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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: 1123199-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) implemented two manual restraints on a vulnerable adult (VA). The manual restraints were done improperly and resulted in bruises, scratches, and abrasions on the VA’s arms. Date of Incident(s): May 28, 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 subdivision2, paragraph (b), clause (1): 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 11, 2026; from documentation at the facility; and through ten interviews conducted with three staff persons (P1–P3), four supervisory staff persons (P4–P7), the SP, the VA, and the VA’s guardian (G). The VA enjoyed playing video games, swimming, bowling, horseback riding, playing laser tag, playing mini golf, playing board games, and watching movies. The VA’s diagnoses included mild intellectual disability, autism spectrum disorder, attention-deficit hyperactivity disorder, persistent depressive disorder, anxiety disorder, and cerebral palsy. The VA also had a brain shunt. The VA’s Individual Abuse Prevention Plan stated that the VA might not recognize dangerous or abusive situations. The VA’s Self-Management Assessment stated that the VA escalated “easily” and at those times, s/he responded better to non-verbal communication rather than verbal reasoning. The VA sometimes took breaks from a situation or asked for medication in order to calm. The VA’s Support Plan Addendum stated that the VA had a history of physical aggression toward others. At times, the staff persons might have to physically redirect the VA by blocking or redirecting his/her limbs or body. The VA’s Hands on Training Guide stated that the VA liked to tell “tall tales.” The staff persons were to avoid power struggles with the VA and to maintain boundaries. The VA enjoyed interacting with staff persons and did not like staff persons spending “a lot” of time on their cell phones. If the VA became upset, the staff persons were to avoid engaging with him/her and give the VA space. The VA stated that s/he lived at the facility for less than one year and s/he was the only resident who lived there. At the time of the incident, the VA, the SP, and P1 were upstairs. The SP was “in [the VA’s] face” so the VA told the SP to back up and leave the VA alone. Then the VA threw his/her game controller, which hit the door frame next to the SP. The SP grabbed the VA by his/her shirt and held the VA’s arms across his/her chest. The VA told the SP that s/he could not breathe. The VA dropped to the floor hitting his/her head on the floor. The SP continued to hold the VA on the floor for three or four minutes. When the SP released the VA, the VA went downstairs. The SP and P1 followed the VA downstairs and the SP continued to talk to the VA even though the VA told the SP to leave him/her alone. The SP then implemented a second restraint and the VA hit his/her head on a dryer. The restraint lasted approximately two minutes. The VA stated that neither P1 nor P2 assisted the SP with the restraints. The SP then went upstairs to the staff office and P4 and P5 arrived at the facility and talked to the VA. The SP later said that the VA shoved the SP into the door frame, but the VA stated that s/he did not push the SP during the incident. P1 provided the following information: · On the day of the incident, P1 worked the morning shift with the SP. The SP received a phone call and went upstairs to the staff office, where s/he continued to talk on his/her cell phone, which “irritated” the VA. The VA told P1 that the SP “always” talked on his/her cell phone. P1 went to the staff office and reminded the SP that s/he needed to work with the VA. P1 believed the SP was in the staff office for approximately 45 minutes to one hour. The SP then went downstairs to the VA and told the VA that if s/he wanted to go out to lunch, they had to leave by 12:30 p.m. The SP did not explain why or that they could not leave later because of staffing issues and no one being available to drive the VA. The VA became “angry and yelled.” The SP told the VA that s/he was not raising his/her voice so the VA could not raise his/her voice, which caused the VA to become more upset. The VA then took his/her gaming items upstairs to his/her gaming room. Shortly before 2 p.m., P2 and P3 arrived for their work shifts and P1 took them outside and explained that the VA was agitated, but was upstairs playing video games and seemed to be calming. P1 offered to stay after his/her work shift ended, but was told that s/he could leave, so P1 left. P1 believed the SP was in the kitchen when P1 left. · A short time after leaving, P1 texted P2 to ask how the VA was doing. Later, P2 texted P1 telling P1 that the SP implemented a manual restraint. A day or two later, when P1 again worked, the VA told P1 that the SP grabbed the VA “really hard” and “it hurt me.” The VA had bruises and marks on his/her arms. · The staff persons were trained to allow the VA time to calm him/herself when s/he became upset. If the VA became aggressive or told the staff persons to “get out,” the staff persons opened the facility’s windows and doors and went outside, where they continued to watch and listen to the VA to ensure that s/he was showing “safe” behavior. If the VA injured him/herself, the staff persons