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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: 1067816-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady Suspected Maltreatment Reported: It was reported that a staff person (SP) pushed a vulnerable adult (VA) down a flight of stairs causing an injury to the VA. Date of Incident(s): Prior to May 18, 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), clauses (1) and (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: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · 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 9, 2022; from documentation at the facility, law enforcement records, medical records, and an agency that provided forensic interviews to vulnerable adults; and through interviews conducted with six facility staff persons, a consumer at the facility, the VA’s case manager, and a family member/guardian of the VA. The VA was interviewed by an agency that provided forensic interviews to vulnerable adults. The VA diagnoses included an intellectual disability. An Assessment Summary and Person Centered Profile for the VA stated: · The VA was able to communicate his/her needs and wants. The VA used an electronic communication device, verbal communication, and some sign language to communicate. At times, what the VA was trying to articulate could be difficult to understand especially for those who were not familiar with him/her. The VA might use full sentences but they might not always make sense. Dialogue between the VA and another individual might need to be back and forth until the individual can determine what the VA was communicating. · The VA understood most directions. Sometimes the VA would not acknowledge whether s/he understood something. In that case the VA would be asked to give a thumbs up or a thumbs if s/he understood what was said to him/her. The VA had an “excellent memory.” · The VA enjoyed participating in a variety of activities at home and in the community and enjoyed spending time with family members and friends. The facility was a single level with a basement. On the main level there were three bedrooms along with a living room and a kitchen/dining area. Off of the kitchen there was full stairway leading to the basement. The stairway was carpeted. There was a common area in the basement as well as the VA’s bedroom which had its own bathroom. Near the base of the stairs in the basement common area were two large plastic cabinets. One had supplies in it and was locked and one was empty. The following information was regarding an injury to the VA’s knee: · A family member (FM) of the VA stated that on May 14, 2022, the FM came to visit the VA because a staff person (P1) told the FM that s/he heard from another staff person (P3) that the SP pinched the VA. After the FM arrived at the facility, a consumer (C) told the FM that the SP pushed the VA down the stairs. The FM asked the VA and the VA indicated “yes” and indicated that s/he left knee hurt. · Medical records stated that on May 14, 2022, the VA diagnosed with a left knee subluxation. The VA was given a stabilizing brace and was to follow up in one month if not improving. · The C stated in a facility internal review that the VA fell down the stairs because s/he was going too fast and was not using the handrail. The C demonstrated that the VA fell on the second step from the bottom and hit his/her head. The SP was working at the time of the fall, but did not hear the VA fall. The C said that s/he told the FM that the SP pushed the VA. When the SP pushed the VA, the C was at work. · The C stated to this investigator that the SP pushed the VA down the stairs. The C said that the incident occurred while the C was at work, but the VA told him/her about it. The C believed that the VA told the C about the push on Thursday (May 12, 2022), two days before s/he got the brace on his/her knee. The C told the FM about the incident on Saturday (May 14, 2022). The C stated that s/he did not notice that the VA’s knee was hurting before the C talked with the FM on Saturday. · In the facility’s internal review and/or in interviews with this investigator, seven staff persons (P1-P6 and the SP) and a staff person (WP) from the VA’s work program did not notice any concerns with the VA’s knee nor did the VA indicate any concerns about his/her knee prior to May 14, 2022. In addition, a facility health care professional (HCP) reviewed documentation in the VA’s progress notes and did not find anything regarding knee pain or injury. The HCP last saw the VA about week and half before the VA’s injury and did not notice anything out of the ordinary with the VA. The VA was able to indicate if s/he was in pain. · P1 stated that on May 14, 2022, P1 was working and the VA. The VA was his/her “normal self,” but a “little bit” quiet. At some point, the VA was crying and saying the SP’s name. The FM arrived to visit and at that point, the VA started to say the SP’s name and talking fast. The FM asked what was wrong, did the VA have a headache, was s/he not sleeping, and then the VA pointed to his/her knee. The FM asked the VA if his/her knee hurt and the VA said yes. At that point, the C was in the kitchen and said that the SP pushed the VA and should not be working at the facility. At some point, P2 arrived, and P2 and the FM asked the C what happened and the C said that the VA refused to get his/her bag from downstairs so the SP pushed him/her down the stairs. The VA had a bag that s/he took with him/her to work and usually brought it up with him/her when s/he came upstairs. The C did not give any additional details. · P2 stated that on May 14, 2022, P2 was not working, but stopped in at the facility. At that time, the FM was there and the VA was “emotional.” The C stated that the SP pushed the VA down the stairs. The C also stated that the SP was mean and yelled at the VA when s/he was getting ready to go to work in the morning. P2 believed that the C said that the incident happened in the morning. · P4 stated that on May 14, 2022, P4 was at the facility when the FM came to the facility and the VA was crying about his/her knee. At that time, the C said that the SP pushed the VA down the