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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: 1131167-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns/Alice Percy 651.431.6513 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not provide adequate supervision to a vulnerable adult (VA) when the VA bit him/herself on the foot, resulting in a “chunk” of skin being bitten from the VA’s foot which required medical treatment. Date of Incident(s): May 19, 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 17, paragraph (a): 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 during a site visit conducted on May 28, 2026; from documentation at the facility and medical records; and through six interviews conducted with a facility staff person (P1), two administrative staff persons (P2 and P3), the SP, and the VA’s two guardians (G1 and G2). This investigator met with the VA, but the VA did not provide information about the incident. The VA enjoyed assisting with food preparation, listening to music, watching television, working on puzzles, playing with cards, and spending time with his/her family members. The VA’s diagnoses included autism, mild developmental disability, Smith-Magenis syndrome (chromosome deletion), attention-deficit hyperactivity disorder, obsessive compulsive disorder, seizures, and generalized epilepsy/staring spells. The VA’s Challenging and Unsafe Behaviors stated that the VA might engage in self-injurious behaviors, such as headbanging, hair-pulling, self-biting, and skin picking during periods of heightened emotional dysregulation. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to self-abuse and might hit walls with his/her head or fists, bite him/herself, hit him/herself in the head, or pick at his/her skin. The staff persons were to provide close observation of the VA during high-stress times and to conduct frequent wellness checks. The staff persons were to also keep the environment calm and structured. The VA’s Support Plan Addendum stated that if the VA engaged in self-injurious behaviors, the staff persons were to redirect the VA and calmly provide other options for coping skills or suggest an activity to engage in. The staff persons were to monitor the VA’s behavior closely to ensure the VA’s safety and to provide positive correction or redirection when needed. The VA required the presence of staff persons while at the facility and had no unsupervised time in the community. Staff persons were to provide “close supervision,” and “continuously monitor for signs of escalation.” The facility’s main level consisted of a kitchen, dining room, and living room. The dining room and living room were open to each other and were in an “L” shape around the walls of the kitchen. A large table and benches were in the dining room. Two couches were placed in the living room and were visible from the dining room. Two video cameras were placed on the wall and provided video of the dining room and living room. P1, P2, and P3 provided the following information: · P3 stated that the VA recently moved into the facility and was the only client living at the facility. P2 and P3 each stated that the VA required 2:1 supervision. Both of the staff persons were not required to “have eyes on” the VA at all times, but at least one staff person needed to be present to provide adequate supervision to ensure the VA was safe. · P1 stated that on May 19, 2026, at the time of the incident, s/he and the SP were working at the facility. P1 went to an upper floor of the facility to use the bathroom and then went to a staff office to complete paperwork and prepare medications, leaving the SP to supervise the VA. · P1 stated that the SP called to P1 and told him/her that there was “blood all over the place.” P1 went downstairs and saw “a lot of blood” on the VA’s hands, face, and clothing, on the floor, and on the bench the VA sat on. The VA bit the bottom of his/her left foot, causing a horizontal cut just below three toes. P1 asked the VA why s/he bit him/herself, but the VA did not say anything. The SP told P1 that s/he “looked up” and there was blood on the floor and the VA was biting his/her foot. P1 called P2 and told him/her about the incident and sent photos of the injury to P2. P2 told P1 to clean and care for the wound while P2 contacted P3. P1 and the SP cleaned the wound and cleaned the blood off the VA and the bench and floor. They put gauze on the VA’s foot so s/he could walk. P2 called P1 back and told him/her that they should take the VA to the hospital. · P1 and the SP took the VA to the hospital, where