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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: 1126931-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock 651-431-6142 Suspected Maltreatment Reported: It was reported that there were concerns with how a staff person (SP) spoke to two vulnerable adults (VA1 and VA2) on two different occasions. Date of Incident(s): April 5 and May 17, 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 (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: 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 June 16, 2026; from documentation at the facility; and through twelve interviews conducted with VA2 eight staff persons (SP and P2-P7), a supervisory staff person (P1), VA1’s guardian (G1) and VA2’s guardians (G2-G3). This investigator met VA1 but s/he declined to be interviewed for this investigation. P7 did not provide information relevant to this report. Attempts were made via telephone and mail to contact and interview another staff person (P8), but P8 did not respond to the requests. VA1 was diagnosed with neuro cognitive defects, anti-social personality disorder, schizoaffective disorder, bipolar disorder, and psychoactive substance dependence. The VA1 enjoyed spending time with family, going out to eat and shopping. VA1’s Individual Abuse Prevention Plan stated that VA1 had a history of assault and abuse towards others. If peers or others where emotionally abusive this could lead to VA1 putting him/herself and others in danger and s/he may retaliate against others. VA1’s Self Management Assessment stated that VA1 had a history of violent outbursts and not being able to manage behaviors. VA2 was diagnosed with schizoaffective disorder and bipolar disorder and substance abuse. VA2 enjoyed music, fishing, going to the gym and sports. VA2’s Individual Abuse Prevention Plan stated that VA2 had a history of physical and verbal aggression towards staff persons and other residents. VA2’s Self Management Assessment stated that VA2 had a history of violent outbursts and inserting him/herself into situations that do not involve him/her. The Conduct between Staff and Individuals Receiving Supports policy stated that individuals will be treated with courtesy, dignity and respect. All staff persons interviewed were trained on VA1 and VA2’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Regarding VA1: P2 provided the following information: · On May 17, 2026, around 12 p.m., P2 was in the office, next to the kitchen, with the door open. The SP was sitting at the dining room table eating and P3 and P5 were in the living room which was open to the kitchen and dining room. VA1 went into the kitchen and asked to no one in particular, what was for lunch and the SP said, “You’re a grown up and can make your own lunch.” VA1 then called the SP a “bitch” and the SP said, “Don’t fucking call me a bitch.” VA1 told the SP to “stop talking” and the SP said, “I don’t have to do shit.” · During this interaction, VA1 and the SP both had raised voices as P2, P3 and P5 tried to deescalate the situation by requesting VA1 go downstairs but VA1 refused and they each remained in the dining room. · For the next five to seven minutes, VA1 and the SP continued use raised voices and swear at each other. Eventually VA1 went downstairs to his/her bedroom. When P2 tried to redirect the SP, the SP said, “I don’t have to leave. [VA1] can move if [s/he] doesn’t like it.” · Before the end of P2’s shift at 1 p.m., s/he spoke with VA1. VA1 was upset and said that s/he “felt like [s/he] lost a friend”. · P2 stated that VA1 and the SP had a “good rapport, and they got along well.” P2 had not seen the SP interact with VA1 in this way in the past. P3 and P5 provided the following information: · On May 17, 2026, “around lunchtime,” P3 and P5 were in the living room with a client and heard an argument between VA1 and the SP. VA1 started yelling at the SP calling the SP names and using “demeaning words” towards the SP. VA1 said “you’re lucky you [have a physical condition]” and the SP said, “What are you going to do? . . . beaters go to jail.” · P3 and P5 attempted to intervene and deescalate the situation but VA1 refused to listen. P5 also told the SP that s/he cannot be going back and forth arguing with a client. · P3 and P5 each stated the interaction lasted about five to six minutes and then VA1 went downstairs. · P3 and P5 each had not heard the SP swear during the interaction with VA1 but that SP used a loud and firm voice and each said they had not seen/heard the SP interact with VA1 in this way in the past. P4 did not work the day of the incident, but on May 18, 