stairs. The C did not say when it occurred. · The SP stated that s/he last worked the morning of May 13, 2022. The VA did not complain of pain and the SP did not see the VA limping. The SP stated that s/he did not push the VA down the steps. The SP was not aware of anytime that the VA fell. On occasions, the SP might have placed a hand the VA’s shoulder to get the VA to go somewhere, but never intentionally pushed the VA. The VA was interviewed by an agency that provided forensic interviews to vulnerable adults. The VA was interviewed twice on back to back days (this investigator observed one interview, reviewed videos of both interviews, and also met the VA. A law enforcement officer [LEO] also observed both interviews). The following is regarding the interviews: · A report from the agency stated that initially the VA seemed to be most comfortable signing yes. After being asked, the VA used his/her communication board to provide some information about him/herself, but it was hard for the interviewer to know exactly what the VA was trying to communicate with his/her board. The VA was either unable or unwilling to answer follow-up questions about the information s/he shared using the board. The VA eventually transitioned to a topic of concern and then verbally gave information. However, it was hard for the interviewer to understand some of his/her words and what s/he was trying to communicate. It appeared the VA was trying, to the best of his/her abilities, to give information. · This investigator when watching the interview noted that the most pertinent information provided by the VA was that the VA used the word “ouch” and pointed at his/her left knee. The VA said that the SP was there when s/he got the “ouch,” but did not provide any additional information regarding his/her knee. The following was regarding an incident on April 25, 2022: · The FM stated that s/he was aware that on April 25, 2022, the SP wrote about an incident where s/he heard a crash in the basement and went down and the VA hit his/her head. The FM believed that might have been the time the SP pushed the VA down the stairs and the documentation was a “cover up.” · The SP documented in the VA’s progress notes that on April 25, 2022, around midnight the SP heard a “loud crash like noise.” The SP went to see what happened and nothing was out of place. The SP went into the VA’s bedroom as the VA was awake and out of bed and rubbing his/her head. The SP asked him/her what happened and to show the SP where it happened. The VA was “toying” with the big empty plastic cabinet that was by the stairwell. Since nothing was out of place, the SP was “sure” that the VA was playing with the cabinet by tilting it and “bonked” him/herself in the forehead. After, out of reaction, the VA might have pushed it back and it hit the wall and then s/he ran from the area. The VA had a small red mark on his/her forehead, but no bruises, cuts, or blood. The facility health care professional was notified. In the morning, the VA was “all smiles.” (In an interview, the SP provided consistent information about the incident.) · P1 stated that s/he was aware of an incident on April 25, 2022, where the VA hit his/her head on a cabinet because s/he read about the incident in the VA’s progress notes written by the SP. After reading the progress notes, P1 and P3 went downstairs and tried to move the cabinet but it was too heavy so P1 did not believe what was written (it should be noted that there were two plastic cabinets at the bottom of the stairs and one was empty which this investigator was able to move and one that was locked with items inside of it). P1 believed if the cabinet fell on the VA’s head, that 9-1-1 should have been called. The following were concerns about the SP pinching the VA: · The FM stated that P1 told the FM that P3 told P1 that the VA told P3 that the SP pinched the VA. The FM stated that P3 told the FM that s/he talked with the SP and the SP said that s/he going to blame the pushing down the stairs and pinching on P1. · P3 stated that the VA was crying and when P3 asked him/her what was wrong, the VA said, “No [the SP].” P3 stated that the VA would say “injured” and when P3 asked the VA if s/he was hit or pinched, the VA nodded yes and said the SP’s name. After, P3 talked to the SP and the SP told P3 that the SP asked the VA if s/he was pinched and then asked of it was P1 and the VA said yes. The SP told P3 that s/he asked the VA where s/he was pinched and the VA did not show him/her. P3 said that the SP did not want to blame anyone for pinching the VA. When asked why the FM got the idea that the SP was going to blame P1 for pinching the VA, P3 said that s/he did not know. · No staff persons interviewed had any first-hand knowledge of anyone pinching the VA. P1 and the SP each denied pinching the VA. The following were additional concerns about the SP interactions with the VA: · The FM stated that staff persons told the FM that the VA was being treated different than the other consumers by the SP. It started with the VA having sleep issues and the FM felt “pushed” to have a sleep medication prescribed for the VA and thought it all had to with the SP. The SP wanted the VA to be on sleep medications and was the only staff persons who had concerns about the VA’s during the overnight. Whenever the FM mention the SP’s name to the VA, the VA started crying. · P1 stated that the VA acted differently when the SP worked than when other staff persons worked. The SP typically worked overnights and the VA did not sleep well when the SP was working. Also when P1 worked in the evening and the SP came into work the overnight shift, the VA would start to cry and tell P1 that s/he was scared. When the SP arrived to work overnights, the SP would go downstairs and search the VA’s room because the SP believed that the VA stole items. One time the VA took two bananas downstairs and the SP “chased” the VA downstairs and took the bananas away from the VA and told the VA that s/he could not have snacks. P1 communicated his/her concerns to P5, a supervisory staff person. P1 did not see any staff person yell at the VA. · P2 stated that the only staff person that the VA complained