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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: 1079315-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Alice Percy 651-431-3444 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) made a vulnerable adult (VA) move the SP’s furniture and belongings in return for an energy drink. While moving the SP’s belongings, the VA injured his/her back. Date of Incident(s): May 16, 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 9, paragraph (b), clause (4); and subdivision 17, paragraph (a): In the absence of legal authority a person forces, compels, coerces, or entices a vulnerable adult against the vulnerable adults will to perform services for the profit or advantage of another. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained remotely; from documentation at the facility and medical records; and through nine interviews conducted with two facility staff persons (P1 and P2), two supervisory staff persons (P3 and P4), the SP, the VA, the VA’s guardian (G), the VA’s case manager (CM1), and the VA’s former case manager (CM2). The VA enjoyed shopping, walking, going to the mall, bowling, participating in Special Olympics, and spending time with his/her friends and family members. The VA’s diagnoses included autism spectrum disorder, attention-deficit disorder, unspecified mood disorder, anxiety disorder, post-traumatic stress disorder, personality disorder, intermittent explosive disorder, mild intellectual disabilities, oppositional defiant disorder, and fetal alcohol syndrome. The VA’s ISSA Assessment Detail stated that the VA did not have any mobility issues or concerns. The VA might have trouble identifying abusive situations and might cooperate when in an abusive situation. A staff person was to accompany the VA in the community at all times. The VA’s Risk Assessment Detail stated that the VA had 15 minutes of unsupervised time while at the facility and in the community. The VA was unable to handle his/her finances. The VA initially stated that s/he was at the SP’s home on two days helping the SP move, but then stated that on three or four occasions, s/he went to the SP’s home to help the SP move. The VA hurt his/her back carrying “heavy stuff” like chairs and bedding. The SP did not pay the VA for helping him/her move even though the SP told the VA s/he would pay the VA $40. The VA then told the G about the incidents. P1 – P4 provided the following information: · P1 stated that on the day of the incident, the SP asked P1 to take the VA to the SP’s home, which P1 did. P1 then left the SP’s home. P2 stated that at 2 p.m. that day, s/he began his/her work shift at the facility. As s/he arrived at the facility, the VA and P1 left to go to the SP’s home. The VA told P2 that s/he was going to “help [the SP] with [his/her] house.” At approximately 4 p.m., the SP called P2 and asked him/her to pick up the VA and drive him/her back to the facility, which P2 did. The VA told P2 that s/he helped the SP move and s/he was tired, but it was “good.” P1 and P2 did not recall the VA complaining of back pain that day or the following day. · P3 stated that on May 18, 2026, the VA called P3 and told him/her that the SP took the VA to his/her home and made the VA move things like chairs and couches and the VA’s back now hurt. P3 told P4 about the incident and had the staff persons take the VA to Urgent Care. The physician said the VA was “fine” and that the VA should take ibuprofen if s/he was in pain. The staff persons “watched” the VA for a week and s/he had no further complaints of pain. · P4 stated that the SP told P4 that on the morning of the incident the VA overheard him/her talking about moving and the VA wanted to see the U-Haul truck the SP had rented for the move. The SP told P4 that the VA did not carry anything while s/he was at the VA’s home. The SP’s “old” home and “new” home were each approximately a 30-minute drive from the facility. · P1 had no concerns about the SP’s interactions with the residents. P3 stated that the SP did not always follow the facility’s policies and that the SP should not have taken the VA to his/her home because the facility’s policies stated that the staff persons were to take the residents on outings into the community and not to the staff persons’ homes. · P1 stated that the VA did not always provide an accurate account of events. P2 stated that when the VA was in a “bad mood,” s/he would provide inaccurate information or would say something because s/he wanted attention. P4 stated that while the VA sometimes told “small fibs,” s/he typically would later provide accurate information.
