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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: 1128174-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste/Beth Virden Samantha.Wueste@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person’s (SP) conduct towards a vulnerable adult (VA) included: · squirting water at the VA to stop the VA’s “behaviors.” · repeatedly telling the VA to clean up and remaining on the task of cleaning up for hours. Date of Incident(s): Ongoing prior to April 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), clause (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: 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 April 2, 2026; from documentation at the facility; and through five interviews conducted with the VA’s guardian (G) who was also the VA’s family member, a facility staff person (SP), a facility supervisory staff person (S1), and two staff persons (P1 and P2) who worked with the VA at a different program operated by a different license holder. Attempts were made by telephone to interview the VA’s case manager (CM), but the CM did not respond by the completion of this investigation. The DHS investigator did not interview the VA due to his/her limited communication skills. The VA’s support plans, including Individual Abuse Prevention Plan, provided the following information: · The VA lived with the G and enjoyed looking at magazines and going to parks. The VA was “somewhat nonverbal” and might point at objects or use short sentences, like to say, “Juice,” when s/he was thirsty. · In 2025, the VA began receiving individualized home support (IHS) from the facility. The facility provided a staff person (e.g., the SP) for 16 hours per week inside the VA’s house. The SP helped with the VA’s activities of daily living, socialization, and meal preparation, and with cleaning and tidying as needed. [Note: P1 and P2 also worked certain hours per week with the VA inside the VA’s house.] · The VA sometimes aggressed towards others, including spitting, which might provoke abuse from others. Staff were to intervene in potentially dangerous situations and report concerns on the VA’s behalf. · The VA’s diagnoses included intellectual disabilities. P1 provided the following information: · “About four years ago,” the SP trained P1 on how to work with the VA. The SP told P1 that if the VA spat at others, staff were to squirt water in the VA’s face using a spray bottle. P1 did not believe the conduct was appropriate and told the G that staff should not be squirting water at the VA. P1 did not say anything directly to the SP about it but believed the SP stopped squirting water at the VA around that time. In March 2026, P1 sent an email to the CM, which mentioned his/her previous concern of the SP squirting water at the VA to stop the VA’s behaviors. P1 assumed the conduct had stopped four years ago but was unsure and believed the conduct might still be going on. P1 said that s/he never witnessed the SP squirt water at the VA. · Also, “about four years ago,” the SP told P1 that if the VA made a mess, the SP sat with him/her for over an hour repeatedly saying, “Pick it up” until the VA did so. P1 never witnessed the SP do this. P2 and S1 each said that they had no additional information and never witnessed the SP engaging in the alleged conduct. The SP provided the following information: · The SP never squirted water at the VA. However, more than once, the SP saw the VA spit at the G and in response, the G squirted water at the VA from a spray bottle, which made the VA laugh. The water pressure was a “mist,” and the VA was never injured. [Note: The Department of Human Services did not have jurisdiction regarding the G squirting water at the VA.] · The VA liked to throw his/her belongings on the floor and when that occurred, the SP told the VA, “Okay, time to clean up. Let’s pick that up and put it up there.” Typically, the VA picked the item up and then dropped it and then sat down and laughed. The SP and the VA might do this for an hour, during which the VA laughed and thought it was funny. The VA was not required to clean up and might stop or leave to watch TV. It was the VA’s choice on how long s/he wanted to clean with the SP. If the VA declined to clean up, the SP typically cleaned up without the VA’s help. The G said that s/he had no concerns with the SP’s conduct. Facility documentation stated that the SP received training on the VA’s support plans, including Individual Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Although it was reported that the SP squirted water at the VA to stop the VA’s behavior and that the SP repeatedly told the VA to clean up, there were no witnesses who saw the SP engaging in the conduct or had additional information to support the allegations. In addition, the allegation was alleged to have occurred approximately four years prior which hindered the department’s ability to obtain information. Therefore, there was not a preponderance of the evidence whether the SP’s conduct produced or could reasonably be expected to produce emotional distress for the VA and included the use of repeated or malicious oral, written or gestured language toward the VA or the treatment of the VA which 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. “The reported behavior of an employee spraying a client’s face with water as a behavior modification technique would not be practices appropriate or reflective to [the facility’s] policies or expectations of it’s employees.” The SP did not provide direct care services during this investigation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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