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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: 1084702-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kimberly Huettl Anderson/Danielle Morrison Suspected Maltreatment Reported: It was reported that a staff person (SP) threw a vulnerable adult (VA) to the ground and punched the VA in the eye resulting in a bruise. Date of Incident(s): March 25, 2022 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 (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 April 29, 2022; from documentation at the facility, medical records; and through seven interviews conducted with two supervisory staff persons (P1 and P2), two facility staff persons (SP and P3), two case managers (CM1 and CM2), and the VA’s guardian (G). The VA’s diagnoses included conduct disorder, autism spectrum disorder, and attention deficit/hyperactivity disorder. The VA liked physical activities, including sports, bicycling, and running obstacle courses. The incident occurred on March 25, 2022, in a retail store parking lot after the SP was driving the VA, the SP, and P3 back from a bowling outing. The VA provided the following information: · The SP, the VA, and P3 went bowling and on the way back the VA was “upset” because the SP would not stop talking. The VA took the SP’s hat and threw it out the window. The SP pulled over and picked up his/her hat. · The VA got “more upset” so s/he hit the SP on the side of the head. The SP said “just wait until we get back.” · The SP parked the vehicle and the VA pushed down on the locks because s/he thought the SP was going to pull the VA from the vehicle. The VA got out of the vehicle to defend him/herself. The VA swung at the SP and the SP got a swollen eye. The VA fell backwards and hit his/her head. The VA could not walk. The SP and the VA got back in the vehicle. · The VA threw his/her glasses at P3. P3 opened the back door and kicked the VA. The VA got out and chased P3. The VA jumped on the vehicle. · The VA ran out of the parking lot and the police pulled up. · The VA did not remember exactly what happened and s/he did not remember getting punched by the SP. P1 heard from the SP and P3 that on the way back from a bowling outing, the VA took the SP’s hat and threw it out the window, the VA made “KKK” references, swore at the SP, punched the back of the SP’s headrest, and punched the SP. The SP pulled into a parking lot at which time the VA ran around the parking lot, “attacked” the SP, jumped on a vehicle and fell and hit his/her head. The police were called and they apprehended the VA. The VA was seen at a hospital where s/he said the SP punched the VA in the face and the VA fell backwards and hit his/her head. On March, 29, 2022, P2 saw the VA on a Zoom meeting and the VA had a black eye, so P2 reported to his/her supervisor. On April 1, 2022, during a follow up conversation, P1 asked the SP about punching the VA at which time the SP did not admit, but did not decline to having done so. CM1 said the VA’s memory was not the best and s/he got dates and incidents mixed up, but CM1 did not have concerns about the VA making false allegations against anyone. CM2 was aware of the incident, but not that the VA had a black eye. The VA had trouble with verbal and physical aggression. The G said the VA could get violent and frustrated. The G had worked with the VA a couple of months, but did not believe the VA to be an accurate reporter based on what the G had been told. P2 provided the following information: · On March 25, 2022, P2 was at the outing with the VA, the SP, P3, and another client. P2 drove the other client back in his/her vehicle while the SP and P3 drove with the VA. P2 received a call that the VA punched the SP. When P2 arrived at the location the VA was being put into a police vehicle. · P2 asked the SP and P3 what happened and was told that the VA punched the SP, so the SP pulled into the parking lot. The VA got out of the vehicle, started hitting the vehicle, as well as other vehicles, and was chasing the SP and P3 around the parking lot. When the VA heard the police sirens, s/he ran away. · At that time P2 did not see a bruise on the VA. On March29, 2022, during a Zoom meeting, P2 saw the VA had a black eye. When P2 asked the VA about the bruise the VA responded s/he “believed [s/he] was hit by staff.” P2 asked which staff, the VA said s/he “was not sure.” · P2 said the VA usually will tell you what was going on. P2 did not think that the SP punched the VA. The following information was provided by the SP and P3: · The SP and P3 each stated that the VA, the SP, and P3 were in a vehicle returning from an outing, the SP was driving, the VA was in the backseat behind the SP, and P3 was in the front passenger seat. The VA was verbally “assaulting” the