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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: 1088572-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-3676 Suspected Maltreatment Reported: It was reported that a staff person (SP) belittled, made rude comments towards, and swore at a vulnerable adult (VA) which caused the VA to “grow small.” It was also reported that the SP used a racially derogatory term (referred to as the n-word throughout the remainder of the report) and that the VA was not allowed to bring concerns to anyone outside of management at the facility. Date of Incident(s): Unknown 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 August 15, 2026; from documentation at the facility and through six interviews conducted with the VA, the VA’s guardian (G), two supervisory staff persons (P1 and P2), a facility staff person (P3), and the SP. The VA was diagnosed with intellectual disability, borderline personality disorder, intermittent explosive disorder, and persistent depressive disorder. The VA enjoyed going on outings, singing, dancing, and playing games. The VA’s Positive Support Transition Plan said that when the VA was confronted with a problem, s/he “created drama” instead of problem solving. The VA believed the world was “hurtful and dangerous” and that nobody sufficiently met his/her needs. The VA viewed others in “black and white terms.” The VA had a history of verbal outbursts, over-reacting, exaggerating and saying things that were “simply not true.” The VA was very talkative, enjoyed “banter” and joking around, and being funny and playful. The VA’s “triggers” included staff persons disagreeing with one another in front of the VA, getting “called out” when attempting to triangulate or manipulate staff persons, and staff persons not knowing “everything” about his/her programming. The VA said s/he “loved” having fun at the facility, but sometimes there was “drama” with staff persons talking about each other, as well as “cussing, swearing, and name calling.” The VA overheard the SP say the n-word, “pussy,” and “whoop de doo” when s/he talked to other staff persons, but the SP never called the VA those words. The VA said that s/he and staff persons joked around a lot, but sometimes the VA and P3 got “frustrated” with the joking. P3 sometimes had a “really hard time emotionally and mentally,” and “expressed” that out loud. Staff persons sometimes said other swear words when they worked, and if the VA had concerns, s/he spoke with P1 and/or P2 to discuss those concerns. P3 said that the SP “belittled” the VA, swore, used the n-word, and made rude comments towards the VA. On an unknown date, P3 heard the SP “jokingly” call another staff person the n-word, and the VA said s/he also heard the SP say that word. The SP was not “aggressive” when s/he said it and P3 thought the SP used the word like s/he was talking to his/her “best friend” outside of work. The VA took things very seriously, and P3 thought jokes should not be made with the VA because s/he did not read social cues well. The SP and other staff persons used words like “peasant, big back and brokie” with the VA. The VA would “laugh it off” but P3 thought the VA “seemed offended” because s/he “became small and quiets down” when staff persons said these things. P3 thought the SP’s interactions with the VA were “unprofessional” and that the SP “antagonized” the VA. The VA was unable to share concerns with staff persons outside of P1 and P2 because they thought the VA could be “manipulative,” however, P3 did not observe the VA to be manipulative and thought P1 and P2 were “gaslighting” the VA. P3 denied hearing another staff person use the n-word. The facility’s Internal Review stated that two unidentified staff persons used the n-word when communicating with each other, however it was not in front of or towards the VA, but may have been overheard by the VA. Staff persons denied hearing the SP use the n-word, the SP denied using the n-word when s/he worked, and there was no information found that supported the allegation that the SP “belittled,” made rude comments to, or taunted the VA. The VA said that on June 15, 2026, the SP used the n-word in conversation, however it was later determined that the SP did not work at the facility on that date. P3 did not provide information regarding the SP using the n-word during the internal review. Staff persons were reminded that the VA was “constantly” observing staff persons interactions and behaviors, paid “close attention” to what was said and done, and may use that information to “triangulate” situations. The expectation of staff persons was always to not engage in conversations and/or concerns about each other with the VA, and to not provide feedback, opinions, or commentary. P1 and P2 provided the following consistent information: · On June 19, 2026, P1 and P2 spoke with the VA and the VA said s/he overheard the SP use the n-word when speaking to another staff person. The VA denied that the SP called the VA the n-word. · P1 and P2 were aware that P3 and the SP did not see “eye to eye” at the facility. The SP was very “laid back” and had “rapport” with the VA, so the SP and the VA often joked around. P3 was more “straight forward” and thought staff persons should not joke around with