2026, P4 heard the SP telling another staff person about it. The SP stated, “[The VA] doesn’t know the kind of ties I have. I’ll get [him/her] locked up where [s/he belongs]. I am not going to hold back because [s/he] was disrespectful.” P4 stated that s/he had not heard the SP swear at any clients but the SP could be rude and dismissive. The SP provided the following information: · On May 17, 2026, the SP worked from 7 a.m. to 3 p.m. Between 11:30 a.m. and 12 p.m., the SP was in the kitchen sitting at the dining room table when VA1 entered and was making lunch for him/herself. VA1 asked the SP if another client ate and the SP answered, “Yes.” VA1 then started yelling at the SP and said, “Answer me fucking bitch?” The SP said, “I answered you, and I was respectful. I do not appreciate being called a name.” · VA1 continued being “upset” and told the SP, “You are lucky [you have a physical condition].” The SP then told VA1 to not threaten him/her and that if the VA “laid hands on the SP, the VA would go to prison. VA1 started slamming things and being aggressive by coming towards the SP. · The SP stated that P3 came into the kitchen to deescalate the situation and offered to go on a walk with VA1 but VA1 declined and eventually went downstairs. · The SP denied swearing at VA1 and said that s/he spoke “audibly” enough for VA1 to hear him/her. P1 provided the following information: · P1 was not at the facility at the time of the incident. P2 completed an Incident Report stating that VA1 and the SP got into a verbal altercation. The Incident Report did not say that the SP swore at VA1 but the SP “continued arguing” with VA1. · Arguing with clients was against facility policy and clients need to be treated with respect. Staff persons are expected to be role models. · P1 later spoke to the SP about respectful interactions with clients. G1 was not aware of the allegations and did not have any concerns with the SP or the facility. Regarding VA2: P6 and P7 provided the following information: · On April 5, 2026, P6, P7, and the SP were working at the facility. Around dinner time, P7 was on an outing with another client, P6 was in the office, and the SP was sitting at the dining room table. VA2 went into the kitchen and started throwing food away and calling the SP racial slurs and “bitch.” P6 stated that s/he could tell VA2 was agitated. · P6 left the office and went into the dining room and sat down next to the SP. VA2 continued using racial slurs towards the SP and throwing food away. VA2 then grabbed the SP’s food and threw it into the garbage. The SP raised his/her voice asking VA2 why s/he threw the SP’s food away. · P6 and the SP went into the office as VA2 continued to throw food away and saying racial slurs. P6 and the SP remained in the office and 15 to 20 minutes later VA2 left the kitchen and went downstairs to his/her bedroom. · P6 denied hearing the SP swear at VA2. P7 never heard SP swear at any of the clients. P6 and P7 each stated that when VA2 is upset or agitated s/he used racial slurs towards staff persons. VA2 provided the following information: · On the date of the incident, VA2 was sitting on the couch in the living room and for an unknown reason s/he got “upset.” VA2 went into the kitchen and grabbed the SP’s plate of food and threw it away. VA2 then went into the refrigerator and threw other staff persons food away.
· VA2 said s/he did not know why s/he did this and the SP “is a kind person” and “I was the one yelling, [s/he] was trying to defend [his/her] property.” VA2 said the SP raised his/her voice but did not swear at VA2. G2 and G3 were not aware of the allegations and had no concerns with staff persons. G2 and G3 stated that there was a period of time when VA2’s psychiatrist changed medications and it caused VA2 to have an increase in behaviors. Conclusion: Although there were two incidents when the SP likely did not speak to VA1 and VA2, respectively, in a therapeutic manner, given that VA2, P1-P6, and G1-G3 did not have concerns with the SP’s previous interactions, there was not a preponderance of the evidence whether the SP’s single interaction with VA1 and VA2, respectively, would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening or could reasonably be expected to produce emotional distress. It was not determined whether 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: 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 stated that their policies and procedures were adequate but not followed. Additional coaching/training was provided to the SP. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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