at 2 p.m., P1 and the SP started their shifts at the facility. Around 2:20 p.m., the SP was at the sink rinsing dishes to go in the dishwasher. P1 was standing outside the bathroom and had a visual of the left side of the SP and the right side of the VA. The VA went into the kitchen and the SP told the VA to put the dishes in the sink. The VA grabbed the SP’s hand, which “surprised” the SP. The VA “grabbed and pulled” the SP. The SP punched the VA in the left cheek with a closed fist. The VA leaned backward and looked toward P1. · P1 said, “[The SP], stop we cannot do that!” The SP responded, “[S/he] grabbed my hand!” P1 responded, “I saw it, but we cannot punch or hurt clients.” · The VA “jumped” around the kitchen and made “noise” and then went to his/her room. The SP “pretended” nothing happened and went to shower another client. The VA’s left cheek was a “little red but nothing concerning.” · P1 texted P3 and P7 and told them the SP punched the VA. P3 and P5 arrived at the facility, sent the SP home, and checked on the VA. Around 4 p.m., LE arrived at the facility and spoke to P1 and checked on the VA. · It was not unusual for the VA to grab staff persons’ hands or the underside of their upper arm or to pinch staff persons. Staff persons were trained to give the VA space, tell the VA to “stop,” and ask the VA what s/he wanted. The VA grabbed the SP previously and P1 was not sure why the SP seemed surprised by it that day. · P1 worked with the SP regularly and did not have any other concerns, other than that the SP mimicked the VA by “quacking” back at the VA when the VA made a “quack” vocalization. P3 provided the following information: · On March 31, 2026, P3 received a text from P1 that said the SP punched the VA. P3 and P5 went to the facility, informed the SP that a report was made, and sent the SP home until the investigation was completed. · P1 told P3 the SP told the VA to put his/her dishes in the dishwasher and the VA grabbed the SP’s arm. The SP turned and punched the VA. · P3 checked on the VA and did not see any injuries. The SP was significantly larger in size than the VA. P3 said if the SP punched the VA, the VA “would’ve went backwards,” and “[the VA] couldn’t have taken a punch from [the SP]. It would have left a mark.” · The VA had a history of grabbing staff persons and P3 “could see [the SP] shake [the VA] off and get unbalanced.” The SP worked with the VA since the VA was a child and “it would surprise” P3 if the SP punched the VA. The SP had a good relationship with the VA and got the VA to do things “that others can’t, like showering.” P3 did not have any concerns with the SP. P4 provided the following information: · P4 was part of an email chain of people who were notified of the incident. On April 1, 2026, P4 went to the facility to check the VA for injuries and did not see any. The VA seemed “happy” and “at baseline.” If the VA had been “hurt” P4 thought s/he would have had “behaviors” or been “distant or aggressive.” · The VA had a history of grabbing people, both in a friendly and aggressive manner. · The SP had a “cool, calm, and collected” demeanor. P5 provided the following information: · P3 asked P5 if s/he would go to the facility to “remove” the SP due to an allegation that the SP struck the VA. P3 told P5 that P1 texted him/her with the allegation. P3 and P5 immediately walked to the facility, which was approximately one block away from the main office. · The SP was told an allegation had been made and s/he was told to clock out and go home pending the investigation. The SP was not told what the allegation was and did not ask about it. · P3 checked the VA and did not see any injuries and the VA appeared “calm.” · The VA would make a “quack” vocalization and during the internal investigation, other staff persons reported the SP “quacks” back at the VA instead of redirecting the VA. The SP received a corrective action for inappropriate verbal interactions with the VA. P7 provided the following information: · P7 was in the group chat that P1 texted about the incident. P7 called P1 and asked if the SP hit the VA with an open-handed slap or a closed fist punch. P1 said it was a closed fist punch, and s/he believed it made contact with the VA’s face, even though the VA tried to move away. P1 told the SP that s/he could not do that and the SP replied, “Well, [s/he] grabbed me.” P1 expressed concern for his/her safety as the SP was larger in stature and P1 was “scared” of what the SP would do if s/he found out P1 provided information about the incident. · The SP and P1 worked together every other weekend and had never had any conflict. · P7 saw the VA a day or two after the incident and the VA was happy. The VA had discolored skin on the right side of his/her nose, possibly from the VA laying on that side of his/her face. P7 did not see any bruising on the VA’s face. P6 provided the following information: · P6 talked with both the SP and P1 about the incident and both said that the SP was by the dishwasher and the VA went into the kitchen to put his/her dishes in the sink. The dishwasher door was open and a shelf was pulled out. The SP asked the VA to put the dish in the dishwasher. The VA put the dish on the counter and grabbed onto the SP’s hand. The VA and the SP pulled back and forth a few times as the SP tried to get his/her hand free. However, P1 said s/he was next to the bathroom door and had a view of the SP’s back and said the SP punched the VA in the face. The SP said s/he lost his/her balance and fell towards the VA making physical contact with the VA but said it was accidental. The SP thought his/her shoulder hit the VA’s sternum and did not think his/her hand hit the VA’s face. · The SP and P1 both agreed there was physical contact between the SP and the VA. The dispute was if it was accidental or deliberate and which of the SP’s body parts came into contact with the VA and where on the VA’s body the contact was made. · P1 said that at the end of his/her shift, s/he noticed “redness” on the VA’s cheek when the VA was sleeping on his/her left side. However, if the VA was lying on his/her left side, the VA’s right