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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: 1071928-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) had behavioral concerns, a staff person (SP) kept the VA in his/her bedroom by holding the door shut for three to four minutes. It was also reported that the SP used a table to block the VA’s access to a kitchen. Date of Incident(s): July 29, 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 August 18, 2026, from documentation at the facility, and through five interviews conducted with the SP, the VA’s guardian (G), a facility manager (P1), and two facility staff persons (P2 and P3). Although this investigator met the VA, the VA was unable to provide information due to his/her abilities. The facility’s kitchen and dining area had an open floor plan design with no barriers between the two. There were two entrances to the kitchen/dining area. The VA and three other clients lived at the facility. The VA’s bedroom door opened into the VA’s bedroom. The VA’s ISSA Assessment Detail stated that the VA was diagnosed with autism and was nonverbal. The VA needed staff assistance with personal cares. The VA enjoyed watching TV and his/her favorite food was barbeque chips. The VA’s Action Plan stated that the VA had a history of physical aggression toward others, self-harm, and taking food. Staff were trained to verbally direct the VA from these behaviors. When the VA engaged in physical aggression, staff were trained to provide verbal redirection and “get between” the VA and a client if the VA was attempting to physically aggress toward the client. The facility’s Internal Investigation provided the following information: · On July 29, 2026, while the SP, P2, and P3 worked, the VA became “increasing agitated,” and “repeatedly attempted” to go into the kitchen to “reach for food” while food was prepared. During this time, staff “redirected” the VA and “attempted to keep [the VA] engaged to another activity.” The SP used a table and “blocked access to the kitchen.” When the VA’s food was ready, a staff person sat with the VA while s/he ate. · When the VA finished eating, the VA left the dining area while the other clients continued eating. The VA “suddenly” began “grabbing and scratching” a staff person. Staff redirected the VA to change his/her clothing, which “temporarily de-escalated the behavior.” A short time later, the VA again grabbed and scratched a staff person “without an apparent trigger.” At some point, the VA moved to his/her bedroom and the SP “locked” the VA in his/her bedroom. · When P2 was interviewed, P2 stated that while the VA was in his/her bedroom, the SP held the door “closed” for two to five minutes while the VA was “banging on the door.” When that happened, P2 told the SP, “Hey, [the VA] doesn’t like that. I can take over for you.” The SP responded, “It’s ok[ay], I got it.” P2 stated that when the VA was agitated, P2 sat in the VA’s bedroom with the VA and that seemed to help the VA calm. · When P3 was interviewed, s/he stated that when s/he and another client returned to the facility, the VA was “having behaviors,” and “running around kind of crazy like [s/he] was riled up and being goofy, rather than being aggressive.” The SP was “upset” with the VA and “redirected” the VA to his/her bedroom. While the VA was in his/her bedroom, the SP held the door shut for three to four minutes while the VA was “banging on the door and wanted out.” At some point, the SP moved the dining room table so the VA “couldn’t enter the kitchen.” · When the SP was interviewed, s/he stated that the VA’s behavior was “extreme” that evening and the VA was “trying to grab food off the griddle and stovetop.” When that happened, the SP “blocked” the VA from touching the griddle. While a staff person cooked, the VA hit, bit, and scratched the staff person and another client. As a result, the SP moved the table, but the VA’s access to the kitchen was not restricted because there was “another route” into the kitchen. When it appeared that the VA was calm, the SP asked the VA to go to his/her bedroom and the VA walked “willingly” to his/her bedroom. After the SP changed the VA’s absorbent adult undergarment, the SP closed the bedroom door in an attempt to “slow [the VA] down and give [the SP] more time to react if [s/he] came back out and bolted for the kitchen.” The SP held the doorknob for about one minute but did not “hold” the door. At some point, the VA came to the door and “pounded” on it, so the SP or the VA opened the door. The SP denied that other staff offered to help the SP. P1 stated that prior to the incident, there were no concerns related to the SP’s employment or his/her interactions with the VA or other clients. P2 provided information that was consistent with the information provided in the facility’s Internal Investigation, but provided the following additional information: · Although P2 did not remember the date, P3 and another client were on a community outing and returned to the facility at about 7 p.m. When they returned, P3 and the client went to the client’s bedroom so P3 could assist the client with getting ready for bed. · P2 described the VA as being “irritated,” which meant that the VA was “just pacing around.” When the SP asked the VA to go to his/her bedroom, the VA followed the SP into the VA’s bedroom. When the VA was in his/her bedroom, P2 was in a hallway within