|
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: 1070479-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Suspected Maltreatment Reported: It was reported that a staff person (SP) punched a vulnerable adult (VA) multiple times causing facial fractures to the VA after the VA attempted to stab the SP with a fork. Date of Incident(s): April 7, 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 17, 2026; from documentation at the facility and medical records; and through six interviews conducted with the VA, two facility staff persons (SP, P1), a supervisory staff person (P2), the VA’s guardian (G), and another client (C) who was witness to the incident. The VA enjoyed rock hunting for agates, playing video games like Minecraft, and building with Legos. The VA looked forward to spending time with family and attending air shows. The VA was diagnosed with development disorder, intellectual disability and attention-deficit hyperactivity disorder. The VA had a goal to learn adaptive skills as an alternative to physical aggression to others and property. The Individual Abuse Prevention Plan stated that the VA was susceptible to physical abuse due to his/her inappropriate interactions with others. The VA physically aggressed towards others and engaged in behaviors that might provoke physical aggression by others. Staff persons monitored situations where there was a greater potential for aggression to occur and intervened utilizing cueing and steps of graduated guidance. Staff persons were aware that the VA had a history of physical aggression towards others and prompted the VA with positive alternatives such as discussing the problem with staff persons, offering calming techniques, and taking a break. Staff persons intervened immediately to prevent physical aggression and keep others safe. The Occurrence/Injury Report stated that on April 7, 2026, around 5:00 p.m., the VA was in his/her room watching TV and waiting for dinner to be done. When dinner was ready, the VA came out to eat. The VA was “taunting” the C with a fork and trying to stab him/her. The C went outside to talk with his/her significant other. The SP tried to give the VA a plastic fork and the VA broke it. The VA was “mad” that the SP tried to take the metal fork away from the VA’s plate. The VA grabbed the SP and tried to get the fork to stab the SP. The SP said s/he “defended myself.” The VA went back to his/her room and staff persons called the police. The VA had a black eye, bruises, and a cut on his/her nose. The VA was not able to recall the date the incident occurred. The VA was upset that the C and the P1 went for a walk and when the C got back from the walk with P1, the VA called the C’s significant other names. The VA was in the kitchen eating dinner and the SP gave the VA a plastic fork to eat with. The VA was upset and wanted a metal fork, so s/he got up and got a metal fork. The VA ran towards the C to chase the C with the fork, but the SP punched the VA in his/her eye. The VA remembered getting punched five times. After the first punch, the VA no longer had the fork in his/her hand and believed the SP did not handle the situation very well. The VA needed to attend appointments after the incident due to his/her face fracture and was still experiencing some pain and some headaches but was feeling better. P1 provided the following information: · On April 7, 2026, P1 went for a walk with the C. When the C and P1 returned, the VA began “bickering” with the C, so the C went to talk to his/her significant other on the phone. The VA was in the dining room sitting at the table, and the C was in the living room near the front door by the phone. P1 was in the kitchen, and the SP was sitting on the couch in the living room. P1 could not get a full view of the living room when in the kitchen. The SP could see the VA and the C from the couch in the living room. · At some point, the VA got up from the chair in the dining room and grabbed a metal fork and attempted to stab the C. The SP got up from the couch and got between the VA and the C. P1 told the C to “run,” and the C went outside. P1 saw a broken plastic fork on the ground but did not see the VA attempt to stab the SP. P1 saw the SP punch the VA eight to ten times while P1 told the SP to “let him/her go.” The VA got up after each time s/he was punched by the SP and did not say anything to the SP during the incident. P1 called 9-1-1 and by that time, the VA was in his/her bedroom. P1 did not recall if the VA had the metal fork in his/her hand throughout the incident between the SP and the VA. · P1 estimated the incident between the SP and VA lasted no more than five minutes. Law enforcement (LE) arrived at the facility approximately ten minutes later and talked to P1, the SP, and the C outside. LE went inside and talked to the VA in his/her bedroom. The VA was transported to the hospital via ambulance. · Before the VA left for the hospital, his/her face was “red and some bruises were