SP by asking about the “KKK,” throwing the SP’s hat out of the car window, and punching the back of the SP’s headrest. · The SP and P3 each stated that the VA punched the SP in the face so the SP turned into and parked the vehicle in a retail store parking lot. Once the vehicle was parked, the VA, the SP, and P3 exited the vehicle. The VA was hitting the vehicle, jumping on other vehicles, hitting the SP, and chasing both the SP and P3. · P3 said at one point s/he returned to the inside of the vehicle to call P2 to say that the SP and P3 needed help and that the VA was “very angry.” P2 instructed P3 to put the VA in a hold and P3 said that was not possible as the VA was running around the parking lot. · At this time P3 said that s/he did not have visual sight of the SP and the VA. Several bystanders asked P3 if s/he and the SP needed help and if the bystanders should call the police. P3 said they were fine, just to give the VA space, but a bystander already called the police. When the VA heard the police sirens, s/he took off running and fell down. The police caught the VA and arrested him/her and asked the SP and P3 what had happened. · P3 said P2 arrived at this time and the SP showed him/her the bruises on his/her face. P3 did not see the SP hit the VA. P3 did not feel the facility trained on how to engage people in this situation. · The SP said the VA knocked the SP’s glasses off when s/he hit the SP. The SP held up his/her hands to protect the VA from hitting the SP in the face. The SP was moving his/her arms “all about” to protect him/herself, but did not see that s/he punched the VA and did not know where s/he would have hit the VA, whether in the arm or the face, while the VA was hitting him/her. · The SP said the VA fell down and the SP tried to help the VA up, but the VA ran. The VA ran out of the parking lot and the police found the VA on the street. The police asked the SP what happened. The SP did not feel s/he was trained by the facility on how to protect him/herself from a client, but how to restrain the client from hurting themselves. The facility records showed that the SP, P2, and P3 received training on Reporting of Maltreatment of Vulnerable Adults and the VA’s plans. Conclusion: The SP and P3 provided consistent information that on March 25, 2022, while returning from an outing the VA was verbally “assaulting” the SP by making references to the “KKK.” The VA proceeded to throw the VA’s hat out the window of the vehicle, punch the back of the SP’s headrest, and punch the SP. The SP parked the vehicle in a retail store parking lot and the SP, the VA, and P3 exited the vehicle. The VA jumped onto vehicles, hit vehicles, hit the SP, and chased the SP and P3 in the parking lot. Both the SP and P3 saw the VA fall down. A bystander called the police. The VA heard the police sirens and ran away from the SP and P3. The police apprehended the VA and spoke with the SP and P3 in regards to the incident. P3 did not see the SP hit the VA. P2 arrived on the scene and did not see that the VA had a bruise, but on March 29, 2022, during a Zoom meeting, the VA had a bruise under his/her eye. When P2 asked the VA about the bruise the VA said s/he “believed [s/he] was hit by staff.” When asked which staff, the VA was not sure. The SP said that the VA was hitting him/her and the SP put his/her arms up to protect his/her face. Because the SP lost his/her glasses when the VA hit him/her, the SP did not see that s/he hit the VA and did not know where s/he would have hit the VA, whether in the arm or the face, while the VA was hitting him/her. The VA said s/he was “upset” with the SP for talking so s/he threw the SP’s hat out the window and hit the SP. The VA got out of the vehicle and swung at the SP. The VA fell backwards and hit his/her head. The VA and SP got back into the vehicle and the VA threw his/her glasses at P3. P3 opened the back door and kicked the VA, at which point the VA got out of the vehicle, chased P3, and jumped onto a vehicle. The VA ran out of the parking lot and the police pulled up. Given that the VA provided a conflicting account of what occurred from the SP and P3’s consistent information, and while there may have been incidental contact between the SP and the VA that caused the VA to sustain a bruise to his/her eye, there was not a preponderance of evidence whether the SP engaged in conduct that was not an accident that produced physical pain or injury. It was not 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). Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures were adequate. The SP no longer worked at the facility. P2 completed retraining on Incident Reporting on April 3, 2022. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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