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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: 1070576-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth/Alice Percy 651-431-6537 Suspected Maltreatment Reported: It was reported that a staff person (SP) was “mean” to a vulnerable adult (VA) and that the SP hit the VA in the stomach. The VA had a bruise below the VA’s belly button. Date of Incident(s): Unknown, prior to May 14, 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), clauses (1) and (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: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · 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 May 29, 2026; from documentation at the facility; and through seven interviews conducted with two facility supervisory staff persons (P1 and P2), two staff persons (P3 and P4), the SP, the VA, and the VA’s guardian (G). The VA enjoyed attending sporting events, going out to eat, and going on community outings. The VA’s diagnoses included intermittent explosive disorder, generalized anxiety disorder, moderate intellectual disability, 18q deletion syndrome (chromosomal disorder), and hearing loss. The VA’s Individual Abuse Prevention Plan stated that the VA might not be able to identify potentially dangerous situations or respond appropriately. The VA had difficulty understanding why others might exhibit verbally aggressive behaviors to him/her or others. When exposed to emotional abuse, the VA experienced heightened anxiety. The staff persons were expected to model appropriate communication and social behavior to the VA and to redirect the VA away from potentially harmful interactions. The VA stated that s/he liked the staff persons and the other residents at the facility and the VA did not provide any information about the incident. No bruise was observed on the VA’s stomach. P1 - P4 provided the following information: · P1 stated that s/he was administering medications to the VA when the VA began to talk about the SP and told P1 that s/he “didn’t like” the SP. When P1 asked the VA why s/he did not like the SP, the VA told P1 that the SP was “mean and hits me.” P1 did not want to question the VA about the incident where they could be overheard so s/he waited and talked to the VA in his/her bedroom after s/he finished administering medications. The VA’s shirt rode up and P1 saw a bruise below the VA’s belly button and asked the VA about it. The bruise was approximately two to three inches long and an inch wide. The VA told P1 that s/he was sitting in his/her chair in the living room when it occurred. The VA had not previously expressed any concerns about the SP to P1. · P2 stated that after P1 told him/her what the VA told P1, s/he talked to the VA. The VA did not tell P2 that anyone hit him/her or was mean to him/her. P2 did not see the bruise, but stated that another supervisor (P5) looked for a bruise and did not see one. P1 took a photograph of the bruise and P2 described the bruise in the photograph as two inches long and one inch wide and located approximately three inches below the VA’s belly button. P1 described it as “an aging bruise” because it was a light yellow color rather than purple. · P2 believed that the VA might have gotten the bruise when s/he bumped into something or possibly from the seatbelt in the facility’s van. P3 stated that the VA sometimes “banged into things” if s/he lost his/her balance and the VA sometimes told the staff persons that s/he did not like them when s/he was upset. Neither P3 nor P4 noticed a bruise on the VA. · P2 believed that the VA was “hit or miss” on accurately describing events, but that when something “significant” happened to the VA, the VA typically told “everyone” about the incident and wanted everyone to know about it. In this case, the VA only talked to P1 about the incident. P2 stated that the VA sometimes “accused” others of doing something the VA did to them. P2 believed that if the VA was hit, s/he would “yell out.” None of the staff persons heard the VA yell about being hit. P4 stated that the VA sometimes said that others were “mean” to him/her, but P4 believed that the VA was talking about someone “not giving [him/her] a snack or something.” The VA did not provide names of those who were “mean” to him/her. · P1 stated that two or three days after the VA told him/her about the incident, the VA walked up to the SP and told the SP, “I like you.” P2 stated that after the incident, the VA and the SP “were working fine” together. P1 stated that the SP was typically “very friendly” with the residents and seemed interested in what they had to say. P3 stated that s/he did not see the SP be disrespectful to the residents. P4 stated that the SP was “good” with the residents and the residents liked the SP’s cooking. The SP provided the following information: · On one occasion, the SP took the VA to an activity where the VA built a birdhouse. The VA and the SP built the birdhouse together and the VA was “excited” and it was a “good day.” When they returned to the facility, another staff person assisted the VA with taking a bath. None of the staff persons observed a bruise on the VA’s stomach. · The SP believed the VA might have gotten a bruise from the seatbelt in the facility’s van because the VA had a “big belly,” but did not know how the bruise occurred. The SP stated that s/he did not hit the VA. · The SP stated that when asked a question, the VA typically answered, “Yes.” The VA sometimes said that s/he did not like someone and when questioned about why s/he did not like that person, the VA would continue to answer “yes” to any questions. The G stated that prior to the incident, the G had no concerns about the care the VA received at the facility. The VA sometimes engaged in self-abuse, but that typically involved the VA biting his/her forearm or hitting his/her head on the wall. The G believed someone might hit the VA to prevent the VA from trying to bite or hit them. A photograph of the VA’s stomach taken on May 13, 2026, by P1, showed a long thin bruise below and to the left of the VA’s belly button. Facility documentation showed that the SP, P1, P2, P3, and P4 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: The VA told P1 that the SP was “mean” and that the SP hit the VA. P1 observed a bruise on the VA’s stomach and took a photograph of it. P2 later saw the photograph and described it as “aging” because it was a light yellow color. The VA did not tell anyone else about the SP hitting the VA even though the VA typically told “everyone” about any significant incidents. The SP stated that s/he did not hit the VA. Although the VA had a bruise on his/her stomach, none of the staff persons except P1 noticed the bruise and it was unclear when or how the bruise occurred. None of the staff persons previously had concerns about the SP’s interactions with the VA. Although the VA told P1 that the SP hit the VA, given the conflicting information provided by the VA and the SP about the incident; that there were no witnesses to the incident; that it was unclear when the bruise on the VA’s stomach occurred; that the VA frequently said that the staff persons were mean to him/her; and that the VA was not always a reliable reporter of events, there was not a preponderance of the evidence whether any of the SP’s actions could reasonably be expected to produce physical pain to the VA or was repeated oral conduct which would be considered by a reasonable person to be disparaging, derogatory, humiliating or threatening and could reasonably be expected to produce emotional distress to the VA. It was not determined whether physical or 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: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and/or 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 the facility’s policies were adequate and followed if the concerns were not “substantiated.” There were prior similar concerns regarding the SP that were not “substantiated.” The VA’s Individual Abuse Prevention Plan was updated to include “considerations regarding potential unreliable reporting patterns” which staff persons were retrained on. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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