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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: 1101574-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock Lisa.shock@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had unexplained bruising/purple marks on his/her torso. Date of Incident(s): April 11, 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 (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 23, 2026; from documentation at the facility, law enforcement records, and medical records; and through six interviews conducted with a supervisory staff person (P1), four facility staff persons (P2, P3, P4 and P5), and the VA’s guardian (G). The VA was unable to provide information regarding the allegations due to his/her diagnosis. The facility was a single-level home with an attached garage, three bedrooms, a living room, dining room, kitchen and laundry room. The VA’s bedroom was at one end of the home, and the VA had his/her own bathroom. The VA was diagnosed with autistic disorder, pervasive developmental disorder and was legally blind. The VA enjoyed going on home visits and car rides. The VA enjoyed attending a day program and did so Tuesday to Friday, 7:45 a.m. to 2:45 p.m. The VA’s Individual Abuse Prevention Plan said the VA required a 24-hour plan of care. Staff persons must be aware of the VA’s location at all times and be in auditory range. During waking hours, staff persons were to visually check on the VA every 15 minutes. In the community, staff persons were to keep the VA in visual range at all times and always be “at or within an arm’s length distance.” If the VA was in a situation that staff persons deemed unsafe, staff persons provided verbal redirection and immediately physically intervened by placing themselves between the VA and the situation. The VA had a history of engaging in self-injurious behaviors. If the VA displayed behaviors that put him/her at risk of injury to self, staff persons provided verbal prompts, redirection and if necessary, staff persons physically intervened by placing their hand over the place the VA was hitting. The VA required assistance with dressing, washing hair and hand over hand assistance to wash his/her hands and body. The VA’s Coordinated Services Support Plan said that the VA was legally blind and utilized a walking cane and staff person assistance to navigate terrain. The VA may carry the cane instead of using it, and staff persons gave the VA verbal reminders to use the cane. The VA received assistance daily to shower. P2 provided the following information: · On April 10, 2026 from 10 p.m. to April 11, 2026 at 7 a.m. P2 worked the overnight shift. When P2 arrived to the facility, the VA was asleep in bed. During the night, P2 assisted the VA with using the bathroom but did not undress the VA and did not notice any bruising. Around 6 a.m., P2 assisted the VA out of bed and into the shower. · While assisting the VA with a shower, P2 saw bruises on both sides of the VA’s torso. P2 described the bruise on the VA’s right side having a dark purple center and the bruise on the VA’s left side was the size of a handprint. The VA did not appear to have any sensitivity or pain from the bruising. · After the VA’s shower, P2 called P1 and told P1 about the bruises. P1 asked P2 to take pictures of the bruises and text them to P1 and P2 did so. · P2 denied causing the bruising and said s/he did not know how the VA sustained the bruising and had not seen bruising “like this” on the VA any other time. · P2 had not worked at the facility for two weeks prior to April 10, 2026. P1 provided the following information: · On April 9, 2026, the G called P1 and asked P1 to take the VA to see a doctor because the VA appeared to have difficulty standing and walking while at the G’s home. That evening, P1 took the VA to an emergency room where the VA was examined and had testing including urine cultures and as well as a CAT (computed axial tomography) scan. P1 stated that the CAT scan did not show any fractures to the VA’s ribs and that the emergency room doctor said that s/he would send the results of the urine culture to the VA’s primary doctor who would discuss with the VA’s G. · Around 9:30 p.m., P1 and the VA returned to the facility from the emergency room and P1 helped change the VA into pajamas and go to bed. At that time, P1 did not see any bruising on the VA. · On April 11, 2026, at an unknown time in the morning, P2 called P1 and said s/he saw bruising on both sides of the VA’s torso. P2 described the bruises as “one bruise was the size of a fist, round and kind of purple, the other bruise looked almost like a handprint, red, black and blue.” P1 directed P2 to take photos of the bruises and send them to P1. P1 received the photos and described the bruises as “purple, pink and blue and looked like new bruises.” · P1 notified his/her supervisor and was told to talk to staff persons about the bruising. P1 contacted and spoke to ten staff persons (P2–P11) who had worked with the VA over the past week and asked if they had seen any bruising on the VA and if they knew where the bruises came from. No staff person was aware of bruising except for P4 who stated that on April 10, 2026, around 6 p.m. s/he assisted the VA to the bathroom and had noticed bruising on the VA’s right side only. P4 told P1 that s/he documented the bruise in the facility T-log but did not tell P1 or any other staff persons. · P1 denied causing the