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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: 1087682-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Sarah Schumacher Suspected Maltreatment Reported: It was alleged that a staff person wrote “the N word” on a vulnerable adult’s (VA) forehead. Date of Incident(s): Unknown date(s) 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 July 21, 2022; from documentation at the facility; and through five interviews conducted with the VA, a facility supervisor (P1), three facility staff persons (P2, SP1, and SP2). The VA’s diagnoses included mild intellectual disability, cerebral palsy, bipolar disorder, intermittent explosive disorder, seizure disorder, and glaucoma. The VA used a power wheelchair for mobility. The VA needed assistance with daily living tasks such as dressing, bathing, and personal cares. The VA had a history of using derogatory phrases or “slurs” toward others. The VA had an incentive program to be rewarded for expressing frustration in other ways instead of saying derogatory phrases or slurs. The VA enjoyed playing video games, going to the library, seeing family, and going out to eat. The VA told this investigator that “they were thinking someone might have wrote a naughty word on me and might have used one of those markers.” When asked about the incident, the VA stated that when P2 and SP2 were working with the VA, they were “playing around” and “joking” with each other so the VA was upset and yelled using the “N word.” The VA thought SP1 might have been there too. The VA provided conflicting information regarding whether SP2 and P2 were in his/her bedroom. Initially the VA stated both that SP2 and P2 were in his/her bedroom but then stated they were not. After they heard the VA say the “N word,” SP2 took a marker with an eraser on one side and touched the eraser side to the VA’s forehead and wrote the “N word.” The VA said that P2 saw SP2 do this. The VA also said that SP2 “pretended to write it.” When asked if any other staff person wrote the “N word” on the VA’s forehead, the VA stated, “Not that I know of.” Information from P1, P2, SP1, and SP2, and facility documentation provided the following information: · On July 1, 2022, P2 and SP2 worked the morning shift and were helping the VA in his/her bedroom. The VA was upset and calling SP2 and P2 derogatory names including the “N word.” In an effort to redirect the VA, P2 stated that SP2 told the VA, “How would you like if that was written on your head?” and SP2 stated that s/he said, “You wouldn’t like it if someone called you the ‘N word’ like it was written on your forehead.” The VA said, “[SP1] already did that.” P2 asked the VA what happened with SP1 and the VA said, “[SP1] did it and I told [him/her] to get it off my forehead.” The VA did not provide further details. The VA calmed and had a “normal” rest of the day. · P2 could not recall if it was the same day or the next day but s/he told P1 what the VA said. P1 then asked the VA if someone wrote the “N word” on the VA’s forehead. The VA told P1, “Yup.” P1 said SP1’s name and the VA replied, “Nope,” and instead said that SP2 was the one who wrote on the VA’s forehead. The VA told P1 that s/he had “proof.” The VA then took off a hat s/he was wearing and told P1, “See, it’s there.” P1 did not see anything and told the VA that there was nothing on his/her forehead. P1 also talked to SP2 who provided information consistent with what P2 provided and denied writing the “N word” on the VA’s forehead. P1 then talked to SP1 and SP1 told P1 that s/he had “no idea” about the allegation and denied writing the “N word” on the VA’s forehead or anywhere.
· P1, P2, SP1, and SP2 each provided consistent information to this investigator that was also consistent with what P2, SP1, and SP2 provided to P1. · SP1 and SP2 each denied writing the “N word” on the VA’s forehead. · P1, P2, SP1, and SP2 each stated that they did not see anything written on the VA’s forehead and saw no marks that could have been worn off writing or indication of anything being written on the VA’s forehead. · P1 stated that the VA did not let anyone touch his/her face or head. If staff persons attempted to wipe the VA’s face the VA would “freak out” and not allow it. · P1, P2, SP1, and SP2 each stated that the VA had a history of inaccurate reporting. P1 stated that the VA would say that staff persons did not feed him/her and were “poisoning” him/her but that was not true. SP2 stated the VA would “change [his/her] story.” · SP2 stated that one or two weeks after the incident, the VA told SP2 that SP2 was “going to get fired for what [SP2] did.” SP2 did not know what the VA was talking about. SP2 stated that the VA “targeted” SP2 and the VA yelled at SP2 most shifts. The VA used the “N word” daily. P1, P2, SP1, and SP2 were each trained on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults. Conclusion: Information showed that when the VA was calling SP2 and P2 the “N word,” SP2 told the VA that s/he would not like it if someone called him/her the “N word” like it was written on his/her forehead, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. The VA told SP2 and P2 that SP1 “already did that.” When P1 asked the VA, the VA told P1 that SP1 did not write on his/her forehead but that SP2 did and that s/he had “proof.” However, when the VA took off his/her hat, P1 did not observe anything written on the VA’s forehead. The VA told this investigator that SP2 used the eraser end of a marker and wrote the “N word” on the VA’s forehead and “pretended” to write it. The VA stated that P2 saw SP2 do this. When asked if other staff persons did this, the VA told this investigator, “Not that I know of.” Although the VA said that SP1 and/or SP2 wrote the “N word” on the VA’s forehead, given that no one saw anything written on the VA’s forehead, that the VA said P2 saw SP2 do so but P2 stated that s/he did not see that happen, that SP2 was redirecting the VA when s/he mentioned the “N word” on the VA’s forehead, that SP1 and SP2 denied the allegations, and that there was no information to support that anyone wrote on the VA’s forehead, there was not a preponderance of the evidence whether a staff person wrote the “N word” on the VA’s forehead or whether all of SP1’s and SP2’s actions were therapeutic conduct. 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 determined that policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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