went inside to assist the VA. Otherwise, the VA let the staff persons know when they could enter the facility. The VA became upset if the staff persons spent extended time using their cell phones instead of interacting with the VA. The VA sometimes exaggerated when s/he talked about things. P2 provided the following information: · P2 stated that on May 28, 2026, at 1:45 p.m., s/he arrived at the facility for his/her work shift. Prior to P2 arriving, P1 text P2 to tell him/her that the VA was upset that the SP spent much of the morning on his/her cell phone. When P2 arrived at the facility, the VA was upstairs playing video games and the SP and P1 were downstairs. P2 talked to the SP and P1 about the morning and the SP wanted P2 to go upstairs with him/her to do the medications count. P1 left the facility and P3 arrived at the facility for his/her work shift. When P2 and the SP went upstairs, P2 could tell that the VA was “angry” with the SP. · P2 stated that when s/he was upset, staff persons typically “let [the VA] be”, but the SP asked the VA if s/he wanted the SP to bring the VA’s gaming chair to the room. The VA told the SP to stop talking to him/her, that s/he did not want the SP there, and the SP should “get the fuck out of my house.” The SP told the VA not to talk to him/her like that and that they needed to do the medications count. P2 stated that both the SP and the VA’s voices were raised, but P2 did not say anything during the exchange. The VA then threw his/her game controller and it hit the wall next to the SP and broke. P2 stated that the SP believed the controller hit him/her but it did not. The SP then “called for a hold.” The SP first held the VA’s wrists behind his/her back and then held the VA’s biceps. Staff persons were trained to maintain a monotone voice during a restraint and to tell the VA that s/he was safe and that it was “okay.” However, the SP yelled at the VA and told the VA that s/he needed to stop. The VA then dropped to the floor. The SP continued to hold the VA’s arms and moved to one side of the VA. · P2 did not understand why the SP called for a “hold,” but when the SP implemented the restraint and the VA was sitting on the floor, P2 held the VA’s legs so that the VA did not kick the SP. P2 yelled downstairs for P3 to call a supervisory staff person (P8). P3 briefly came upstairs and then went back downstairs and to call P8. P2 believed the SP pushed the VA onto his/her back and the VA then rolled onto his/her stomach. The VA told them s/he could not breathe, so P2 told the SP that s/he was releasing the VA and did so. Forty-five to fifty seconds later the SP also released the VA and the VA went downstairs, followed by the SP and P2. P2 then told the SP that they had to go outside to let the VA calm, but the SP continued to “bicker” with the VA and tell the VA that s/he could not leave the VA alone. · At this time, P3 was outside and opened the door and told the SP and P2 to come outside. As P2 and the SP started to leave, the VA “went full force” at the SP and tried to push the SP outside so the SP grabbed the VA by his/her shoulders and pushed the VA so that his/her back was against the wall. They moved until the VA was backed against the dryer and then the VA sat on the floor while the SP continued to hold him/her. The VA then lay on his/her back as the SP held the VA’s arms crossed on his/her chest. The VA attempted to kick the SP so P2 again held the VA’s legs and asked the VA to show them s/he was safe so they could leave. After a couple of minutes, the VA told them s/he would be safe and the SP and P2 released the VA and went outside. P2 then saw the VA stumble and fall. The VA went to his/her bedroom and cried and then called a friend. P4 and P5 arrived at the facility and went inside and talked to the VA while P2, P3, and the SP remained outside. · Once the VA calmed, P2 asked him/her if they could enter the facility and the VA agreed. The SP went to the staff office to document the incident while P2 and P3 talked with the VA, P4, and P5. The VA asked for his/her medication, so P2 went upstairs to the staff office to get it. While s/he was there, the SP told him/her that if the VA’s family members had “roughed up” the VA when s/he was younger, s/he “wouldn’t be like this.” P2 go the VA’s medications, returned downstairs and administered the VA’s medication to the VA and the rest of the day “went very smooth.” Before leaving the facility, the SP apologized to the VA. Later that day, the VA showed injuries to P2 and P3, which included bruises and scrapes on his/her inner biceps. The VA did not have bruises anywhere else.