cheek would have been seen and the VA’s left cheek would not have been visible. P1 stated the SP had punched the VA in the left cheek. · On April 1, 2026, P4 went to the facility to check on the VA and noted his/her right cheek was red but no injuries were seen. On April 2, 2026, staff persons did not note any injuries before the VA left for work. · There were no previous concerns with the SP’s employment. · It was normal for the VA to grab onto staff persons and the VA had a history of physical aggression. When the VA grabbed onto staff persons, staff persons were to disengage and walk away. If that was not possible, another staff person used a blocking pad to assist with the disengagement and kept a barrier between the VA and the targeted staff person. P2 provided the following information: · On March 31, 2026, P2 arrived for work at the facility approximately 15 minutes after the incident occurred. P1 and the SP were not looking at each other and were not talking to each other like they normally do. The SP left the room and P1 showed P2 the text message P1 sent to P3 and P7. About 10 minutes later, P3 and P5 arrived at the facility and spoke to the SP. · The SP was sent home and P3 and P5 spoke to P1. P2 assisted P1 with filling out the incident report. LE arrived a short time later. P2 did not see any injuries on the VA. · The VA stayed in his/her room most of the night and had more behaviors than normal at dinner. The VA exhibited behaviors when s/he was upset. The VA stomped his/her feet, hit the table with his/her hands, screamed, and slapped him/herself in the cheeks. The behaviors lasted until the VA got his/her medication at 6:15 p.m. The VA went to his/her room for the rest of the night and did not come out for his/her nightly snack and ice cream, or for a shower. · P2 worked with the VA almost every day. P2 heard the VA grabbed staff persons in the past but never witnessed it. · The SP previously “mocked” the VA’s behaviors by “quacking” back at the VA when the VA made a “quack” vocalization and hitting the table in front of the VA, which the VA did when s/he was “really riled up.” The facility previously addressed the issues with the SP. P2 did not have any other concerns with the SP and had not seen the SP ever get physical with any client. The G and CM were notified of the incident by the facility. The VA had a history of pinching staff persons and throwing objects. The VA was a “strong” individual and grabbed onto people and squeezed, which left bruises. The SP provided the following information: · The SP was in the kitchen next to the dishwasher when the VA entered the kitchen with dirty dishes. The SP put his/her hand on the VA’s arm and said, “Let’s put them in the dishwasher.” The SP touched the VA’s arm to stop the VA from throwing the dishes in the sink. · The VA grabbed the SP’s arm and they “jostled around a little bit.” The VA left go and the SP tripped over the open dishwasher door and lost his/her balance. The SP fell forward towards the VA and the SP’s right shoulder made physical contact with the VA in the sternum/chest area. The physical contact was accidental and not intentional. The SP denied his/her fist came in contact with the VA. The VA was not injured. · The VA had never grabbed onto the SP or any other staff persons before and the SP was surprised by it. · P1 was in the corner of the kitchen and witnessed the incident. After the physical contact happened, P1 said, “We don’t do that.” The SP thought P1 directed the comment to the VA because the VA had grabbed the SP’s arm. No other conversation about the incident occurred between the SP and P1. P1, P2, and the SP were trained on the VA’s plans and all staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults. Conclusion: Information showed that on March 31, 2026, at 2 p.m., the SP and P1 worked at the facility. Around 2:15 p.m., the SP and the VA were in the kitchen while P1 assisted another client in the bathroom. P1 was in the bathroom doorway and saw the VA bring his/her bowl over to the sink area. The SP asked the VA to put the bowl in the dishwasher instead of the sink. The VA grabbed the SP’s wrist and P1 saw the SP punch the VA on the left cheek with a closed fist. The VA leaned back and looked at P1. P1 said, “You can’t do that!” and the SP replied that the VA had grabbed him/her. The VA “jumped and stomped” around the kitchen and then went to his/her bedroom. P1 stated the VA’s left cheek was red immediately after the incident and was still “slightly discolored” several hours later. The incident report that was completed by P1 and P2 stated, “No injury to [the VA].” P2, P3, P4, P5, P7, and LE did not see any injuries on the VA. The SP said s/he lost his/her balance trying to get his/her arm away from the VA and the SP’s shoulder accidentally made physical contact with the VA’s chest area. The SP denied punching the VA. Although P1 said the SP punched the VA in the face with a closed fist and the SP had reason to minimize his/her actions, given that the SP denied punching the VA; that the SP stated s/he tripped, lost his/her balance and made physical contact with the VA’s chest area in the process; that P1 was approximately 15 feet away from the SP at the time with P1’s line of sight possibly partially obstructed by a kitchen island and cabinetry, that the VA was not able to provide details of the incident; that the VA was not injured; and that there was no further information to corroborate or refute P1’s or the SP’s account of the incident, there was not a preponderance of the evidence whether the SP punched the VA or whether the SP’s actions were not accidental and could cause pain or injury to the VA. 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 and followed and that corrective action and additional training were needed. The SP received formal disciplinary action and was retrained on abuse and neglect, de-escalation, and person-centered training. All staff persons were retained on following support plans and not repeating/”mocking” the VA. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action.
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