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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: 1128241-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson (651) 431-6578 Suspected Maltreatment Reported: It was reported that a staff person (SP) repeatedly slapped a vulnerable adult (VA) during a van ride when the VA reached for snacks. Date of Incident(s): November 24, 2025 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 December 8, 2025; from documentation at the facility; and through six interviews conducted with the SP, the VA, the VA’s case manager (CM), two staff persons (P1 and P2), and a supervisory staff person (P3). Attempts were made via phone to contact and interview another supervisory staff person (P4) but P4 did not respond. P4 provided information for the facility’s Internal Review that was included below. The VA’s guardian (G) did not have additional information to provide about the incident. This investigator met the VA; however, s/he hid and did not wish to provide information. The VA was the only person who lived at the facility, had lived there since July 2025, and previously lived at a different residential program operated by the same license holder. The VA was diagnosed with attention deficit hyperactivity disorder, autism spectrum disorder, profound intellectual disability, mood disorders, and cognitive impairments, and was non-verbal. The VA’s plans stated that s/he required 2:1 staff supervision while at home and in the community. The VA was susceptible to physical abuse due to his/her inability to identify potentially dangerous situations, lack of community orientation skills, inappropriate interactions with others, inability to deal with aggressive persons, and because s/he was physically abusive to others in the past. The VA had a history of biting, hitting, and banging his/her head when s/he was upset. Staff persons were directed to verbally redirect the VA’s self-injurious behaviors and “inappropriate” actions. P1 provided the following information in the interview and in an Incident Review dated December 1, 2025: · On November 24, 2025, P1 and the SP worked together for the first time. The VA was having a “hard day,” and was hitting P1 and the SP. P1 and the SP thought that taking the VA on a ride in the facility vehicle might calm the VA. · Before getting in the vehicle, P1 and the SP packed a bag for the VA that included snacks in case s/he got hungry. In the car, P1 sat in the driver’s seat, the VA sat behind P1, and the SP sat next to the VA. The SP put the VA’s snack bag on the front passenger seat of the vehicle. In the past, the VA tried to reach for the bag in the front seat from the back seat while the vehicle was in motion, so staff persons typically did not put the snack bag on the front seat. P1 then moved the bag near the VA’s feet, within the VA’s reach because P1 thought that the VA would want a snack while they were driving. · After an unknown amount of time while they were still driving around, the SP put the VA’s bag back on front seat of the vehicle. The VA was hitting him/herself and P1 thought the VA wanted his/her bag or a snack. P1 tried to put the bag in the back seat but swerved into another lane while trying to do so. P1 then left the bag on the front seat. “A few minutes” passed, and the VA tried to grab the bag from the front seat. P1 turned his/her head to check what was happening in the backseat and the SP told P1 that s/he needed to focus on the road. P1 then saw the SP grab the VA’s shoulder and then slap the VA on the shoulder. The VA reached for the bag again and the SP slapped the VA’s hand. · P1 then gave the VA the bag and told the SP, “You can’t do that,” and that the SP needed to tell the VA to sit and wait because the VA understood when just talked to. Staff persons were not allowed to touch the VA at all because it made him/her “aggressive.” P1 argued with the SP about what happened as they drove back to the facility and P1 reiterated to the SP that s/he could not hit the VA, but the SP denied having hit the VA. After P1, the VA, and the SP returned to the facility, P1 and the SP continued to “argue” about the way that the SP treated the VA. P1 then texted P2 and informed him/her what happened. P1 stated that s/he did not check the VA for injuries. [Note: Requests were made to P1 for screenshots of his/her text messages to P2, but P1 did not provide them by the completion of this report.] P1 stated that after their shift on November 24, 2025, s/he did not work with or see the SP again. The SP provided the following information: · On November 24, 2025, the SP and P1 worked together for the first time, and they took the VA on a ride in the facility vehicle; P1 drove and the SP sat in the backseat with the VA. The VA ate a snack during the drive and when s/he was finished, s/he tried to hit the SP. The VA’s snack bag was then placed on the front