starting to form”. On April 8, 2026, P1 worked at the facility and talked to the VA who was upset with P1 because s/he called LE. P1 observed the VA’s “whole face looked like a big bruise.” The only part not bruised was the VA’s chin and forehead. The VA had a dislocated eye-socket. The C provided the following information: · The C could not recall the date but recalled that before s/he went on a walk with P1, the VA was upset. When P1 and the C came back from the walk, the C was going to call his/her significant other. The VA began calling the C’s significant other a “bitch” and the C got upset. P1 told the VA to “knock it off”. · The VA was sitting in the dining room at the table, and the C was standing near the front door of the facility where the phone was located. The C’s back was turned towards the dining room. The VA ran at the C and attempted to stab the C with a fork in the back of the head and his/her back. P1, who was in the kitchen, told the C to “run” and the C went out the front door. · The C was able to see inside the facility from the front screen door and saw the SP punch the VA approximately 15 times in the VA’s eye and face. The VA’s face and eye were “black and blue and swollen” following the incident. The C was not sure if the VA had the fork in his/her hand throughout the incident. · LE arrived at the facility shortly after the incident and talked briefly with the C and the VA was taken to the hospital. The VA had a history of being verbally and physically aggressive towards the C and others at the facility. Three days after the incident, the VA moved out of the facility to another facility within the company. The SP provided the following information: · On April 7, 2026, the SP worked at the facility with P1. P1 went on a walk with the C, and the VA was “jealous” and got “angry”. When P1 and the C came back, the C found out that his/her significant other had called when they were out, so the C was going to call his/her significant other back. The VA was “saying stuff” to the C about his/her significant other and the C did not like what the VA was saying. The C said s/he wanted to punch the VA. The C went outside to call his/her significant other. · The VA got up from the dining room chair and attempted to stab the C with a metal fork in the back and in the head. The SP and P1 tried to calm the VA by telling the VA “Let’s stop doing that.” The SP attempted to give the VA a plastic fork because the SP did not feel safe with the VA having a metal fork. The VA broke the plastic fork, so the SP attempted to grab the broken fork. The VA grabbed the SP’s arm and attempted to stab the SP with the metal fork. The SP attempted to take the fork from the VA and “defended” him/herself by punching the VA in the face. · The SP “had the adrenaline” and was not able to remember details and did not know how many times s/he punched the VA in the face but it “wasn’t a lot” but was more than one time. The VA was grabbing the SP’s arm with one hand and had a metal fork in the other hand, attempting to stab the SP with the metal fork. The SP did not want to punch the VA but “felt scared” the VA was going to stab him/her with the metal fork. · P1 called 9-1-1 during the incident and the VA went back to his/her bedroom before LE arrived at the facility. The SP could not recall what time LE arrived and was taken outside to talk to LE. The SP did not get a good look at the VA’s injuries before s/he was taken by ambulance to the hospital, but saw that the VA’s face was “red.” LE informed the SP that LE was not going to press charges against the SP because the SP’s actions were “self-defense.” · The SP “took a week off” and received training regarding self-defense and on April 14, 2025, returned to work. The VA was moved to another facility within the company. The SP acknowledged that his/her actions did not align with the training s/he received. P2 said the VA had a history of becoming verbally and physically aggressive towards the C and other housemates. P2 briefly followed up with the SP regarding the incident and P2 believed the SP punched the VA once. P2 talked to the VA following the incident and the VA was “remorseful” about the incident. The VA was discharged from the hospital on April 8, 2026, and returned to the facility. The VA had a fractured orbital bone and required further follow-up appointments to determine if surgery was needed. The VA was moved to another facility within the company on April 10, 2026. The G said the VA had a history of “playing around” with the C and other housemates but was not always able to pick up on cues that indicated that the other person was becoming upset or offended. At times, the VA became frustrated and was verbally or physically aggressive. The G was concerned that P1 and the SP did not pick up on the VA’s non-verbal cues. The G understood that the SP was “protecting themselves but took it too far.” LE records provided the following information: · On April 7, 2026, at 