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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: 1127083-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock 651-431-6142 Suspected Maltreatment Reported: It was reported that a staff person (SP) pulled a knife on a vulnerable adult (VA) during an argument. Date of Incident(s): September 14, 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 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 September 25, 2026; from documentation at the facility and law enforcement records; and through three interviews conducted with one supervisory staff person (P1), the staff person (SP), and the vulnerable adult (VA). Law enforcement investigated but did not take further action and closed their case. The VA was diagnosed with major depressive disorder, anxiety disorder and developmental disorder of scholastic skills. The VA enjoyed going to play Bingo, being with family and friends and being out in the community. The VA lived in an apartment that had two bedrooms separated by a living room and kitchen and dining area. The VA had a roommate who spent most of his/her time in his/her bedroom. The VA’s Individual Abuse Prevention Plan stated that if the VA was feeling overwhelmed, s/he may become aggressive. Staff persons were to monitor the VA for signs of agitation such as yelling and gesturing and allow the VA to vent his/her frustrations while redirecting him/her. The VA did not report things maliciously but had reported inaccurately in the past and may not understand the situation or may forget some details. Staff persons were to allow the VA to talk about his/her concerns or frustrations and then ask the VA questions to help the VA think through the situation. The VA stated that on September 14, 2026, around 5:45 p.m., the SP was sitting down at the kitchen table, and the VA was standing in front of the table. The VA got upset with the SP because the SP said s/he would not drive the VA to his/her family member’s house. The VA stated that s/he “snapped” and “went off” screaming at the SP. The VA said, “I was yelling. I was mad and spit came out of my mouth.” The VA said there was a steak knife on the table and when the VA stated yelling, the SP grabbed it and held it to the SP’s chest and said, “Get out of my face.” The VA then left the apartment to “cool off” and when s/he returned s/he spent the rest of the evening in his/her bedroom. The VA stated that she was “not scared but shocked” by what the SP did. The VA and the SP did not talk to each other the rest of the SP’s shift. (Note: The Internal Review, said that the VA stated that s/he was “scared and shocked” during the incident.) The SP stated that on September 14, 2026, s/he worked from 8 a.m. to 10 p.m. Around 5:45 p.m. after the VA returned from a doctor’s appointment, the SP was going to scan the VA’s after-visit paperwork into the computer. The SP was sitting at the dining table, using a butter knife to remove staples out of the paperwork when the VA went downstairs and went outside. When the VA returned inside, the VA asked the SP to drive him/her to a family member’s house and the SP told the VA that s/he would not drive to the VA’s family member’s house after 6 p.m. for “safety reasons.” The VA then got upset and started yelling at the SP saying s/he was “going to kill” the SP. The SP said s/he grabbed the knife and moved it under the computer because s/he was “scared.” The SP denied holding the knife to his/her chest or motioning towards the VA with the knife. (Note: The Internal Review, said that the SP provided information that s/he was taking the staple out of the VA’s paperwork but when the paperwork was checked for staple marks there were none and the paperwork did not appear to have been stapled.) P1 stated that on September 14, 2026, the VA contacted him/her and said that s/he was upset with the SP because the SP would not drive the VA to his/her family member’s house. The VA told P1 that s/he got upset with the SP and said s/he was “sick” of the SP not driving him/her places. The VA did not say anything at that time to P1 about the SP grabbing a knife. P1 then spoke with the SP about driving the VA and the SP had mentioned “something about using a knife to take out staples” but did not say anything about the VA yelling and getting upset. P1 stated that s/he did not hear concerns about knife until the next day when told by P1’s supervisor. Facility documentation showed that P1 and the SP were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Although the VA stated that when the VA began yelling at the SP, the SP grabbed the knife and held it to his/her chest, the SP denied doing so and stated that s/he put the knife under the computer because the VA said s/he was going to “kill” the SP. The SP denied holding the knife to his/her chest or motioning towards the VA with the knife. Given the conflicting information between the SP and the VA, that the VA acknowledged being upset and yelling, that the SP’s information regarding using the knife to remove staples conflicted with the appearance of the paperwork, that the VA had a history of reporting inaccurately and not understanding situations, and that there was no additional information to support or refute the VA’s or SP’s account of the incident, there was not a preponderance of the evidence whether the SP acted in a nontherapeutic manner that would be considered by a reasonable persons to be disparaging, derogatory, humiliating, harassing, or threatening. 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 facility policies and procedures were adequate but not followed. The SP received a counseling report and was transferred to another program. Action Taken by Department of Human Services, Office of Inspector General: No further action
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