the VA. P2 said P3 had a history of “feeding into” what the VA said, which created “drama and problems.” · Staff persons were encouraged to create a “playful” and “high energy” environment for the VA to keep him/her busy. The VA and staff persons often joked around and “poked fun” at each other, but never with malicious intent or to cause psychological harm to the VA. The VA knew that s/he could stop joking, and/or tell staff persons if s/he became upset. · P1 and/or P2 checked in with the VA daily, and the VA was able to contact P1, P2, and the G through telephone and email. This was arranged, because the VA had “frequent concerns” with staff persons, and the VA’s interdisciplinary team determined it was most appropriate for the VA to have a clear plan for discussing his/her concerns. The VA knew to bring concerns with staff persons to P1 and P2 to be addressed, so that staff persons could focus on supporting the VA with his/her coping skills and be a positive reinforcement for the VA, rather than focus on issues with individuals they worked with. · Neither P1 nor P2 thought the VA was an accurate provider of information due to his/her diagnosis and P2 said the VA would hear something and “twist it into a fabricated extreme.” P2 thought the VA knew the SP and P3 “butted heads” and so the VA “triangulated” the situation between the two. P1 and P2 did not have prior concern with the SP and his/her treatment of the VA. The SP provided the following information: · Staff persons had a lot of “playfulness” and “banter” back and forth, and the SP thought the more the VA did those things, the happier s/he was. The VA “always” told staff persons if something upset him/her, and staff persons helped the VA process those emotions. · When the VA had concerns with staff persons, s/he spoke with P1 and P2 about those concerns to avoid “triangulation” between staff persons at the facility. The VA had a history of wanting to “get into the mix” and “stir things around” with staff persons, and the SP thought newer staff persons did not always know how to navigate that. · The SP denied hearing staff persons use the n-word towards or around the VA, and denied s/he using the n-word towards or around the VA. The SP said s/he heard that word used in music and/or movies the VA listened to, but never from staff persons. · The SP thought the VA “fabricated” things to get attention. The G was aware of the allegation and said the VA talked to the G about concerns with staff persons “close to every day” and that the VA’s concerns were “usually” attention seeking. The G worked closely with the facility to create a “pretty tight” protocol when the VA voiced concerns, to avoid confusing information. When the VA had a concern with staff persons, s/he was directed to P1 and P2, and they completed an investigation. The G was notified after the investigation was completed; however, the VA could contact the G through telephone and email at any time. The G was aware that staff persons used derogatory language around the VA, but did not believe it was recently, and the VA had never told the G that a staff person called the VA the n-word or used the n-word around the VA. The G did not have previous concerns with the facility and was “incredibly happy” with the care provided to the VA. The facility’s Employee Policies & Procedures said that staff persons maintained professional behavior and communication and fostered a positive living environment for residents, and productive working environment for staff persons. Using “abusive, demeaning, insulting, or belittling” language towards others was prohibited. Personnel files showed that P1-P3 and the SP were all trained on the VA’s plans, facility policies and procedures and the Reporting Maltreatment of Vulnerable Adults Act. Conclusion: Information from all sources was consistent that staff persons frequently bantered and “joked” with the VA. Although P3 said that the SP “belittled” the VA, swore, used the n-word, and made rude comments towards the VA, there was no information to support that the SP or any other staff persons verbal interactions were directed towards the VA in a malicious or derogatory manner. The VA said s/he “loved” having fun at the facility and staff persons joked around a lot including talking about each other, as well as “cussing, swearing, and name calling.” If the VA had concerns, s/he spoke with P1 and/or P2 to discuss those concerns and told staff persons when s/he did not like the joking. Given that staff persons and the VA frequently joked around with each other for which the VA stated s/he “loved;” that staff persons’, including the SP’s, joking was not directed towards the VA; and that while the VA might at times get frustrated by the joking, s/he told staff persons when s/he did not like it and discussed these concerns with P1 and P2, there was not a preponderance of the evidence whether the SP or any other staff person engaged with the VA in a manner that 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 determined that policies and procedures were adequate but not followed. Staff persons were reminded to remain professional and use appropriate language while working at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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