The employee appeals the compensation judge’s determination that her January 7, 2020, right knee injury did not arise out of her employment.  We affirm.

The employee, Etta Tomah, worked as a nursing assistant for the employer, Good Samaritan Society, at a nursing care facility.  On January 7, 2020, the employee injured her right knee while using the bathroom facilities during her shift.  At the time, the employee was approximately 28 weeks pregnant.  At the hearing, the employee testified that she stood up from the toilet and was simultaneously pulling up her pants and walking to the sink when she slipped on water and as she fell, her knee twisted.  Contrarily, two of the employee’s supervisors testified at the hearing on behalf of the employer.  One of the supervisors testified that she prepared the employee’s occurrence report following the accident.  She also testified that the employee did not mention slipping on water and she did not see any water absorbed into the employee's clothing on the date of injury.  The other supervisor testified that shortly after the fall, the employee described the incident to her and did not mention slipping on water.

Following the injury, an ambulance brought the employee to Maple Grove Hospital.  The employee was seen in the emergency department by Dr. Nicholas Menth.  She described falling from a standing position after her right knee “gave out.”  X-rays showed a small bony fragment along the lateral aspect of the patella.  The next day, the employee was evaluated at Twin City Orthopedics by Dr. Kurt Anderson.  The employee reported twisting her knee at work.^[1]  Dr. Anderson recommended an MRI scan, which indicated a right lateral patellar dislocation and a small patellar fracture with a displaced fragment.  Physical therapy was recommended.

On January 23, 2020, the employee filed a claim petition seeking temporary total disability and temporary partial disability benefits for the January 7, 2020, right knee injury.  The employer and its insurer denied primary liability.

The employee participated in physical therapy at Twin Cities Orthopedics from February through June 2020.  While the employee noted improvement, she continued to complain of knee soreness with squatting and stairs.

The employee was evaluated by Dr. Mark Thomas on May 28, 2020, at the request of the employer and insurer.  In his June 20, 2020, report, Dr. Thomas indicated that the employee suffered an acute right knee patellar dislocation, six weeks of physical therapy would have been reasonable and necessary, and maximum medical improvement would have been reached following completion of physical therapy.

At a visit on August 31, 2020, Dr. Anderson recommended arthroscopic surgery to address the loose-body fragment he believed was causing the employee’s discomfort.

The employee was evaluated by Dr. Jack Bert at the request of her attorney on March 29, 2021.  Dr. Bert opined that the employee sustained a right lateral patellar dislocation directly related to the January 7, 2020, fall and she required reconstruction surgery to address her extreme instability.  He also stated that the employee should avoid squatting, kneeling, and lifting over 25 pounds and should use a patellar brace until the recommended surgery.

The employee underwent a right knee arthroscopic surgery to remove the bony fragment, which was performed by Dr. Anderson on April 15, 2021.  The employee was released to return to work without restrictions on April 30, 2021.

Dr. Thomas completed a supplemental record review at the request of the employer and insurer on July 26, 2021.  He agreed with Dr. Anderson that the arthroscopic procedure was reasonable and necessary, but opined that the reconstruction surgery recommended by Dr. Bert was unwarranted.  He also agreed with Dr. Anderson that the employee would not require restrictions as of April 30, 2021, and further opined that the employee had reached maximum medical improvement (MMI) on May 19, 2021.

In his October 1, 2021, Findings and Order, the compensation judge found that the employee's right knee injury did not arise out of her employment with the employer, and therefore was not compensable.  The compensation judge relied upon the testimony of the other witnesses, buttressed by the initial medical records, in determining that the employee did not slip on water and that there was no evidence of any risk or hazard in the bathroom.  In his memorandum, the compensation judge explained that the employee fell short of meeting her burden of proof.  The judge also explained that while a twisting or turning mechanism can be an increased risk causing a work injury, there were no such circumstances in this case.  The employee appeals.

On appeal, the Workers’ Compensation Court of Appeals must determine whether “the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.”  Minn. Stat. § 176.421, subd. 1(3).  Substantial evidence supports the findings if, in the context of the entire record, “they are supported by evidence that a reasonable mind might accept as adequate.”  Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984).  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.  Id. at 60, 37 W.C.D. at 240.  Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, “unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of evidence or not reasonably supported by the evidence as a whole.”  Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).

A decision which rests upon the application of a statute or rule to essentially undisputed facts generally involves a question of law which the Workers’ Compensation Court of Appeals may consider de novo.  Krovchuk v. Koch Oil Refinery, 48 W.C.D. 607, 608 (W.C.C.A. 1993), summarily aff’d (Minn. June 3, 1993).

