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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: 1075952-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled and swore at four vulnerable adults (VA1-VA4), that the SP hid the van keys because s/he did not want another staff person and one of the VAs to go and get food, that the SP told one of the VAs to “get the fuck out of here” and “go to your room,” that the SP restricted food, that the SP told one of the VAs they could starve if they did not like what the SP was preparing, and that the VAs were hungry when the SP worked. Date of Incident(s): Prior to April 20, 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 April 26, 2022, from documentation at the facility, and through nine interviews conducted with VA1, VA2, VA3, VA4, the SP, a facility management staff person (P1), and three facility staff persons (P2-P4). The facility provided residential services to VAs that had mental health diagnoses. VA1’s Coordinated Service and Support Plan (CSSP) Addendum-Intensive showed that s/he enjoyed being around people, “engaging in activities,” and “does not like being bossed around and yelled at.” VA2’s Self-Management Assessment showed that s/he enjoyed accessing the community and “may have difficulty regulating [his/her] emotions and may act out in anger.” As a result, staff persons were to encourage him/her to “practice the techniques that [s/he] states have worked in the past.” VA3’s Coordinated Service and Support Plan (CSSP) Addendum-Intensive showed that s/he enjoyed spending time with staff and that it was “important” for him/her to be “respected.” VA4’s Self-Management Assessment showed that s/he “wants to be a successful member of the community,” had diabetes, and “often chooses to eat foods that are high in carbs and salt.” As a result, staff were to “support” him/her by offering foods that were “low in sodium and carbs.” P1 and facility documentation provided the following information: · When P1 talked to VA1 on April 6, 2022, VA1 was initially “reluctant” to talk to P1 because s/he was “afraid” of what the SP might do if information got back to the SP that VA1 had talked to P1. When P1 “assured” VA1 that nothing would happen to him/her, VA1 shared instances of when the SP “yelled” and “screamed” at him/her, such as saying, “get the fuck out of here,” that VA1 “hid” in his/her bedroom when the SP worked, and that VA1 was “always hungry.” VA1 specifically talked with P1 about an incident in which s/he and P3 were going to leave the facility to get food and when P3 went to get the van keys, P3 could not find them. While they looked for the keys, the SP “screamed” to VA1, who was allowed to be in the office with staff, to “get out.” The keys were found at about 10 p.m. that night and P1 believed that the SP “hid” the keys so P3 and VA1 could not go out. VA1 also indicated to P1 that the conduct from the SP “happened all the time.” · VA2 told P1 that s/he “hides” in his/her bedroom when the SP worked and that s/he tried to “avoid” the SP, but that VA2 was “not really concerned” about the food even though VA2 wished that s/he had “more food.” · VA3 told P1 that s/he was “not afraid” of the SP even though s/he “may yell” at VA1 and VA3. VA3 also stated that s/he was “always hungry” and that s/he “wishes [the SP] would get over the food rules” even though the SP was a “fine staff.” · P1 then talked to VA4, who said that s/he was not “very concerned” about the food situation, but VA4 was “not really a motivated food person.” VA4 also told P1 that s/he did not “trust” the SP and thought that s/he would be “mean” if s/he came back to the facility, but VA2 did not specify to P1 what “mean” meant. · When P1 was asked about the SP’s conduct before this report, s/he stated that staff were aware that the SP “could be rude or disrespectful,” but no one “understood the extent.” The facility’s Incident Report and Internal Review for VA1 stated that on April 4, 2022, VA1 was in the office trying to help find the van keys when the SP said, “get the f%&k out of here.” When VA1 left the office and stood on the other side of the “open door,” the SP “continued to yell” at VA1 to “get the f%&k out of here, this doesn’t concern you! Back up! Back up!” After the SP left that night, “all the house residents came to the office to talk to the staff (P3).” They told P3 that the SP “often yells and swears at all the residents,” that the SP “often refuses to give the resident’s access to food” and that they were “all intimidated” by the SP. The facility had an Incident Report and Internal Review for VA2-VA4 that provided information that was similar to the information provided in the Incident Report and Internal Review for VA1. VA1 provided the following information to this investigator: · VA1 described the SP as being “very disrespectful” to others and that s/he had an “attitude.” VA1 gave an example in which the SP said “at least I get to see” my family. VA1 thought that comment was “really fucked up” and made him/her feel “sad and angry.” · There were occasions when VA1 tried to talk to the SP, but the SP “always ignores me.” VA1 also mentioned that when s/he lost a job, the SP said, “Don’t talk to me unless you get a job.” · When VA1 was asked to provide information about access to food, s/he stated that the SP was “very strict” regarding food and that the VAs got a “portion for a meal, but not get snacks really that much and if we did we were lucky” and that s/he was “still hungry” after the SP served the meals. On one occasion, VA1 heard the SP tell VA3 that s/he was “overweight.” VA2 stated that the SP was “kind of rude” and made comments that VA1 “wet the bed” and “smells like pee.” When