· P2 stated that s/he rarely worked with the SP because they typically worked different shifts. In the past, the VA told P2 that s/he was sometimes upset with the SP because the SP frequently used his/her cell phone instead of talking to and interacting with the VA. · Sometimes the VA became frustrated and yelled at the staff persons or threw items and staff persons were trained to “disengage” with the VA and allow him/her space to self-regulate. Staff persons could also offer the VA an “as needed” medication to help him/her calm. If the VA became angry and told the staff persons to leave his/her home, they would open the windows and doors and go outside until the VA calmed. Staff persons were trained that when the VA told them to leave, they were to go outside and wait until the VA calmed. P2 stated that the VA was “kind of a storyteller” and sometimes exaggerated when s/he talked about events. P3 provided the following information: · P3 stated that on the day of the incident, at approximately 1:55 p.m., s/he arrived at the facility for his/her work shift and the VA was upstairs playing video games. P1 told P3 that the VA was upset about a cancelled community outing. The SP and P2 then went upstairs to do medication counts and P3 went to the kitchen. P3 then heard the SP and the VA yelling upstairs and went to the door to go outside so as to “give [the VA] space.” The VA told the SP and P2 to “get out of [his/her] home” and the SP told the VA that s/he was being “disrespectful.” The SP spoke “very loudly.” P3 believed the SP and P2 would also be coming outside, but P3 then heard the SP yell, “Hold,” and then a “thump.” P3 ran upstairs and saw the SP on his/her knees next to the VA holding the VA’s upper arms as the VA lay on his/her back while P2 held the VA’s feet. P3 did not believe the SP implemented the manual restraint as they were trained to do. P2 told P3 to go downstairs and call P8, which P3 did. During this time, P3 heard the VA yell that the SP was hurting him/her, that s/he could not breathe, and that s/he wanted the SP to get out of the facility. · P3 stated that after three to four minutes, the VA, the SP, and P2 joined P3 downstairs. P2 asked the VA and the SP to “be calm.” The VA told the staff persons to get out of his/her home and the SP then implemented another restraint on the VA. P3 then went outside where s/he talked to P8 on the telephone so s/he did not see what occurred during the restraint. At some point, P3 told the SP that the VA wanted them out of his/her home and they needed to go outside. After approximately one minute, the SP released the VA and P2 and the SP came outside while the VA went to his/her bedroom. P4 arrived at the facility and asked the SP to go upstairs to document the incident and P4 then talked to the VA. · P3 stated that later that day, P2 told P3 that when the SP initiated the restraint, the SP grabbed the VA’s upper arms and pulled the VA’s arms behind his/her back “like [s/he] was putting handcuffs on” the VA and then pulled the VA to the floor. P3 observed “really bad” purple, black, and brown bruises on the VA’s upper arms and five scratch marks. Staff persons treated the scratches with Neosporin and bandages and iced the bruises. The VA told P3 that his/her arms hurt so the VA was administered a pain medication. · P3 stated that in the past, the SP was “loud,” which sometimes irritated the VA, but the VA and the SP did not have a “physical or verbal problem” until the day of the incident. P3 stated that the VA sometimes exaggerated when s/he talked about events. P4–P7 provided the following information: · P4 stated that on the day of the incident, when s/he arrived at the facility, the staff persons were outside. They told P4 that the VA was upset because s/he was unable to go out to eat, so s/he threw a game controller and it broke and part of it hit the SP’s back. They then implemented two restraints on the VA. P4 went to the VA’s bedroom and talked to the VA, who was crying. The VA told P4 that the SP “should not have put hands on” the VA. The VA showed P4 injuries on his/her arms and as they talked about the incident, P4 bandaged the injuries. The VA calmed and agreed to take an “as needed” medication. P4 then assisted staff persons with documenting the incident. · At approximately 2:50 p.m., P5 arrived at the facility. The VA told P5 that staff persons did not allow him/her to go out to eat, so s/he became angry and the staff persons implemented a restraint. P5 observed “very large bruising and marks” on the VA’s biceps. After the incident, the SP called P6 and asked him/her about documenting the incident. · P4, P5, P6, and P7 each believed that a manual restraint was not warranted that day because there was no risk of imminent danger to the VA or the staff persons. Staff persons were trained to immediately stop a restraint if the client moved on to his/her stomach. P6 stated that prior to the incident, s/he had no concerns about how the SP interacted with the VA. The SP was trained on how and when to implement manual restraints. P6 stated that during training, s/he told the staff persons that when the VA told them to get out of his/her home, they needed to open the doors and windows and go outside to give the VA space to calm. P7 stated that the SP did not follow the facility’s procedures or his/her training during the incident with the VA. The SP provided the following information: · On the morning of the incident, the SP worked with P1. The SP told the VA that if s/he wanted to go out to lunch, they had to leave early because there was no staff person available that afternoon who could drive the VA. The VA was upset about the limits on going out to eat that day. P1 then asked the SP if s/he could leave work early and the SP told P1 that the VA required two staff persons. The VA overheard the conversation and became upset about the comments about needing two staff persons. The SP texted P6 and told him/her that the VA was escalating and asked what s/he should do. The SP then went upstairs to the staff office to give the VA time to calm while they waited