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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: 1070008-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Danielle Morrison Suspected Maltreatment Reported: It was reported that there were concerns regarding a staff person’s (SP’s) interactions with two vulnerable adults (VA1 and VA2). The concerns included: · The SP threatened to “beat” VA1 with a broom. VA1 “stomped” down the stairs and said the SP “was a bitch,” to which the SP replied, “Your mom is a bitch.” · The SP yelled at VA2 when s/he poured too much milk. VA2 became upset and hit the SP and other clients. Date of Incident(s): Unknown date in March 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 (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 June 2, 2022; from documentation at the facility; and through nine interviews conducted with four facility staff persons (the SP, P1, P2, and P3), VA1’s case manager (CM1), VA2’s case manager (CM2), VA1’s guardians (G1 and G2), and VA2’s guardian (G3). This investigator met with VA1 and VA2. The facility was a one level home with an open floor plan. There were three bedrooms down the hallway from the living room. VA1 enjoyed watching baseball, basketball, and football on TV. VA1’s favorite team was the Minnesota Twins. VA1’s diagnoses included moderate intellectual disabilities, depressive disorder, attention deficit hyperactivity disorder, and generalized anxiety disorder. VA2 like going out to eat at Perkins, going to Target for soda and chips, and watching movies. VA2’s diagnoses included moderate intellectual disabilities, persistent mood disorder, adjustment disorder, and attention deficit hyperactivity disorder. This investigator met with VA1 and VA2, but they were not able to provide pertinent information in regards to these allegations. Information provided by the facility showed that the SP, P1, P2, and P3 were all trained on the Reporting of Maltreatment of Vulnerable Adults and the clients’ plans. Regarding the SP threatening VA1 with a broom and calling VA1’s mom names: VA1 said that the SP “yelled at me, screamed at me, and threatened me.” When asked by this investigator what the SP said, the VA replied, “[S/he] wanted me to get my ass downstairs to my room.” VA1 also said that the SP threatened him/her “with a knife” and that it happened “a long time ago, like 30 years.” P1 said that on an unknown date, s/he was in the kitchen with VA1 and the SP. VA1 wanted to open the oven door and the SP did not let him/her. The SP said s/he was going to “hit [VA1] upside the head with a broom.” At that point VA1 said “bitch” to which the SP said “your mama is a bitch.” P1 said P2 was going downstairs, but heard the exchange. When asked by this investigator if the SP said the comment in a joking or hurtful way, P1 said s/he did not know if the SP was “threatening or serious.” P1 said that the clients in the facility argued with the SP when s/he worked. P2 recalled overhearing an incident where the SP said something like “I am going to smack you upside the head or hit you upside the head” to VA1 if VA1 kept doing what s/he was doing. P2 was standing at the bottom of the stairs so s/he was not sure what VA1 was doing or how the exchange started. VA1 then called the SP a “bitch,” which was a normal term VA1 used, to which the SP responded “your mama is a bitch.” VA1 went downstairs, was “upset,” and went to his/her room. P2 said the interaction between VA1 and the SP was more back and forth and that what the SP said was “not to be hurtful, but to be spiteful.” In addition, P2 described the SP’s interactions with P1 as “confrontational” and said the SP “liked to grill” P1 about political subjects in which they had different views. The SP “escalated” the conversations with P1 until P1 needed to go outside to take a break so the conversation could end. P3 did not witness this incident, but heard from P1 that the SP told VA1 to “shut the hell up.” P3 did not know anything about a threat with a broom. P3 had not observed the SP use harsh words or actions. G1 said that the VA1’s ability to accurately report events was “very low” and VA1 did not tell G1 anything about the incident. G2 said VA1 cried and said “nasty” things when frightened. CM1 said VA1 would be able to recall pieces of events and verbalize what happened. The SP said that VA1 came in from outside and opened the oven without washing his/her hands. The SP told VA1 not to do that and VA1 told the SP “fuck you, you bitch” and VA1 ran downstairs. The SP caught VA1 partway down the stairs and asked why s/he said that. The SP said VA1 called his/her mother a “bitch.” The SP denied calling VA1’s mother a “bitch” and denied saying s/he was going to hit VA1 with a broom. Regarding the SP yelling