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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: 1070578-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Antonina Puente/Rebecca Mesto Suspected Maltreatment Reported: It was reported that a staff person (SP) hit a vulnerable adult’s (VA’s) arm with a metal spatula and then hit the VA with the VA’s laptop, breaking the hinge of the laptop. Date of Incident(s): October 31, 2021 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 December 22, 2021; from documentation at the facility and law enforcement records; and through four interviews conducted with the VA, two facility staff persons (P1 and the SP), and a supervisory staff person (P2). This investigator attempted to contact the VA’s guardian (G), but was unsuccessful. The VA enjoyed participating in community events, going out to eat and visiting with family members. The VA’s diagnoses included diabetes, end stage renal failure, attention deficit hyperactivity disorder, post-traumatic stress disorder, bipolar disorder, pervasive development disorder, oppositional defiant disorder, reactive attachment disorder, and mild intellectual disability. The VA’s program plans including the Coordinated Service and Support Plan Addendum (CSSPA), the Self- Management Assessment (SMA), the Individual Abuse Prevention Plan (IAPP), and Rights Restrictions, provided the following information: · The CSSPA stated that the VA required supervision from three staff persons in the community and at the facility between 8:30 a.m.-10:30 p.m., and two staff persons during the overnight hours. At the facility, staff persons remained within audio and/or visual range of the VA. · The SMA stated that VA typically became frustrated when various triggers arose such as; being told s/he was not able to do or to have something when s/he preferred, including an activity, food, or finances. The VA had a history of contacting 9-1-1 and making allegations against staff persons when the VA did not prefer what staff persons told him/her or asked of him/her. Staff persons avoided using the word “No,” but offered explanations or redirection to the VA, and referred to the VA’s Crisis Prevention and Management Plan to identify various situations that may arise and how to respond at different levels of escalation. · The VA may engage in self-injurious behaviors or become verbally and/or physically aggressive towards staff persons. The SMA stated that staff persons used “blocks” to redirect the VA, were permitted to use a simple escort with no resistance from the VA for less than 60 seconds, and utilized positive verbal correction to provide alternative options and to offer reassurance, validation, and encouragement to the VA. The IAPP added that when the VA became physically aggressive towards a staff person, other staff persons were directed to use EASE training techniques to remove the VA from the situation. When they were unable to manage the situation, staff persons called 9-1-1. · The CSSPA stated that due to the VA’s history of using items as weapons, kitchen equipment was locked in the staff office. The VA was able to utilize a sharp object, such as a knife, when his/her behaviors were at baseline and staff persons remained within one foot of him/her. · The Rights Restrictions stated that the VA had restricted access to private telephone use, time spent with others/strangers, and food. The VA had a history of making phone calls to make “false allegations of physical and sexual assault against staff.” Information was consistent that the VA had a fistula (arteriovenous) located in his/her right arm from previous dialysis treatment. The VA provided the following information: · On the evening of day of the incident, the VA came back to the facility after attending a dance and got “really mad” because the SP would not give him/her a snack and staff persons turned off the internet. The SP and P1 were working at the time and were in the kitchen with the VA. The VA told P1 and the SP that s/he was hungry and there was nothing to eat except fruit and vegetables, which made the VA “really, really mad.” The VA threw a jar at the SP and the SP grabbed a metal spatula and the VA moved to the corner and the SP hit the VA’s arm “very hard,” with the spatula, and then hit the VA’s leg with the spatula. Then, the SP threatened to throw the VA’s laptop and then the SP picked up the VA’s laptop and hit the VA with the laptop on his/her right arm, near the VA’s fistula, causing the hinge of the laptop to break. The laptop also had a “little crack” on the screen from the incident. The VA had a bruise near his/her fistula. After the incident, the police came to the facility and brought the VA to the hospital. · The incident lasted 30 minutes. The VA also said that sometime during the interaction, the VA spilled something on the floor and refused to clean it up, which made the SP “mad.” P1 may have been near the kitchen or in the office at the time of the incident. · The VA said that typically, s/he could have an “unhealthy snack” first, then could eat fruits and vegetables if s/he was still hungry. · The VA was allowed to use the internet from 6 to 9 p.m. Law enforcement (LE) conducted a separate investigation and the LE record provided the following information: · On November 3, 2021, around 6 p.m., LE arrived at the facility and spoke with the VA. The VA told LE that on the day of the incident, s/he became upset because the internet was shut off, but since P1 was on his/her cell phone, the VA thought P1 was “lying.” Then P1 left the facility, while the SP remained with the VA. The VA was “very mad” and destroyed the kitchen and the living room by throwing objects around and spraying a fire extinguisher that s/he removed from the wall. At some point, the VA was standing behind the couch using his/her iPad when the SP approached the VA. The SP and the VA exchanged some words and then the SP used a metal spatula like a fly swatter and hit the VA’s arm, which caused a mark on his/her lower right arm. The VA then walked around the table, around the SP and towards the front door. The SP followed the VA, grabbed his/her laptop, yelled at the VA, and slammed the computer onto the VA’s arm. Then, the VA walked towards his/her bedroom, removed a plastic piece from the wall, and told the SP that s/he would use it as “self-defense” if the SP approached him/her. The VA went to his/her bedroom and locked the door. · P1 told LE that the VA was mad that the internet was turned off and started to “destroy” the facility. The VA attempted to hit P1 with a long, small object and then P1 went into the office. When P1 came out of the office, the SP said that the VA “destroyed” the facility. P1 said that the SP was a “very gentle” person who cared about his/her job. · P2 told LE that the VA got “very upset” when the internet was turned off at the scheduled time and sprayed the fire extinguisher and slammed his/her laptop onto the table. When the SP checked the laptop to see if it was broken, the screen was still on. Then the VA ripped a