they took an x-ray and determined that there was no fracture to the foot. The VA was prescribed amoxicillin and bacitracin and P1 and the SP drove the VA back to the facility. The overnight staff person arrived at the facility for his/her work shift and assisted the VA with his/her bedtime routine. · P2 saw the VA’s injury later that week and stated that the VA bit “a sizeable chunk of skin” off the bottom of his/her foot. P2 described the wound as approximately 1 inch wide, 1.5 inches long, and .25 inches deep. P2 stated that it was not the first time the VA bit his/her foot and caused an injury. The VA typically bit the same spot on his/her left foot creating scar tissue on that area of the foot, which was easier to bite off. P2 stated that it could happen “in the blink of an eye.” When the VA began to exhibit self-injurious behaviors, the staff persons were to try and redirect the VA or ask another staff person to attempt to intervene. However, P2 stated, “Once [the VA] gets like that, it’s usually going to escalate until [s/he] accomplishes what [s/he] is trying to accomplish.” · P3 stated that the staff persons had blocking pads that they could place between the VA and any part of his/her body that s/he was biting, but they could not force the pads or touch the VA with their hands. If the VA engaged in self-injurious behaviors, the staff persons were to attempt to distract him/her. The VA liked “to be left alone” and sometimes yelled at the staff persons to leave him/her alone. P1 stated that the VA did not like to have others in his/her “personal space.” The VA did “not allow” the staff persons to sit at the dining room table when the VA sat there, so the staff persons typically sat on one of the living room couches while the VA was at the table. If one staff person had to complete tasks around the facility, they would typically tell the other staff person what they were going to do so that the other staff person could ensure that they were available to supervise the VA. · P3 stated that P2 notified him/her about the incident. The following day, P3 watched the videos from the cameras in the facility and determined that the VA bit his/her foot for eight minutes before the SP noticed that the VA was biting him/herself. P3 believed that the piece of skin that the VA bit off his/her foot was about the size of a dime. At the time of the incident, the VA sat at the dining room table. The SP sat on a living room couch with a laptop computer on his/her lap and a cell phone in his/her hand. P1 was on the upper level of the facility. · P1 stated that prior to the incident, s/he worked with the SP on two other occasions. Although the SP checked emails or texts, the SP did not look at his/her personal electronic devices “to an absurd extent.” P2 stated that the staff persons were not to use their personal electronic devices while they were working at the facility. The SP provided the following information: · The SP recently began working at the facility. The day of the incident was his/her second work shift after three days of “shadowing” other staff persons. On previous days when the SP was at the facility, the VA began to bite him/herself, but s/he stopped biting when the staff persons asked him/her to stop. The SP stated that since s/he was a “new” staff person, the VA did not “listen” to him/her and only listened to P1. · On the day of the incident, at 2 p.m., the SP began his/her work shift and at approximately 3 p.m., the VA arrived back at the facility from school. The VA had a snack and then told the staff persons to “go away and don’t come near me.” At approximately 7 p.m., P1 went upstairs to the staff office to prepare medications and do documentation, leaving the SP to supervise the VA. The VA sat at the dining room table and the SP sat on a living room couch, holding either his/her laptop or cell phone. The SP stated that s/he watched the VA, but when the VA saw the SP look at him/her, the VA told the SP to stop looking at him/her, so the SP had to watch the VA “from the side.” The SP looked at the VA “every two minutes.” When the VA began to bite his/her foot, the SP asked him/her to stop, but the VA continued to bite, so the SP asked the VA not to take off his/her sock. The VA took off his/her sock, continued to bite his/her foot, and told the SP to not tell him/her what to do. The SP called out for P1 to assist him/her. As P1 came downstairs, the VA continued to bite his/her foot and P1 was there when the VA bit off a piece of his/her skin. The VA then placed his/her foot on the floor and the wound began to bleed on the