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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: 1070054-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler Suspected Maltreatment Reported: It was reported a staff person (SP) hit a vulnerable adult (VA) in the back. Date of Incident(s): March 9, 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 19, 2022; from documentation at the facility and law enforcement records; and through five interviews conducted with a facility staff person (P1), a facility supervisor (P2), the VA’s case manager (CM), guardian (G), and the SP. Facility documentation showed the VA did “best” when provided a single staff whom s/he felt comfortable and familiar with. It was important for the VA to have calmness and structure within the facility. The VA enjoyed spending time with family during weekends, and liked gong on activities such as the zoo, walking in the mall, and bowling. The VA was diagnosed with Down syndrome, autistic disorder, personality disorder, obsessive-compulsive disorder, attention-deficit hyperactivity disorders, Tourette syndrome, cerebral palsy, and developmental disabilities. The VA engaged in physical and verbal aggression, and one of the VA’s programming goals was to “refrain from slapping” other persons and staff person were to redirect, use social stories, and or use positive interactions/re-enforcement. The VA’s Individual Abuse Prevention Plan (IAPP) showed the VA was susceptible to physical abuse. An interview was attempted with the VA, however s/he was unable to provide any details related to the incident. This investigator observed the SP and the VA interact while completing the site visit, and the VA appeared willing to have the SP provide him/her services. The CM said the facility had done a “good job” with the VA and having a 1:1 staff was good for the VA. The G said the VA had been at the facility for a significant amount of time and “overall care” at the facility had been “good.” The G said the VA was accident prone, but s/he was not aware of any “unusual” bruises. The facility completed an Internal Review (IR), which provided the following information: · On March 10, 2022, P1 informed P2 the SP had “hit” the VA in the back. P1 was assisting the VA’s housemate (HM) when s/he observed the VA attempt to hug the SP and a different housemate tried to grab the SP’s side/butt. The SP “hit” the VA on the back to “get [him/her] to move.” P2 asked why P1 did not assist the SP during the interaction, and P1 said s/he was with the HM. P2 acknowledged the HM did not need assistance with toileting, but P1 repeated that s/he was “with” the HM. · The SP said s/he was attempting to get the VA in his/her bedroom while another housemate was trying to grab the SP’s butt and tickle his/her side. The SP put his/her hand on the VA’s back and directed the VA to his/her bedroom. The SP said s/he did not observe P1 during the interaction and believed P1 was with the HM in the bathroom. · P2 observed the VA’s back and there was no bruise or mark. It was noted that the VA had a history of bruising easily. · Based on the information the facility determined no abuse had occurred. · On March 31, 2022, P2 arrived at the facility at 5 a.m., and found P1 and another employee asleep, and P1’s employment with the facility ended thereafter. · On April 1, 2022, P1 contacted P2’s supervisor (P3) regarding the concern of abuse on March 9, 2022. P1 was informed the investigation had concluded. · On April 4, 2022, the facility received a phone call from P1 stating it was “unfair” the SP was “getting special consideration.” P1 said the VA had a “bruise” that was “so bad [s/he] had to put ice on it.” P1 was told the VA was observed the following day and there was not a bruise. P1 provided the following information: · P1 was with the HM, but could see the SP was with the VA as P1 was in the doorway of the bathroom. P1 observed the SP hit the VA with a closed fist in the back/shoulder area, and the SP told P1 “oh [s/he] hit me.” After the SP hit the VA, the VA started screaming while going into his/her bedroom. P1 checked on the VA while s/he was in his/her bedroom, and the VA was “shaking in fear.” The VA asked P1 to sit with him/her, which P1 did. P1 later got an ice pack and placed it on the VA’s back. P1 did not observe any redness or bruise when applying an ice pack. P1 could see “fear” in the VA’s face, and s/he was “shivering” while in his/her bed. P1 said the VA appeared to act or look different than normal. The VA did not require any medical appointment due to the incident. · P1 contacted P2 regarding his/her concern, and did not feel the facility took action to protect the VA or other persons served. P1 described a lack of communication from P1 after the alleged maltreatment occurred. P1 believed the SP should have been removed from the schedule and the incident investigated, similar to what had previously occurred with another staff person. P1 made multiple comments about the race of the persons involved and the dynamics of relationships between staff persons. · The HM observed the incident, but was not a “viable” reporter to explain the incident. · Within the interview P1 said there were concerns of racial bias, and his/her employment ended after the alleged maltreatment report was made. P2 provided the following information: · P2 received a text message from P1 on March 9, 2022, regarding a concern between the SP and the VA. P1 said the SP hit the VA around 6 p.m., but was informed there were no injuries. P1 said s/he would follow up on the information the following day. On March 10, 2022, P2 observed the VA and there was no bruise or injury. P2 added the VA had a history of bruising easily.