bruises and did not have concerns that other staff persons had done so. · P1 stated that the VA was taking two medications, Fish Oil and acetazolamide, that each had possible side effects of bruising. P3, P4, and P5 provided the following information: · On April 8, 2026, P3 worked from 3 to 11 p.m., and P4 worked from 3 to 9 p.m. Each denied seeing any bruises on the VA. · On April 9, 2026, P5 worked from 7 a.m. to 3 p.m., P3 worked from 3 p.m. to the next morning at 8 a.m., and P4 worked 3 to 9 p.m. Each denied seeing any bruises on the VA. After the VA’s day program s/he went and visited the G. The G called P3 and asked P3 to pick the VA up at 6 p.m. When P3 arrived, the G asked P3 to come inside and assist the VA because the VA was not feeling well. P3 and G assisted the VA to the car. P3 stated that the VA walked “well” and P3 did not notice anything unusual. · When they returned to the facility, P1 came at the request of the G and brought the VA to the emergency room. About 9:30 p.m., P1 and the VA returned from the emergency room and P1 assisted the VA into his/her pajamas and the VA went to bed. P3 did not assist with changing the VA into his/her pajamas. The next morning (April 10, 2026), P3 assisted the VA with a morning shower and did not see any bruises on the VA. On April 10, 2026, P4 worked from 3 to 9 p.m. When P4 arrived at work the VA was on a home visit with the G. Around 6 p.m., the VA returned home and P4 helped the VA put on pajamas and noticed a bruise on the VA’s right torso. At that time, P4 did not see a bruise on the VA’s left torso. · P4 documented the bruise in the facility T-logs but did not tell anyone about the bruise. · P3, P4, and P5 each denied seeing any bruises on the VA in the past, denied causing the bruising to the VA and were not aware of any other staff causing bruises to the VA. The G provided information that was consistent with the information provided by P1 and P3 regarding the VA’s home visit and the following additional information: · On April 11, 2026, the G was notified about the bruises on the VA’s left and right torso. · The G was visually impaired and asked to have the photos of the bruises sent to another family member so they could describe to the G what the bruises looked like. The family member described deep purple bruise on the VA’s right side and a bruise on the VA’s left side. · On April 20, 2026, the G brought the VA to a pre-scheduled follow up doctor appointment where the VA’s primary care doctor did not observe other signs of bruising or bleeding that would lead the provider to believe there was an underlying medical explanation for the bruising. The VA’s medications included: · Fish oil softgel 1000 milligrams two times a day, at 8 a.m. and 8 p.m. According to www.Drugs.com, a side effect of taking this medication was unexplained bruising or bleeding. · Acetazolamide (diuretic) 250 milligrams two times a day at 8 a.m. and 8 p.m. According to www.Drugs.com, a side effect of taking this medication is red skin lesions, often with a purple center. The VA’s medical records were requested but not received by the completion of this report. Photographs provided by the facility showed on the VA’s left torso, faint yellowish bruising in approximately three horizontal lines. On the VA’s right torso was a dark purple bruise that was approximately the size of a baseball with faint irregular bruising around it. Law enforcement investigated and did not identify any staff person as causing injury to the VA. Law enforcement closed the case with no additional action. Facility documentation showed that all staff persons interviewed were trained on the VA’s plans, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: Information showed that on the evening of April 10, 2026, P4 saw a bruise on the VA’s right torso and did not observe any bruising on the VA’s left torso. The next morning, April 11, 2026, while giving the VA a shower, P2 saw bruising on the VA’s right and left torso including a large purple spot on the VA’s right torso. Consistent information was provided by P1-P5, who worked with the VA on April 8, 9, and/or 10, 2026, that each did not know about or see the bruises until P4 and P2 each respectively observed them. P1-P5 each did not know how the VA sustained the bruises and each denied causing the bruises. P1 stated that the VA was taking two medications that could cause unexplained bruising which was consistent with the information provided by Drugs.com for the VA’s two medications. Although the VA had bruises on his/her right and left torso, consistent information was given by P1-P5 that they do not know how the VA sustained the bruises, the VA was taking medications that could cause bruising, and no staff persons had concerns regarding others interactions with the VA. Therefore, there was not a preponderance of the evidence whether a staff person caused the bruises on the VA or whether the VA’s bruises occurred by any means other than accidental. 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 the facility’s policies were adequate and were followed by the staff persons. The facility implemented daily body checks in the morning during the VA’s shower and in the evening when changing the VA into pajamas. Staff persons were trained on scanning the VA’s body for bruises and documenting findings on a bruise chart. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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