floor. · The SP and P1 took the VA to the hospital, where the VA’s physician prescribed an antibiotic for the VA, gave the SP and P1 items to use to dress the wound, and gave them instructions on how to dress the wound. The SP stated that the staff persons could use a blocking pad when the VA began to his/her head on the wall or floor. The staff persons were not supposed to touch the VA when s/he had behaviors, but could tell the VA to stop the behaviors or try to redirect him/her. The facility had two video cameras that showed the kitchen and living room areas of the facility. Both videos included audio. A review of two video recordings dated May 19, 2026, from 6:39:37 to 7:26:29 p.m. showed the following: o At 6:39:39 p.m., the VA was eating at the dining room table. The VA took his/her plate into the kitchen and then returned to the dining room table. The VA was wearing socks. The SP sat on the couch talking on his/her cell phone. o At 6:40 to 6:46:20 p.m., P1 entered the dining room from the kitchen and gave the VA a 20-minute notice to take a shower. The VA told P1 to leave him/her alone and s/he took a shower that morning. The VA played with cards. The SP continued to talk on his/her cell phone. o At 6:46:20 p.m., the VA looked at the SP, who was talking on his/her cell phone. o At 6:48 p.m., the VA continued to look at and write on his/her cards. The SP talked on his/her cell phone. o At 6:48:53 to 6:49:33 p.m., the VA picked at his/her right wrist and grimaced while still picking at his/her arm. o At 6:50:03 to 6:50:51 p.m., the VA bit a finger on his/her right hand, then returned to picking at his/her right wrist. o At 6:51 p.m., the SP sat on the couch and faced the television. S/he was talking on his/her cell phone while his/her laptop was on his/her lap. o At 6:51:36 p.m., the VA picked at his/her left hand and looked at the SP, who was still talking on his/her cell phone. o At 6:52:26 p.m., the VA began to bite his/her left hand and looked at the SP. o At 6:53:31 p.m., the VA reached for his/her right foot which was folded over his/her knee under the table and looked at the SP. o At 6:53:58 p.m., the VA pulled his/her right foot into view and brought it towards his/her mouth. There was no sock on the VA’s foot. o At 6:54 to 6:57:02 p.m., the VA bit his/her right foot and then put the sock back on the foot. o At 6:57:19 p.m., the VA turned to face the living room and brought his/her left foot onto the bench, looked at the SP, took off his/her sock, and looked at his/her foot and toes. o At 6:57:25 p.m., the VA picked at his/her toes. o At 6:57:42 p.m., the SP continued to talk on his/her cell phone as s/he used his/her computer. o At 6:57:52 p.m., the VA put his/her left foot in his/her mouth and alternated biting and picking at the bottom of his/her left foot. The SP was talking on his/her cell phone. o At 6:58 to 6:59:52 p.m., the SP continued to talk on his/her cell phone and did not look at the VA. o At 6:59:53 p.m., the SP ended his/her phone call and the VA continued to bite his/her foot. The SP did not look at the VA. o At 7:01:23 p.m., the SP looked at his/her cell phone. Audible digital sound played and the SP stopped using his/her cell phone and started using the computer. o At 7:02:23 p.m., the SP looked over at the VA for the first time and told him/her to stop biting. o At 7:02:45 p.m., the VA told the SP to go away and the SP told the VA that s/he was bleeding. The SP called for P1. The SP told the VA that P2 was in the driveway even though P2 was not there. o At 7:02:49 p.m., the VA had blood on his/her face and blood was dripping from the VA’s foot onto the floor. The SP again told the VA that P2 was there. o At 7:03:02 p.m., the VA told the SP that P2 was not there and began to bite his/her foot again. The SP left the room and there were sounds of him/her going upstairs. o At 7:03:19 p.m., the SP and P1 came down the stairs and entered the room. P1 asked the VA to stop biting him/herself. The VA stopped biting and lowered his/her foot. P1 looked at the VA’s foot and left the area. o At 7:04:07 p.m., P1 returned to the dining room with a first aid kit and asked the VA why s/he bit him/herself. o At 7:05:04 p.m., the SP asked P1 if s/he could clean the VA and suggested that P1 take a photograph of the VA’s foot before s/he cleaned it. o At 7:05:49 p.m., P1 called P2 and sent a photograph of the VA’s foot to him/her. The SP cleaned the VA’s foot. P2 told P1 that s/he would contact P3 to see if they should take the VA to the hospital. The SP continued to clean the VA’s foot. o At 7:13 p.m., P2 called P1 and told