for the staff persons to arrive for the 2 p.m. work shift and then do the medications count. · After P2 arrived at the facility s/he came upstairs to the staff office, where the SP explained that earlier that morning, the VA was upset so the SP wanted to do the medication counts so s/he could leave. The SP then counted the medications and waited for P2 to count them. During this time, the VA came upstairs and stood in the doorway to the staff office. The SP asked if the VA wanted him/her to get his/her gaming chair to sit in and the VA “blew up” and began swearing at the SP and telling the SP that s/he did not want the chair. The SP said s/he did not tell the VA not to talk to him/her in that manner, but instead told the VA that s/he just asked a question and that they had to do the medication counts before they could leave. The SP denied raising his/her voice when s/he talked to the VA. At that point, the SP was standing by the office door approximately three feet from the VA. The VA then picked up a video game controller from a shelf and “launched” it at the SP’s head. The SP ducked and the controller hit the wall behind him/her. The SP believed that if s/he did not duck, the controller would have hit him/her in the nose or eyes. The SP then yelled, “Hold,” because s/he believed the VA might throw other items. · The SP and P2 then implemented a restraint and “took [the VA]” down to the floor. The SP was behind the VA holding the VA’s wrists behind the VA’s back. The VA became “more angry” and tried to scratch the SP and rip the SP’s shirt. When the VA tried to hit his/her head on the floor, the SP placed a hand between the VA’s head and the floor. The VA then kicked at P2, so the SP moved one hand to the VA’s shoulder and one to the VA’s leg. The VA rolled onto his/her stomach and again tried to hit his/her head on the floor. The VA said that s/he could not breathe, so the SP placed one hand under the VA’s head and used the other hand to turn the VA onto his/her back. The SP told the VA that it was “okay” and that s/he needed to calm but the VA swore at him/her. The SP was on the VA’s left side and P2 was on the VA’s right side. The SP stated that P2 “did exactly what I did.” When the VA calmed, the SP “gave the signal” to “break” and s/he and P2 released the VA. The VA cried and ran downstairs while the SP and P2 remained upstairs “in shock.” The SP stated that s/he did not hear the VA tell the staff persons to “get the fuck out of my house” until after s/he and P2 implemented the restraint. The SP denied yelling at the VA during the incident and said s/he only told the VA to calm. · The SP told P2 to get his/her cell phone and call a supervisor, but P2’s cell phone was downstairs, so they both went downstairs where the VA was in the living room. P2 had to walk past the VA to get his/her cell phone and the SP would not leave the facility until P2 left, so s/he waited for P2 to find his/her cell phone and told the VA that they would leave as soon as P2 got his/her cell phone. The SP denied telling the VA that s/he could not leave the VA alone because s/he was trained to leave the facility when the VA became upset. The SP opened the facility’s main door so they could leave and as P2 walked back past the VA towards the door, the VA “rushed towards” the SP with his/her hands up as though s/he was going to hit or scratch the SP. The SP held up his/her arms to block the VA and the VA hit, scratched, and tried to bite the SP. The SP then pivoted and “placed” the VA against the wall to keep the VA from hitting him/her. The SP pushed against the VA with his/her back, as the VA continued to try to scratch the SP and rip the SP’s shirt, the SP moved the VA towards the washing machine and then stepped out of the door. The VA did not fall on the washing machine and the SP said s/he did not implement a second restraint on the VA. The VA then sat on the floor, but the SP did not interact with the VA at that time. P2 came outside and the VA went to his/her bedroom. The SP believed that s/he implemented the manual restraint “exactly as [s/he] was trained to do.” The SP said s/he did not see P3 until they were downstairs. · The SP remained outside until P5 arrived at the facility and talked to the VA, P2, and the SP about the incident. P5 had the SP document the incident, and told the SP what s/he should write, even though it did not accurately describe what occurred. The SP believed that P2 did not accurately describe what occurred because s/he was “trying to save [his/her] job.” The SP and the other staff persons checked the VA for injury and saw only a red mark on his/her wrist. The SP said that s/he bit his/her nails so they were not long enough to cause nail/scratch marks on the VA’s arms and that s/he did not touch the VA’s upper arms. The SP denied telling any staff person that the VA’s family members should have “roughed up” the VA more when s/he was young and had never met the VA’s family members. Later, the VA apologized to the SP and they hugged. The SP finished his/her documentation, but everyone else, including the VA, left the facility. The SP stayed until s/he was able to contact a supervisor, who told the SP s/he could leave. · When the VA became upset, the staff persons were trained to “talk [the VA] down” and try to find out why the VA was upset. If the VA’s behavior escalated, the