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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: 1071633-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) punched a vulnerable adult (VA) in the upper left chest causing the VA to lose his/her balance and leaving a red mark on the VA’s chest. Date of Incident(s): August 22, 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 September 2, 2026; from documentation at the facility and law enforcement records; and through five interviews conducted with the VA, one supervisory staff person (P1), two facility staff persons (P2 and P3), and the VA’s case manager (CM). Attempts were made via telephone and certified mail to contact and interview the SP; however, those attempts were unsuccessful. The VA was diagnosed with schizotypal disorder, schizophrenia, obsessive-compulsive disorder, unspecified anxiety, and unspecified depression. The VA enjoyed watching birds, listening to music, going for walks, and playing games on his/her telephone. The VA was not subject to guardianship. The VA’s Individual Service and Support Advocacy Plan said that when the VA was under “extreme stress,” s/he displayed agitation and irritable behaviors, was “quick” to anger, threatened harm, made derogatory remarks, and/or threatened harm. If the VA exhibited these behaviors, staff persons redirected the VA to a safe place to “decompress,” or offered alternative activities such as listening to music, or going outside for air. The VA’s Mental Health Intervention Plan said that if the VA made verbal threats but did not show intent of harm to him/herself or others, staff persons asked the VA if s/he would like to talk. If the VA did not want to talk, staff persons ended verbal engagement with the VA and were a “silent safety monitor.” If the VA wished to talk, staff persons stopped what they were doing and provided the VA their “full attention” to discuss what was bothering the VA. If the VA went towards staff persons in a threatening manner, staff persons called 9-1-1. Law enforcement records provided the following information: · On August 22, 2026, at 9:20 p.m., law enforcement was dispatched to the facility for an alleged assault. At 9:30 p.m., a law enforcement officer (LEO) arrived at the facility and spoke with P1. P1 told the LEO that the SP “shoved or struck” the VA, and that P2 witnessed the incident. · P2 said the VA and the SP did not get along. Prior to when the incident occurred, P2 and the VA went on an outing and when they returned to the facility, the VA wanted to give the SP a slushie from their outing. The SP ignored the VA which “upset” the VA and s/he “yelled” at the SP. P2 stood in between the SP and the VA, and the SP “pushed” the VA with a closed fist using his/her knuckles. · The SP said the VA “antagonized” the SP “frequently.” The VA yelled at the SP, so the SP ignored the VA. The VA then got closer and would not stop talking to the SP, so the SP “pushed” the VA with an “open hand.” · The VA said the SP “ignored” the VA which “upset” him/her. The SP “pushed” the VA in the chest with a fist which caused a red mark. The VA showed the LEO his/her chest, but the LEO did not see a red mark. Photos were requested but not provided. · The SP was asked to leave the facility, and charges for “Misdemeanor Assault- 5th Deg-Inflict or Attempt Bodily Harm and Misdemeanor Disorderly Conduct-Caregiver-Against Vulnerable Adult” were sent to the City Attorney’s Office for review. The VA said s/he returned from an outing with P2 and attempted to give the SP a slushie. The SP “ignored” the VA, which upset him/her, and the VA said s/he “yelled” at the SP and asked the SP if s/he was “illegal.” P2 stood between the VA and the SP, and the SP “one inch punched” the VA in the chest. The VA said that because P2 stood between the VA and the SP, the punch wasn’t “quite as bad” because it was “restrained.” The SP punched the VA on the left side of his/her chest, but the VA did not know what hand the SP used to do so. The VA said the punch caused him/her pain for “six to seven” days and a red mark for “a day or two.” P2 provided the following information: · On an unknown date (determined to be August 22, 2026), P2 and the VA went on an outing. During the outing, P2 and the VA each got a slushie, however, the VA was given the wrong flavor slushie so P2 gave the VA P2’s slushie. P2 told the VA s/he could “do what [s/he] wanted” with the other slushie. · Between 8:40 and 9 p.m., P2 and the VA returned to the facility and the SP was in the office. P2 went into the office to clock out, and the VA followed P2. The VA attempted to give the SP the extra slushie, and P2 thought this was a “gesture of niceness.” · P2 heard the VA say, “Is that okay for [the SP] to treat [me] like that?” P2 looked at the SP and saw him/her “ignore” the VA “like a child would do.” The VA got upset that the SP ignored him/her and said s/he could have the SP “fired.” At this time, the SP stepped behind P2, which placed P2 between the SP and the VA. · The VA yelled at the SP, but did not swear, make racial slurs, or move towards the SP aggressively. The VA had two slushies in his/her hands, and “all of a sudden” the SP reached around P2’s right shoulder and “punched” the VA in the chest with his/her right hand. The SP had a “closed fist,” and his/her knuckles were “white.” When the SP punched the VA, the VA lost his/her balance and took “one and a half steps backwards.” P2 was “shocked,” but separated the SP and the VA, and called P1, who drove to the facility. P2 ensured the VA and the SP remained separate, and when P1 arrived, s/he called 9-1-1. P2 did not remember if the SP said anything when s/he punched the VA. · At an unknown time, the LEO arrived at the facility. The LEO spoke with the SP, the VA, P1, and P2, and the SP was asked to leave the property. After the LEO left, P2 looked at the VA’s chest and saw a red mark but was unsure if it was from the SP punching the VA, or because the VA “poked” him/herself in the area to show where the SP hit him/her. P2 did not take photographs of the VA’s chest. · Since the incident occurred, the VA had “non-stop behaviors” and did not trust staff persons. Staff persons were trained to give the VA “space” if s/he was upset, and punching a resident was not an approved intervention. The CM was aware of the incident and did not have prior concern with the facility. P1, P3, and the facility’s Internal Review provided information that was consistent with Law Enforcement Records, P2, and the VA’s interviews. Personnel files showed that the SP was trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act.
Conclusion: A. Maltreatment: Information obtained showed that on August 22, 2026, at 9:40 p.m., law enforcement was dispatched to the facility. P2 and the VA provided consistent information that the VA attempted to give the SP a slushie, and became upset when the SP “ignored” the VA. The VA yelled at the SP and asked the SP if s/he was “illegal” and told the SP s/he could get the SP “fired.” The SP then punched the VA in the chest with a closed fist which caused the VA to lose his/her balance and take “one and a half” steps backwards. The SP told the LEO that s/he “pushed” the VA with an open hand. After the incident, both P2 and the VA saw a small red mark on the VA’s chest. P2 was unsure if this was from the punch or from the VA poking his/her chest while describing the incident. Although the SP said s/he pushed the VA, given that both the VA and P2 provided consistent information that the SP punched the VA with a closed fist and that the SP had reason to minimize his/her actions, there was a preponderance of the evidence that the SP punched the VA which was not accidental or therapeutic and could reasonably be expected to produce physical pain. 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. The SP received training on the VA’s support plans, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. 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 or serious. It was a single incident, and although the VA sustained a red mark, P2 said because the VA “poked” him/herself in the area to show where the SP hit him/her it was not determined that the red mark was caused by the SP’s actions or the VA’s poking. Action Taken by Facility: The facility completed an internal review and determined policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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