him/her to take the VA to the hospital. o At 7:16:15 p.m., P2 suggested that the VA take a shower and the VA reached for the SP’s hand to help him/her walk off camera. P1 cleaned the floor and bench. The hospital’s Emergency Department Note stated that on May 19, 2026, at 8:18 p.m., the VA was seen by a physician for a self-inflicted bite wound to the left foot. The VA bit the bottom of his/her left foot near his/her toes. A staff person noted that the VA bit “pretty hard” and there were pieces of skin on the floor after the bite. An x-ray showed no fracture of the foot. The wound was cleaned and dressed and the VA was prescribed the antibiotic amoxicillin-clavulanate. At 9:29 p.m., the VA was discharged and returned to the facility with the staff persons. G1 stated that the VA had been picking at and biting the skin on his/her feet for years and it was hard to redirect the VA. G1 and G2 did not go to the hospital every time the VA was taken there for his/her injuries, because they did not want to give the VA positive attention for his/her actions. G2 stated that the VA had a history of self-harm and the facility notified them whenever s/he had an injury. The VA recently moved into the facility and the VA took time to adjust any time there was a change in his/her environment. The VA was unable to provide accurate information about incidents. Facility documentation showed that the SP, P1, P2, and P3 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: A. Maltreatment: On May 19, 2026, P1 went to the staff office to complete paperwork and prepare medications while the SP remained in the living room/dining room area with the VA. While the VA sat at the dining room table, the SP sat on one of the couches in the living room holding a cell phone and a laptop computer. The SP stated that the VA told him/her not to look at the VA, so the SP watched the VA “from the side” and looked at the VA “every two minutes.” When the VA began to bite his/her foot, the SP asked him/her to stop, but the VA continued to bite, so the SP called out for P1 to assist him/her and then went upstairs to get P1. P1 went downstairs and saw “a lot of blood” from where the VA bit his/her foot. P1 asked the VA to stop biting him/herself, which the VA did. P1 called P2 while the SP began to clean and cover the VA’s wound. P1 and the SP took the VA to the hospital, where s/he was prescribed amoxicillin, and then drove the VA back to the facility. Although the SP stated that s/he watched the VA “from the side” after the VA told the SP not to look at him/her and then looked at the VA every two minutes, given that the video recordings from the time of the incident showed the SP did not look at the VA every two minutes and showed the VA biting and picking at his/her hands and feet from 6:46:20 p.m., when P1 went upstairs, until 7:02:23 p.m., when the SP looked over at the VA for the first time and told him/her to stop biting by at which point the VA bit skin off of his/her foot and was bleeding; that the VA had a history of self-injurious behaviors; and that the VA’s plans stated that if the VA engaged in self-injurious behaviors, the staff persons were to redirect the VA and calmly provide other options for coping skills or suggest an activity to engage in and monitor the VA’s behavior closely to ensure the VA’s safety and to provide positive correction or redirection when needed which the SP did not do, there was a preponderance of the evidence that there was a failure to supply the VA with care or services that were reasonable and necessary to maintain the VA’s physical or mental health or safety. It was determined that 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). 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. Facility documentation showed that the SP and P1 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. Although P1 was also responsible for the VA’s supervision, given that P1 was engaged in work activities in the staff office at the time of the incident, his/her responsibility was mitigated. 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 neglect for which the SP was responsible was not recurring maltreatment because it was a single incident, but was serious maltreatment because the VA sustained an injury that required the care of a physician. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate but were not followed. After the incident, all staff persons were retrained on the VA’s plans. The SP no longer worked at the facility.
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.
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