The SP provided the following information: · The SP had a good relationship with the VA and when the VA heard that the SP was moving to a new home, the VA “got really excited” because the VA was also moving soon. The VA asked the SP if s/he could see the “process” of moving and explore the U-Haul truck the SP rented for the move. At approximately 2:30 p.m., the SP asked P1 to drive the VA to the SP’s home so that the VA could watch the moving process. The SP had hired movers to move his/her belongings so they watched them move items and the SP purchased food for the movers and the VA to eat. The VA wanted to see the SP’s new home, so the SP drove the VA to his/her new home and showed the VA the home’s “amenities.” The SP believed the VA was with him/her for approximately an hour and then at approximately 4 to 4:30 p.m., the SP called P2 to pick the VA up and drive him/her back to the facility. The SP worked at the facility that day and was “on the clock” during the time the VA was with him/her. The SP believed that taking the VA to his/her home was an “outing” for the VA and the VA was excited to go. · The SP stated that the VA was with the SP the entire time and the SP did not leave the VA alone “for even a second.” The SP did not ask the VA to help move any items because s/he had hired others to do the work. The VA did not try to carry anything and the SP believed the VA did not have the capacity to lift or move things. The VA asked for an energy drink, but the SP gave the VA water because energy drinks often caused the VA to be in a bad mood because of the caffeine. The SP told the VA that s/he might get an energy drink for the VA “later.” · The VA did not mention anything about his/her back hurting until two days later. The SP was not scheduled to work that day and s/he believed the VA might have been waiting to get the energy drink and when the SP did not get the energy drink for the VA, the VA was “triggered” and complained that the SP made him/her work. In the past, the VA made “false allegations” about the staff persons and told the G that the staff persons were not providing him/her food even when the reason was that the VA declined food. · The VA did not have a history of back pain and in the past had not complained to the SP about back pain. The VA had not been to the SP’s home on any previous occasions. The G stated that on May 18, 2026, the VA told the G that s/he was “super excited” because the SP was going to give him/her an energy drink because the VA helped the SP move his/her furniture. The VA was not mad that the SP had the VA move furniture, but was excited to get an energy drink. Later that day, the VA’s clinic sent a text to the G saying that the VA had an appointment scheduled. The G called the facility and was told that the VA was complaining of back pain so they were taking him/her to Urgent Care. The G asked to talk to the VA, who told the G that his/her back hurt because s/he moved the SP’s furniture. The VA told the SP that his/her back hurt, but the SP told the VA that it would be “okay.” The G stated that the SP should not take the VA to his/her home, have the VA help him/her move, pay the VA with only an energy drink, and then not seek medical care for the VA when the VA told him/her that s/he hurt his/her back. The SP later sent an email to the G saying that s/he took the VA to his/her home, but did not have the VA move any of his/her belongings. In the past, the G had several concerns about the care the VA received at the facility which the G shared with the supervisory staff persons. CM1 stated that the G notified CM1 about the incident after the VA told the G that s/he injured him/herself moving items at the SP’s home. The VA told the G that the SP “paid” the VA by buying him/her an energy drink. CM2 stated that the VA was inconsistent with providing accurate information about events. The VA valued his/her relationships with others, including the staff persons. The facility’s Internal Investigation stated that a moving company employee who was hired to move the SP’s belongings provided information that on the day of the incident s/he did not see the VA carry any boxes. The hospital’s Urgency Room Note stated that the VA told the physician that s/he was in the process of moving and two days ago s/he lifted heavy boxes and developed lower back pain. The physician believed the VA “likely” had a muscle strain. The VA declined pain medications. 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: On the morning of May 16, 2026, the VA heard the SP talking about moving and renting a U-Haul truck. The SP stated that the VA was also planning on moving and was excited to see the truck, so at approximately 2 p.m., the SP had P1 drive the VA to the SP’s home. The SP hired movers to move his/her belongings and while the VA was there, s/he purchased food for the movers and the VA to eat. The VA wanted to see the SP’s “new” home so the SP then drove the VA to the new home and showed the VA around. At approximately 4 p.m., the SP telephoned P2 and asked him/her to drive the VA back to the facility. The SP stated that s/he was with the VA the entire time and VA did not move any of the SP’s belongings because the SP had hired movers. P4 stated that both of the SP’s homes were a 30-minute drive from the facility. The SP, P1, and P2 each provided information that the VA did not tell the staff persons that s/he had back pain until two days after s/he went to the SP’s home. The SP believed the VA was upset with him/her for not giving the VA an energy drink in the days after the VA went to the SP’s home. When the VA complained of back pain, the VA was taken to Urgent Care, where the physician believed the VA had muscle strain. Regarding financial exploitation: The VA stated that the SP did not give the VA $40 for helping the SP move like the SP promised. The VA told the G that s/he was excited that the SP was going to give him/her an energy drink for helping the SP move furniture. The SP stated that the VA did not help move any of the SP’s belongings and although the VA asked for an energy drink while s/he was with the SP, the SP gave the VA water because the VA was not to have caffeine. According to the facility’s Internal Investigation a moving company employee who was hired to move the SP’s belongings provided information that on the day of the incident s/he did not see the VA carry any boxes. Although the VA stated that s/he helped the SP move his/her furniture and belongings and was promised payment, given the inconsistent information provided by the VA and the SP and that no additional information was provided that the VA moved any of the SP’s belongings, there was not a preponderance of the evidence that the SP forced, compelled, coerced or enticed the VA to move the SP’s belongings. It was not determined whether financial exploitation occurred (in the absence of legal authority a person forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult’s will to perform services for the profit or advantage of another). Regarding neglect: The VA provided consistent information to the G and during his/her interview that s/he hurt his/her back when moving the SP’s furniture. The SP stated that the VA wanted to go to the SP’s home to see the U-Haul truck and to see the SP’s new home. The SP had hired movers to move his/her belongings and the VA did not help move any of the SP’s belongings. The VA was with the SP less than two hours, including the time eating and going to see the SP’s new home. Given that it was not determined whether the VA moved the SP’s belongings and that the VA did not complain of back pain until two days after s/he went to the VA’s home, it was unclear when or how the VA strained his/her back muscles. In addition, when the VA complained of pain, the VA was taken to the urgency room for evaluation. Therefore, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services which were reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. After the incident, the VA’s plans were updated, the staff persons received additional training, and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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