5:37 p.m., LE responded to a call regarding the VA attempting to stab the SP with a fork. The C and SP were outside the facility. The C told LE the VA chased the C with a fork and the SP told LE that the VA chased the SP with a fork. · LE went inside the facility to talk to the VA. The VA was in his/her bedroom lying on his/her bed. LE observed blood coming from the VA’s nose and the VA was struggling to open his/her right eye. The VA did not want to talk to LE about the incident but told LE s/he was talking with the C. The C said something to the VA that caused him/her to be upset. · The VA grabbed a fork and chased the C. The VA told LE s/he wanted to stab the C with the fork but was punched by the SP. EMS was called for the VA by LE and the VA walked out of the facility and to the ambulance and was transported to the hospital. The SP told LE that s/he was acting out of self-defense. Medical records provided the following information: · On April 7, 2026, the VA received care at an emergency room near the facility and received a computed tomography (CT) scan. The VA had bruising around his/her right eyelid and hemorrhaging in his/her right eye. CT scans showed a fracture of the right orbital bone and nasal bone. Due to the VA’s injuries, the VA required a higher level of care and was transferred to another hospital on April 7, 2026. · The VA was reassessed, and it was found the VA’s orbital fracture caused the VA’s eye to become displaced and the VA struggled to look upwards. The VA was scheduled for future appointments due to the possibility of surgical intervention to ensure eye function. The VA was discharged with additional medication orders for eye drops and oral steroids. · On April 16, 2026, the VA attended a follow-up appointment regarding his/her facial fractures. The VA noted that s/he experienced some double vision when looking up and had mild light sensitivity. Another CT scan was completed and showed the VA’s orbital bone was still fractured. Medical professionals recommended a repair that could require an implant. The VA was scheduled for further medical appointments. All staff interviewed were training on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plan of care and the facilities policies and procedures including therapeutic intervention. Conclusion: A. Maltreatment: Consistent information was provided that on April 7, 2026, at around 5:00 p.m., the VA became upset, grabbed a metal fork, and ran towards the C in an attempt to stab the C with the fork. The SP got between the VA and the C. The C and P1 saw the SP punch the VA in the face 8 to 15 times. The VA said that s/he remembered the SP punching him/her at least five times in the face. P1 and the C each provided information that the SP punched the VA in the face more than once. P1 contacted LE who arrived at the facility ten minutes later. The VA was transferred to the hospital via ambulance. The SP said that s/he punched the VA more than once when the VA grabbed the SP’s arm and tried to stab the SP in the arm with a metal fork. The SP “defended” him/herself by punching the VA in the face. The SP acknowledged that his/her actions did not align with the training s/he received. The VA had bruising and hemorrhaging in his/her right eye and a fracture of the right orbital bone and nasal bone. The fracture caused the eye to become displaced and resulted in a possible repair that could require an implant. Although the SP said s/he “defended” him/herself by punching the VA, given that information was consistent that the SP received training on therapeutic intervention but did not utilize appropriate therapeutic techniques and instead punched the VA in the face multiple times causing significant injuries, there was a preponderance of the evidence that the SP’s actions were not accidental or therapeutic conduct and resulted in pain and injury to the VA. It was determined that 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; 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 was trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plan of care and the facilities policies and procedures including therapeutic intervention. 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 physical abuse for which the SP was responsible was not “recurring” maltreatment as it was a single incident, but it was “serious” maltreatment because the VA’s injuries resulted in bruises, fractures, and a dislocated eye which required continued monitoring and care by a physician. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined policies and procedures were adequate but were not followed by the SP. On April 14, 2026, the SP received retraining regarding Therapeutic Intervention Holds, Understanding Assault Degrees in Minnesota, and 245D definitions of Abuse and Maltreatment of a Vulnerable Adult. 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. On June 9, 2026, the facility was issued a Correction Order for not reporting a serious injury.
|