view of the VA’s door. The SP left the bedroom and closed the door, but the VA began “banging on the door” while the SP held the door shut with his/her hand for one or two minutes. When the SP stopped holding the door, the VA left his/her bedroom and “slapped” P2 and hit the SP. When that happened, the SP said, “Nice hands,” to the VA, which was a technique used to help the VA calm. When the VA was calm within a couple minutes, P2 and the VA went to the VA’s bedroom to watch television. · P2 remembered that the SP moved the table but did not remember when that happened that night. When the table was moved, the VA was “irritated,” but the VA knew that even though the kitchen was partially blocked, the VA could access the kitchen from another access point. P3 provided information that was consistent with the information provided in the facility’s Internal Investigation but told this investigator that the SP held the bedroom door for three to four minutes. The SP provided information that was consistent with the information provided in the facility’s Internal Investigation but provided the following additional information: · When the SP asked the VA to go to his/her bedroom to relax, the VA followed the SP and when the SP turned the VA’s television on, the VA was calm and rested on his/her bed. The SP left the room, closed the door, and although the SP had his/her hand on the doorknob, the SP denied that s/he held the door. · As the SP stood outside the VA’s bedroom, the SP listened to the VA and heard nothing. After a few minutes, the VA came to the door, pounded on it, and loudly “screamed” one time. When that happened, the SP took his/her hand off the doorknob. The door opened, but the SP did not remember if s/he or the VA opened the door. · The SP stated s/he moved the table so the VA could not harm his/herself but did not remember when that happened. The SP recalled an incident about a month earlier in which the VA accessed the kitchen and was able to partially put his/her hand into a crockpot that was cooking food. The SP did not believe that the VA was harmed because of that incident. · When the SP was asked why information had been provided that s/he held the VA’s bedroom door shut for a period of time and moved the table in an attempt to restrict the VA’s access to the kitchen, the SP stated that the VA always had access to the kitchen. The SP also stated that at a previous staff meeting, about one month earlier, the SP pointed out that staff should be spending more time actively working with the clients and spending less time on their personal cell phones. When the SP made those comments at a staff meeting, various staff persons were “upset” with the SP. P1-P3 were specifically asked whether they had observed previous times in which the SP held any client’s door shut or moved the table to prevent the VA from accessing the kitchen and each stated, “No.” The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to July 29, 2026. Relevant Minnesota Rules and Statutes: Minnesota Statutes, section 245D.06, subdivision 5, stated that the license holder was prohibited from using time out, seclusion, or any other aversive or deprivation procedure, as a substitute for adequate staffing, for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience. Conclusion: Information showed that on July 20, 2026, at some point the SP moved a table to partially block the VA’s entrance to the kitchen. The SP stated it was to protect the VA from harm while food was being prepared, and the VA could access the kitchen a different way. Then, the SP asked the VA to go to his/her bedroom, and the VA did. The SP stated s/he shut the door and had his/her hand on the doorknob. There was inconsistent information regarding how long the SP’s hand was on the doorknob. The SP stated s/he had his/her hand on the doorknob for about one minute but did not “hold” the door. At some point, the VA came to the door and “pounded” on it, so the SP or the VA opened the door. P2 and P3 each stated that the SP held the door shut and the VA was banging on the door because s/he wanted to exit and provided inconsistent information regarding how long the SP held the door shut, including times from one minute to five minutes. Although the SP denied holding the door shut, s/he had his/her hand on the doorknob which could have prevented the VA from leaving the room and the SP placed the table to block the VA which were both a violation of Minnesota Statutes, section 245D.06, subdivision 5. However, given that the VA was not harmed, the VA had access to the kitchen a different way, that P1, P2, and P3 each stated the SP had not held the VA’s door or moved a table to block the VA on other occasions, that there was inconsistent information regarding how long the SP’s hand was on the doorknob, and that the SP stated s/he had his/her hand on the doorknob but did not hold the door, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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’s Internal Investigation showed that although policies and procedures were adequate, they were not followed. Additional training was provided, and the SP was no longer employed by the facility. The VA’s plans were reviewed and changed to provide additional guidance for staff. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because they took immediate corrective action.
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