· P1 discussed the incident with P2, who said s/he in the bathroom, which did not “make sense” to P2, as the description of events occurred in a hallway that would not be observable from the bathroom. Additionally, the HM was also engaging in a negative behavior and instead of engaging and assisting P1, P2 stayed in the bathroom. Based on the information P1 obtained, s/he “questioned the validity” of P1’s information. Moreover, P2 believed the reported information was “retaliation” and described multiple interpersonal concerns between P1 and other staff persons.
· P2 questioned the SP about the alleged incident and the SP said s/he put his/her hand on the VA’s back to “guide” the VA towards his/her bedroom. P2 said staff were trained to physically “redirect” the VA, and placing a hand on the back of the VA with some pressure would be a technique that staff would use to ensure the VA’s safety and the safety of others. · P2 said prior to the report being made to the Department of Human Services, P1 and another staff were terminated due to an employment concern not related the alleged maltreatment on March 9, 2022. · There were no other concerns with the SP’s work performance and P2 had not observed any change in how the VA acted around the SP after the alleged incident. P2 also said there was no previous concern with how the SP reacted to negative behaviors by the VA. · There were other concerns regarding P1’s work performance and his/her interactions with other staff persons. P2 described significant interpersonal conflicts and gossip/drama that had occurred at the facility. The SP provided the following information: · The SP said there was an incident involving him/herself, the HM and the VA, however the SP denied hitting the VA, and said the VA was not harmed during the interaction. The SP said P1 was in the doorway of the bathroom while the SP attempted to redirect the VA due to the interaction of negative behaviors between the VA and the HM. The SP described the redirection of placing his/her hand on the VA’s shirt (on his/her back/shoulder area) and prompted him/her to go to his/her bedroom. The SP held the VA’s shirt as used as a way to control the VA’s movement, but did not hurt or harm the VA in any way. The VA did “yell” during the interaction, but that was not abnormal given the situation. The SP denied the VA was fearful or shaking after the alleged incident occurred. Moreover, the SP was near P1 after the alleged incident and said P1 did not place any ice on the VA’s back or assist the VA. The SP added that if the incident occurred as reported the VA would have had bruising. · The SP felt the alleged incident was reported in retaliation due to P1’s friend being suspended due to a separate concern. The SP felt there were negative racial feelings from P1 towards other staff persons. · The SP said that during the interaction the HM was instigating the VA and the VA had hit the SP’s “backside.” · The SP did not believe P1 would have been able to observe the interaction well based on the SP’s location and the SP’s body “blocking” P1’s view. · The SP said there were multiple concerns with P1’s work performance, but those were addressed by P2. P2 made note on March 10, 2022, which stated s/he “received a report from a coworker that [the SP] had hit an individual served during [his/her] shift.” P2 interviewed both the SP and P1, and consulted with the Area Director and it was determined that the "hit" was actually a redirection and not abuse. It also appeared to be “retribution for an earlier VA report made.” The facility completed training with staff on the VA’s client specific plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: It was reported the SP hit the VA in the back. The VA was unable to provide any information related to the alleged incident. The SP and P1 provided conflicting information regarding the incident, however P2 said s/he observed the VA the following day and there was no apparent injuries to the VA. Moreover, P2 did not observe any change in the behavior of the VA while the SP was present. The SP and P2 described concerns with P1’s employment, and the SP, P1, and P2 all described concerns with racial bias and interpersonal conflict. The information obtained was conflicting, and without further information, there was not a preponderance of the evidence whether the VA was subject to treatment that produced or could reasonably be expected to produce physical pain or emotional distress. 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. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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