at VA2: P1 said that VA2 wanted milk, but the SP did not want VA2 to get the milk. The SP told VA2 “no milk.” P1 told VA2 to save the milk for the morning, but VA2 grabbed for the milk. The SP tried to grab the milk from VA2. VA2 yelled, screamed, and charged at P1. P1 ran to a corner and balled up. After VA2 ran up to P1, s/he ran towards another client (C) and grabbed his/her arm. When P3 arrived at the house, the SP and P1 were laughing about the incident. P1 said that the SP told him/her to “walk up to them, walk towards them, they will run from you.” P2 said s/he was on the couch when VA2 wanted milk. VA2 got upset and instead of calming VA2 down, the SP yelled and made it “worse.” VA2 bit him/herself and yelled. P3 entered the facility after the incident and saw P1 and the SP laughing and giggling. The SP told P3 that VA2 had a behavior and P1 ran to the garage. P3 told P1 “don’t show you are afraid of [VA2], talk him/her down, or [s/he] will bully you.” P3 said to resolve it and try to give VA2 what s/he wanted. G3 said VA2 was limited in what s/he could tell you. G3 said VA2 got “frustrated” with the word no, but said that VA2 would not be able to make a report about the staff. CM2 said VA2 does not talk a lot and it was on the low end if s/he was a reliable reporter. The SP said that s/he and the C were at the table when VA2 came in the kitchen for milk. VA2 poured the milk and P1 said “hey you can’t have that much milk,” and grabbed the glass from VA2. VA2 and P1 ran to the back door. The SP told VA2 that s/he needed to go to his/her bedroom. The SP “pushed” VA2 towards his/her room, when VA2 grabbed the C and tried to bite him/her. VA2 tried to get back in the kitchen, but the SP did not let him/her. The SP got VA2 to his/her bedroom. The SP denied hitting VA2. The SP said s/he might get loud, but did not yell. Relevant Rules and/or Statute Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: Regarding the SP threatening VA1 with a broom and calling VA1’s mom names: P1 and P2 shared similar accounts of the SP telling the VA that the SP was going to hit the VA with a broom or hit the VA upside the head and saying “your mama is a bitch” to VA1. However, P1 stated that P2 was going downstairs at the time and P2 stated s/he was at the bottom of the stairs when the exchange started between the SP and VA1 and was not sure what started it. The SP stated that VA1 came into the house and opened the oven door without washing his/her hands. The SP asked VA1 not do that to which VA1 responded to the SP “fuck you, you bitch.” VA1 went downstairs. The SP stopped him/her partway down the stairs and asked why s/he would say that. The SP denied saying s/he was going to hit VA1 with a broom and denied calling VA1’s mom a “bitch.” Given that P1 and P2 were in separate spaces of the facility while this exchange took place and that their accounts differed from the SP, that P2 provided information that there may have been interpersonal conflict between the SP and P1, and that P3 had not observed the SP using harsh words or actions, there was not a preponderance of the evidence whether any version of the SP’s comments or tone produced or could reasonably be expected to produce emotional distress. 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). Regarding the SP yelling at VA2: P1 and P2 stated that VA2 wanted milk. P1 said that the SP told VA2 s/he could not have the milk and VA2 became upset and grabbed for the milk. VA2 ran at P1, so P1 balled up in the corner. VA2 then grabbed at the C. P2 said VA2 was upset and instead of calming him/her down, the SP yelled and it made it “worse.” The SP said P1 told VA2 s/he could not have that much milk and P1 grabbed the milk from VA2. VA2 was upset and ran after P1. VA2 grabbed at the C and tried to bite him/her. The SP “pushed” VA2 towards his/her room so s/he could calm down. Given that P1 and P2’s accounts differed from the SP, there was not a preponderance of the evidence whether the SP engaged in interactions or tone of voice that produced or could reasonably be expected to produce emotional distress. 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 found their policies and procedures were adequate, but not followed. Staff were retrained on Reporting of Maltreatment of Vulnerable Adults and clients’ Individual Rights. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Although accounts of what the SP said or whether the SP “yelled” at VA1 and/or VA2 differed, the consistency of accounts show the SP engaged with VA1 and/or VA2 in a disrespectful manner. However, given that the facility took corrective action in regard to the SP’s actions, no correction order was issued for the violation outlined in this report.
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