seat. As they drove, the VA unbuckled and tried to get up to get his/her bag of snacks that was on the front seat and the SP told him/her to sit down and buckle up, which the VA did with the SP’s assistance. While they were driving back to the facility, the SP held the VA’s seat belt so that the VA could not unbuckle it. During this time, the VA again tried to hit the SP. Once they returned, the SP administered the VA a PRN (as needed) medication. The SP stated that “nothing happened” in the van and there was nothing said between P1 and the SP about P1’s actions in the van. · The SP stated that P1 and the SP worked together the following weekend, November 29 and 30, 2025. On November 30, 2025, the SP and P1 got in to an “argument” over a matter unrelated to the SP’s treatment of the VA but rather the SP having raised a concern to management about P1’s work performance. Then on December 1, 2025, an unknown administrative staff person called the SP and said s/he was no longer employed because an allegation was made that on November 24, 2025, during a car ride the SP hit the VA on the shoulder. The SP denied hitting the VA. The SP believed that P1 made the allegation due to the SP raising the work performance concern about P1 and their subsequent argument because the administrative staff person told the SP that the report had been made the day prior and not on November 24, 2025, the day of the alleged incident. · The VA was “sometimes aggressive” when s/he went on rides and tried to stand up and get out of the vehicle when it was moving. The SP said that s/he held the VA’s seatbelt in the past to prevent the VA from unbuckling it and help him/her stay seated. Information provided by P4 in the Internal Review and by an administrative staff person (P5), via email, showed that on November 30, 2025, P1 told P4 that on November 24, 2025, the SP slapped the VA on the shoulder twice and yelled at him/her “aggressively.” The Internal Review stated that November 30, 2025, was the first time that P4 or another supervisor (P5) received information on the alleged incident. P3 stated that on an unknown date, P4 told him/her about “an incident” that occurred between the SP and the VA, but P4 said s/he was “dealing with it.” P3 did not work with the SP beyond training him/her in. If the VA was demonstrating a maladaptive behavior in the car, staff persons were trained to keep the VA’s seatbelt buckled but not to hold him/her in the seat if s/he unbuckled, and give him/her a snack. P2 stated that s/he never worked with the SP nor P1 and did not have information about any incident that occurred between the SP and the VA. P2 denied receiving any text messages about an incident on November 24, 2025, that day nor afterwards. The CM stated that on December 1, 2025, s/he was told by facility administrative staff persons that the SP slapped the VA when they were in the car after the VA reached for snacks. The CM said that “at times,” the VA could be “a handful.” The VA was waiting to begin services with an occupational therapist for his/her sensory needs and the VA’s team recently started working with a behavior specialist to create a behavior support plan for the VA. All persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Conclusion: P1 said that on November 24, 2025, s/he saw the SP slap the VA on the shoulder and on the hand while they were on a car ride and that s/he text P2 about it the same day. However, P2 said s/he was not aware of the incident or text any information about the incident. In addition, the Internal Review showed thatP4 and/or P5 were first made aware of the incident on November 30, 2025, when P1 emailed that s/he saw the SP slap the VA twice on the shoulder. The SP denied hitting the VA. Although the SP had reason to minimize his/her actions, P1’s credibility was diminished when s/he provided inaccurate information regarding when and who s/he reported the incident to and different information regarding where the SP slapped the VA (the shoulder and hand or twice on the shoulder). P1 emailed P4 about the incident six days later which the SP said was after an argument with the SP who P1 said s/he never worked with again after the incident. Given P1’s diminished credibility, that the SP denied hitting the VA, and that there were no additional witnesses to support or refute either account, there was not a preponderance of the evidence whether the SP hit 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 but not followed. On December 1, 2025, all staff persons who worked at the facility were retrained. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that one individual failed to report suspected maltreatment as required. A letter from DHS was sent to the individual regarding their failure to report the suspected maltreatment and potential consequences for future such failures.
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