corner strip off of the wall and threatened to use it as self-defense if the SP came close to him/her. Then the VA went into his/her room and locked the door and began crying. The VA came out later and sat on the couch. The SP denied hitting the VA with a spatula or the laptop. During the incident, P1 was in the office. · The VA had a history of “assaultive behavior and lying to law enforcement.” The LE record was sent to the county attorney for further review. P1, P2, the SP, and facility documentation including the Internal Review, the Incident Report, and Progress Notes provided the following information: · On October 31, 2021, around 10 p.m., the SP and P1 arrived at the facility to work the overnight shift and the VA was in the living room. Around 10:45 p.m., the VA stated that s/he wanted to play games on his/her laptop in his/her bedroom, but P1 and the SP disengaged the internet/Wi-Fi (in accordance to the VA’s agreement). At 11 p.m., the VA exited his/her bedroom and asked P1 to turn the internet back on, but P1 reminded the VA that the internet was to remain off until the morning. Then the VA became aggressive and threatened to harm P1 with a strip of plastic or metal that s/he had removed from the wall. Because the VA was targeting P1, P1 went into the office, but was able to hear what was happening in the living room. P1 heard the VA swearing at the SP and heard the SP talking to the VA, telling him/her that s/he wanted to make sure the VA was safe. When P1 came out of the office, the VA may have been in the living room. · The SP stated that at 11 p.m., after P1 went into the office, the VA asked for the internet to be turned on and then emptied the contents of the refrigerator. The VA then went to the laundry room and sprayed the fire extinguisher in the living room. At 12:15 or 12:30 a.m., the VA asked the SP to log into his/her laptop to see if the internet was working and when s/he could not, the VA “cuss[ed]” at the SP, ripped the clock off the wall and slammed it on the floor, and ripped the smoke alarm apart. The VA also “slammed” his/her laptop on the table. The VA asked the SP to call the police and when the SP said that s/he was not going to call the police, the VA threw chairs at the SP. The VA was not in immediate danger, so the SP followed the VA around the house, attempted to talk to him/her, offered the VA medication, but the SP did not call the police. Between 3:30 and 4 a.m., the VA had something to eat and then took some medication. At 4:15 p.m., the VA fell asleep. · After the incident, the SP saw that the laptop had a dent on the corner but the screen was intact. The VA had a history of destructive behavior and sometimes was not truthful if s/he did not agree with others. When the VA’s behaviors were escalated, staff persons were to try to calm him/her down by offering medication or distracting him/her. · The SP denied hitting the VA or breaking the VA’s laptop, and stated that s/he was not aware that the VA had any bruises. P1 said that the next day, the VA told an unknown staff person that s/he had a bruise but did not complain of any pain and P1 did not observe any bruises on the VA. · P2 stated that P1 went into the office because when a specific staff person was a “target” of the VA’s, the VA did not typically stop aggressing toward them. · P2 stated that the VA had a history of seeking medical attention after a behavioral incident. After the incident, the VA requested to go to the hospital because of pain in his/her right arm. The VA was seen at a medical facility and his/her fistula was fine and no irregularities were noted. P2 was not aware of the VA having any bruising after the incident. · P2 stated that it was common for the VA to have a “different recollection of events.” P1 stated that sometimes the VA “flip[ped]” “around” words. · P2 stated that on November 2, 2021, during a meeting with the VA’s interdisciplinary team (IDT), P2 discussed the incident, but the G stated that s/he did not receive the notification that an incident occurred. P2 informed the G of the incident and later saw that the notification was sent to an incorrect email. The SP’s job position description stated that staff persons were to provide respectful and person-centered care services to the residents. Facility information showed that staff persons interviewed for this investigation each received training on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies, and the VA’s plan prior to the incident. Conclusion: The VA stated that on the night of the incident, s/he was mad because there was nothing but fruit and vegetables to eat and the internet was turned off. The VA threw a jar at the SP and the SP hit the VA’s arm with a metal spatula and then hit the VA with the VA’s laptop, causing the hinge of the laptop and the screen to break. The VA said that s/he sustained a bruise near his/her fistula. The SP stated that during a behavioral incident, the VA emptied the contents of the refrigerator, sprayed the fire extinguisher, ripped a clock off of the wall, “slammed” his/her laptop onto a table, and broke a smoke alarm. During the VA’s escalated behaviors, the SP followed the VA, attempted to talk to him/her, and offered the VA medication. The SP denied hitting the VA or breaking the VA’s laptop. The SP and P2 each stated that they did not observe any bruising on the VA after the incident. The VA’s plans stated that the VA had a history of making allegations against staff persons when s/he did not want to do what a staff person asked of him/her, and had a history of self-injurious behaviors and being physically aggressive toward staff persons. P2 stated that it was common for the VA to have a “different recollection of events,” and P1 stated that sometimes the VA “flip[ped]” “around” words. Given that there is no information that the VA sustained an injury to his/her arm, that there was no additional corroborating information that could be obtained regarding the incident, that the SP denied hitting the VA, and that the VA had a history of making allegations against staff persons, there was not a preponderance of the evidence whether there was conduct that was not accidental or therapeutic which either produced or was reasonably able to produce physical pain or injury. It was not determined whether 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 determined that its policies and procedures were adequate and followed. There had been several incidents during which the VA engaged in physical aggression towards others and property destruction, and the VA’s explanation of the events differed from the staff person’s explanation. Staff persons were to receive further training to ensure that potentially dangerous items were removed from the common areas when the VA’s behavior escalated. In addition, at the next staff meeting scheduled for December 28, 2021, staff persons were to participate in a discussion about effective crisis prevention and management. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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