about was the SP. P5 knew about the VA’s concerns regarding the SP, but did not take any action. P2 stated that the VA “flip[ped] out” when s/he heard the SP’s name. P2 stated that the SP was “rude” to the VA and did not use the VA’s name when talking to the VA. P2 said that the SP did not interact with the “loving care” that s/he interacted with the other consumers. If P2 arrived at the facility do an overnight shift, the VA ran downstairs until s/he realized that it was not the SP working. The VA was more relaxed when the SP was not at the facility. · P3 stated that s/he was out on leave for a while and when s/he returned, the VA was “different.” P3 was aware of the SP using words like “shenanigans” and called the VA “that one.” P3 stated that when the SP worked the overnight the VA went to bed at 8:30 p.m., but did not have any issues when other staff persons worked the overnight. P3 did not witness any staff persons yelling at the VA. · P4 did not know anything about staff persons calling the VA names. P4 said s/he, as well as P2 and P3, would ask the VA if s/he liked staff persons and would say staff persons’ names and the VA only responded negatively to the SP’s name. · P5 stated that s/he was aware that there were concerns about insomnia with the VA beginning in February or March 2022. The SP reported that the VA was awake at night engaging in destructive behaviors such as taking pictures off of the wall. P5 met with the FM and the VA with a physician and eventually ended up with an as needed sleep aid for the VA. Staff persons brought concerns to P5 that the VA was afraid of the SP and when the SP arrived at for work, the VA ran downstairs. At one point after hearing of concerns asked the VA if s/he liked the SP and the VA gave P5 two thumbs up. P5 then asked the VA if s/he felt safe with the SP, the VA also gave two thumbs up. P5 told the FM about the responses by the VA. P5 did not witness any concerns between the VA and the SP. · The SP stated that s/he usually worked from 10 p.m. until 8:30 a.m. In the morning, the VA typically got up around 6 or 6:15 a.m. The VA got dressed for work came up and ate breakfast and by that time it was almost time to leave for day program. The SP said that s/he usually worked well with the VA. At times the VA’s behavior had been “tricky” and the SP wanted to figure out why. The SP always used “good manners” with the VA. · The SP stated that s/he occasionally got frustrated with the VA and other consumers, but was not negative with them. The SP did not discipline or correct the VA unless saying to the VA that it was not nice if s/he took food. One time while trying to comb the VA hair, the SP might combed too hard to get through his/her hair. · The SP stated that s/he did not why someone would made allegations about the SP. The VA’s case manager (CM) was aware of the concerns regarding the VA as s/he was in contact with the CM and the facility. The CM was concerned that the facility was being “dismissive” regarding the allegations. Law enforcement also investigated the allegation. The LEO stated that a the completion of their investigation, law enforcement took no additional action. Staff persons stated that they received training specific to the VA, training on consumer rights, and training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Based on when the incident happened (April 25, 2022), where the SP said that the VA bumped his/her head on the cabinet downstairs, the time that the VA said that s/he knee hurt (May 14, 2022), and that there was no information during that time that the VA complained of knee pain, it was likely that the incident with the cabinet was not related to the VA’s knee pain. On May 14, 2022, the VA pointed to his/her left knee and said that it hurt (the VA went to the doctor that day and was diagnosed with a left knee subluxation and given a stabilizing brace to wear on his/her knee). At that time, the C said that the SP pushed the VA down the stairs. The C did not give additional details regarding the time or date of the incident occurred. Later in the internal review, the C said the VA fell down the stairs when the SP was working, but the SP did not see the VA fall. The C told this investigator that the SP pushed the VA down the stairs. The C said that s/he did not witness it as s/he was gone at the time, but the VA told him/her that the SP pushed the VA. When the FM asked about the SP, the VA indicated yes and pointed at his/her left knee. In an interview conducted by an agency that specialized in interviewing vulnerable adults, the VA said that the SP was there when s/he got the “ouch,” but did not provide any additional information regarding his/her knee. The SP denied pushing the VA down the stairs. Given the aforementioned, and without witnesses and information to corroborate what happened, it was not determined how the VA received the injury to his/her knee or whether the injury was caused by the SP. There were also concerns that the SP pinched the VA, but no one had any first-hand knowledge that the SP pinched the VA and the SP denied that s/he pinched the VA. In addition, there were also concerns about how the SP treated the VA including how s/he spoke to the VA as several staff persons stated that the VA indicated that s/he did not like the SP and/or was afraid of the SP. Given the descriptions of the VA’s actions surrounding the SP or the mention of the SP’s name, it was reasonable to believe that the VA did not like the SP. However, the reason or reasons for the VA disliking the SP were unclear. Given the aforementioned, it was likely that not all of the SP’s interactions with the VA were therapeutic in nature. However, there was not a preponderance of the evidence whether the SP’s actions would reasonably be expected to cause the VA physical pain or injury or emotional distress. It was not determined whether 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 and/or 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 determined that there policies and procedures were adequate and followed. The SP no longer worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action action.
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