At the hearing, the employee alleged that she encountered a slippery floor which led to her fall in the restroom.  The compensation judge rejected this allegation and determined that the employee had failed to prove she had slipped on water on the floor.  On appeal, the employee does not dispute the compensation judge’s finding that she did not slip on water and there is no dispute that the employee did not encounter an external hazard, a special hazard, or an unsafe condition.  Rather, the employee argues her injury is compensable because it falls under the personal comfort doctrine. 

To be compensable, an injury must arise out of and in the course of employment.  Minn. Stat. § 176.021, subd. 1.  The “arising out of” requirement of the statute connotes a causal connection and the “in the course of” requirement refers to the time, place, and circumstances of the incident causing the injury.  Gibberd v. Control Data Corp., 424 N.W.2d 776, 780, 40 W.C.D. 1040, 1047 (Minn. 1988).  Each requirement must be proven for an injury to be compensable.  See, e.g., Dykhoff v. Xcel Energy, 840 N.W.2d 821, 73 W.C.D. 865 (Minn. 2013); Roller-Dick v. CentraCare Health Sys., 916 N.W.2d 373, 78 W.C.D. 483 (Minn. 2018).

In this case, the employee’s injury occurred during her work shift and on the employer’s premises.  At the time, the employee was engaged in a short period of personal rest, which is considered to be in the course of employment under the personal comfort doctrine.  Hill v. Terrazzo Machine & Supply Co., 279 Minn. 428, 157 N.W.2d 374, 24 W.C.D. 511 (1968).  There is no dispute that the employee’s injury occurred while she was in the course of her employment.  Contrary to the assertion of the employee, the personal comfort doctrine is not applicable to the analysis of whether the employee’s injury arose out of her employment.  Rather, in order to show that her injury arose out of her employment, she has to show circumstances at the time of her injury in her working environment increased her risk of injury.

For an injury sustained on an employer’s premises to arise out of employment, the employee must have faced a hazard that originated on the premises as part of the working environment, such as an external hazard, a special hazard, an unsafe condition, or a neutral condition with circumstances originating on the premises as part of the working environment that increased the employee’s risk of injury, in order to have the requisite causal connection between the injury and employment.  Dykhoff, 840 N.W.2d at 826-27, 73 W.C.D. at 871-72; see also Roller-Dick, 916 N.W.2d at 377, 78 W.C.D. at 487-88.

The employee asserts that her case is similar to James v. Duluth Clinic, 79 W.C.D. 39 (W.C.C.A. 2018), summarily aff’d (Minn. Jan. 8, 2019), where this court held that injuries sustained when the employee stood and twisted were compensable.  In that case, the employee, a nurse anesthetist, was working in an operating room in tight quarters and focusing on his patient when he injured his knee while twisting and standing in order to enter data into the patient’s chart.  This court held that the totality of the circumstances increased the risk of the employee’s injury and provided the necessary causal connection to satisfy the “arising out of” component of the statute.  Id. at 45; see also Roller-Dick, 916 N.W.2d at 379, 78 W.C.D. at 491 (the circumstances of the employee descending a staircase while carrying a plant created an increased risk that she would fall); see also Erven v. Magnetation, LLC, 76 W.C.D. 433, 437 (W.C.C.A. 2016) (analysis of an increased risk involves examining the totality of the circumstances at the time of the injury).  We disagree that the circumstances in this case created an increased risk of injury for the employee.

In this case, the employee’s act of standing up from a seated position with no other extenuating circumstances did not involve an increased risk of a neutral condition.  The compensation judge acknowledged that a twisting or turning mechanism can create an increased risk, but found there were no such circumstances in this case.  In the absence of circumstances creating an increased risk of injury, the employee’s fall is unexplained and her injury is not compensable under Minnesota workers’ compensation law.  See Dykhoff, 840 N.W.2d at 828, 73 W.C.D. at 874 (an injury sustained when the employee was injured in an unexplained fall was not compensable); Rosar v. Southview Acres Health Care Ctr, 78 W.C.D. 559, 563 (W.C.C.A. 2018) (where the employee had no reason for falling on the floor, the injury sustained in the fall was not compensable); see also Roller-Dick, 916 N.W.2d at 379, 78 W.C.D. at 491-92.

Substantial evidence supports the compensation judge’s determination that the employee’s knee injury did not arise out of her employment, and we affirm.