staff persons were to open the windows and the door and “just sit there and watch from afar.” The SP was trained to only implement a restraint when the VA or others were in imminent danger. The SP was not trained to administer an “as needed” medication when the VA became agitated. The G stated that the VA could be “volatile” and it was difficult to predict what might frustrate the VA. The VA had lived at the facility for approximately three years and the G believed that the staff persons worked well with the VA. The VA was encouraged to go on community outings and participate in various activities. Staff persons focused on what the VA needed to be successful and the G had no concerns about the care the VA received. The VA did not provide any information to the G about the incident. The VA was not always an accurate reporter of events. A review of ten photographs of the VA’s arms taken on the day of the incident showed a large bruised area on one of his/her upper arms, next to five dark red scratch marks. There were also several other oval-shaped bruises and a long scratch on his/her arms. The facility’s Emergency Use of Manual Restraint Policy stated that the staff persons were to implement the manual restraint that was the least restrictive intervention to eliminate the immediate risk of harm. The staff persons were prohibited from using a prone restraint. Facility documentation showed that the SP, P1, P2, P3, P4, P5, P6, and P7 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 incidents. Conclusion: A. Maltreatment: On May 28, 2026, the VA became upset and told the staff persons to leave the facility. Staff persons were trained to open the doors and windows and go outside to give the VA space to calm when the VA told them to get out of his/her home. They were also trained to “disengage” with the VA when s/he became frustrated and allow him/her space to self-regulate. The SP did not follow that training and continued to interact with the VA when the VA was becoming frustrated. When the VA threw a gaming controller at the SP, the SP called for a restraint and held the VA’s arms and brought the VA to the floor. When the VA kicked at the SP, P2 held the VA’s legs. When the VA complained that s/he could not breathe, P2 released the VA and told the SP to also release the VA, which the SP did not immediately do. The SP initiated a second restraint a few minutes later after they all went downstairs. The SP believed that s/he was in imminent danger when the VA threw the controller at him/her and believed that s/he followed his/her training during the first restraint. The SP denied that his/her actions the second time were a restraint. P2 said s/he did not understand why the SP called for a “hold,” but when the SP implemented the manual restraint, P2 held the VA’s legs so that s/he did not kick the SP. P3 stated that the SP did not implement the restraint as the staff persons were trained to do. After the incident, the VA had multiple bruises and scratches on his/her arms. Consistent information was provided that staff persons were trained that restraints were only to be implemented in cases of imminent danger. Although the VA threw a gaming controller at the SP, it did not hit the SP, and the VA did not engage in any other dangerous actions that put either the VA or staff persons at risk of harm. In addition, staff persons were trained to leave the facility when the VA told them to leave and to not engage in challenging conversations with the VA when s/he was upset. The SP did not follow that training. Given that the VA nor others were at risk of harm when the SP implemented the restraints, that the descriptions given by the VA, P2, and P3 of the SP’s physical interactions with the VA during the restraints, and that the VA sustained several bruises and scratches on his/her arms as a result of the SP’s actions, there was a preponderance of the evidence that the SP’s actions were not accidental or therapeutic conduct and produced and could reasonably be expected to produce physical pain or injury to the VA. It was determined that physical 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). 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 P2 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 incidents. At the time of the two restraints, the SP initiated the restraints and during the first one, P2 then assisted the SP so that the VA did not kick the SP. When the VA complained that s/he could not breathe, P2 released the VA and told the SP to also release the VA, which the SP did not immediately do. Given that P2 tried to end the manual restraints initiated by the SP and did not cause the injuries to the VA, P2’s 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, abuse resulting in serious injury, or financial exploitation of a vulnerable adult if the value of the funds or property is $1,000 or greater. 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 physical abuse for which the SP was responsible was not recurring maltreatment because it was considered a single incident, but was serious maltreatment because it resulted in serious injuries, including bruises and skin lacerations, which were visible for several days. 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. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
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