that happened, VA1 “just walked off.” Although VA2 did not have concerns related to food, s/he heard the SP tell VA4 that s/he would not serve him/her food unless VA4 did some cleaning. When that happened, VA4 “walked away.” Although VA2 did not eat at the time, the SP left food out for him/her to eat later. VA3 stated that the SP was “really protective” in terms of how much food s/he “gives out,” but VA3 felt that s/he had enough food, that the SP was “aggressive” and “demanding” and that the SP said “fuck” and “shit” on a number of occasions. VA3 acknowledged that the SP told him/her that s/he was “overweight,” but that was a “true” comment because VA3 felt that s/he was overweight. In addition, the SP told VA3 that s/he “can’t” have more food, that s/he needed to “lose weight” and that s/he should “go for a walk.” VA4 stated that the SP treated the other VAs “really bad.” VA4 gave an example in which the SP told VA1 that s/he was “disgusting” and “you should clean up after yourself.” VA4 also heard the SP say that VA1 and VA3 were “fucking disgusting” but VA4 did not remember how they responded to those comments. VA4 did not have concerns related to the food. P2 stated that the SP was “rude” to the VAs and told them to “get the fuck out of the kitchen.” When the SP cooked and there were leftovers, the SP told P2, “No, they can’t have more.” When the SP was not around, the VAs told P2 that they were “hungry.” P2 described seeing “sadness” on the VAs faces when the SP yelled at them. P3 provided information to this investigator that was similar to the information s/he provided in the facility’s Incident Report and Internal Review for VA1-VA4, but added that the SP “hid” the key before s/he left and that P3 found the van key in a garbage bag in the staff office after the SP left. P4 described the SP as being “verbally demanding” to the VAs and stated that s/he heard the SP say “clean up your fucking mess.” P4 felt that it looked like the SP was “angry at them.” VA1 and VA3 told P4 that they did not like the SP’s “energy” or “attitude.” The SP provided the following information: · Prior to food being purchased, the SP sat down with the VAs and offered them the opportunity to help plan the menus. · When the SP cooked, there were never any leftovers and when the VAs asked for more food, the SP offered fruits and vegetables, but the VAs would sometimes get “pissed off” at those options. · Although the SP denied yelling or swearing at the VAs, s/he told one of the VAs to “step out” of the office. The SP acknowledged that s/he hid the keys because the SP felt that P3 did not have “authorization” to leave the facility to get food. · The SP also denied telling a VA that they could starve if they did not like what the SP prepared for a meal. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act, “individual rights” and the VAs specific care plans prior to April 4, 2022. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, (6) stated that persons had the right to be treated with courtesy and respect. Minnesota Statutes, section 245D.04, subdivision 3b, (3) and (5) stated that persons had the right to have “use and free access to common areas in the residence” and had the right to “have access to three nutritionally balanced and nutritious snacks between meals.” Conclusion: A. Maltreatment: Although the SP denied the allegations, information from VA1-VA4 and P2-P4 showed that the SP engaged in conduct toward the VAs that included telling VA1 and VA4 that they were “fucking disgusting” and that VA1 “wet the bed” and “smells like pee.” The SP was “strict” with food portions, withheld seconds of food from the VAs, and told VA3 that s/he was “overweight.” The SP told the VAs to “get the fuck out” of the kitchen and told VA1 to “get out” of the office and hid the keys so P3 and VA1 could not go get food. In addition, VA1 stated that the SP told him/her “at least I get to see” my family. VA1 thought that comment was “really fucked up” and made him/her feel “sad and angry.” P2-P4 witnessed some of the incidents and provided information that the SP was “verbally demanding” and “rude.” The SP’s treatment toward VA1-VA4, which included yelling, swearing, disrespectful comments, and restrictions on their access to food and common areas, was a violation of Minnesota Statutes, section 245D.04, subdivision 3, and 3(b) and could be considered by a reasonable person to be disparaging, derogatory, and harassing. The SP’s overall conduct could reasonably be expected to produce emotional distress. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and rights prior to April 4, 2022, The SP engaged in conduct that was contrary to that training and was therefore responsible for emotional abuse of the VAs. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated emotional abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring because the SP’s overall conduct was considered a single event of maltreatment and not serious because the VAs did not sustain serious injury as defined in Minnesota Statutes. Action Taken by Facility: The facility completed an Incident Report and Internal Review and determined that although policies and procedures were adequate and followed, there was a need for additional training and that the “alleged perpetrator of the verbal abuse and the restricting of food has been given an overview of what the appropriate way of interacting with residents is and that residents have a right to access to food at all times.” Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Given that corrective action was taken, no Correction Order was issued for the violations outlined in this report.
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