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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: 1098839-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka Suspected Maltreatment Reported: It was reported that a staff person (SP) pushed a vulnerable adult (VA) through a closet door, leaving a thumb sized bruise on the VA’s bicep. The SP also tapped his/her cheek “daring” the VA to aggress towards the SP. Date of Incident(s): July 4, 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 August 4, 2022; from documentation at the facility; and through six interviews conducted with three facility staff persons (SP, P1, P2), the VA’s case manager (CM), the VA’s guardian (G), and the VA. The VA was diagnosed with neurocognitive disorder, anti-personality disorder, conduct disorder, post-traumatic stress disorder, and developmental disabilities. The VA enjoyed writing his/her own music. The Individual Abuse Prevention Plan indicated the VA was at risk for physical abuse. The VA might not accurately interpret events or situation and had the potential to walk into dangerous situations. The VA might provoke others into a fight, swear, become physically aggressive, and/or destroy property. Staff persons provided opportunities for physical activity and reminded the VA to walk away from a situation using verbal cues, simple instructions, and redirection. The VA provided the following information: · The VA and a housemate (C) had a disagreement and the VA yelled at the C. The C attempted to throw a plate at the VA. The VA tried to go towards the C and the staff persons “broke it up.” · The SP got in front of the VA by the closet door which had previously been broken. The VA tried to move forward and the SP put up his/her hands up to stop the VA and “gently” pushed the VA and s/he stumbled back into the closet door. The door broke again and the VA told the SP that s/he was going to hurt the SP. · The SP took his/her right hand by his/her face and said “Right here.” The VA did not do anything after that because staff persons were there. · The VA was not injured during the incident. The SP and the VA apologized to each other after the incident and the VA respected the SP’s apology. P1 and P2 provided the following information: · On the date of the incident, the individuals who lived at the facility had just returned to the facility from watching fireworks out in the community. The VA and the C got into a verbal argument which escalated and the VA started to come towards the C. · Staff persons tried to verbally redirect the VA and the SP got in between the VA and the C. The VA charged toward the SP and the C so the SP had his/hands up and lightly pushed the VA back. The VA stumbled back and fell back into a closet door. · The VA got up and started yelling at the SP saying that the VA was going to punch the SP in the face. The SP walked closer to the VA, put a hand on the SP’s face and said something like “Hit me.” or “Right here.” · P1 tried to calm the VA down by suggesting that s/he go downstairs, or outside. The VA then went outside for a walk. · In the past, the VA had punched the C resulting in law enforcement involvement. Staff persons did not use any type of holds on the VA. When the VA was upset, staff persons tried to calm the VA down suggesting activities such as going outside, watching a movie, or giving him/her some space. The SP provided the following information: · When the individuals returned from the firework display, the VA and the C were talking and they both got “a little excited.” At one point, the VA came towards the C and the C grabbed a plate to throw. The SP got in between the VA and the C. · The VA went to his/her bedroom but then came back out into the hallway. The SP put his/hands up as the VA approached and continued to tell the VA to calm down. The SP thought the VA possibly hit the SP’s stomach and fell back into the closet. The VA then turned his/her anger from the C to the SP. The SP and P1 continued to tell the VA to calm down and try to take deep breaths. · When asked if the SP put his/her hand to his/her face and said something the SP said “Not that I know of.” The SP said s/he did not believe the VA was injured as the SP had his/her hands open during the incident. Video footage of the incident showed the C sitting in the kitchen at the table. The VA yelled and attempted to come close to the C. The SP stepped in between the C and the VA and put a hand on the VA’s chest while P1 came up behind the VA. P1 put a hand on each of the VA’s biceps and pulled the VA back while the SP appeared to push on the VA’s chest. They all walked back a couple steps and then the VA turned and went towards the hallway and continued to yell. The VA walked away past the hallway but then turned back toward the SP and came towards the SP quickly. The SP put his/her hands up at his/her chest as the VA pushed his/her body into the SP. The VA stumbled back and again came toward the SP quickly and put his/her hands up to push through the SP. The SP had his/her hands up as well and pushed the VA back so the VA took a step back. The VA again tried to come forward so the SP held up his/her hands to the VA’s chest and the VA stumbled back again and hit the closet door. The VA walked away from the closet and the door fell to the floor. Throughout the footage the SP told the VA to “settle down.” The VA continued to yell and said “you threw me in a closet…I’ll break your teeth.” The SP appeared to point to his/her face and say “Right here.” The VA continued to make threats and the SP said “settle down” several more times. The VA moved out to the living room and continued to yell. The G had no previous concerns with the facility or staff persons. All staff persons were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and the facility policies. Relevant Rules and/or Statutes: 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: Information was consistent from P1, P2, the VA, and video footage, that on the evening of July 4, 2022, the VA and the C got into an argument and the VA started to come towards the C. The SP got in between the C and the SP and put his/hands up to stop the VA from coming forward. The VA continued to try to move towards the C multiple times while the SP kept his/her hands up and lightly pushed or held the VA back. At one point, the VA stumbled backward into the closet and the door fell to the floor. The VA then became upset with the SP and said s/he would “break your teeth.” The SP pointed to his/her face and said “Right here.” The SP said “not that I know of” when asked if s/he made the comment to the VA. Regarding the injury: Given the VA, P1, P2, and video footage provided consistent accounts that the SP gently/lightly pushed or held the VA back when s/he tried to aggress toward the C, and that the VA reported s/he was not injured during the incident, there was not a preponderance of the evidence whether the SP engaged in actions that produced physical pain or injury to the VA. 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. Regarding the comments: Although the SP engaged in language which was not therapeutic which was inconsistent with the role of a professional caregiver in a facility licensed by the Minnesota Department of Human Services; and a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6), given that it was a single incident and likely not done maliciously, there was not a preponderance of the evidence whether the comment could produce or 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 determined that policies and procedures were adequate and the followed. The facility completed a debriefing with all staff persons involved in the incident. Action Taken by Department of Human Services, Office of Inspector General: Given the facility took immediate action, a correction order was not issued for the violation outlined in this report.
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