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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: 1101750-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Danielle Morrison Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was hit on the top of his/her head by a staff person (SP) and barricaded in the VA’s bedroom. The SP was angry the VA’s catheter bag opened and leaked on the floor. Date of Incident(s): July 5, 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 5, 2022; from documentation at the facility; and through six interviews conducted with three facility staff persons (the SP, P1, and P2), the VA’s case manager (CM), the VA’s guardian (G), and the vulnerable adult (VA). This investigator reached out to P3 via multiple means, but did not hear back from him/her. The VA’s diagnoses included tetraplegia (paraplegia caused by an injury), traumatic brain injury, and neurogenic bladder. The VA wore a catheter. The VA enjoyed watching crime shows, helping with chores, and going to pawn shows. The facility was one level and had wide hallways and doorframes for the clients’ to maneuver in wheelchairs. The facility’s Internal Investigation provided the following information: · The VA said that s/he had “never” been hit by the SP. The SP called the VA a “motherfucker,” and had the VA clean up urine off the floor that leaked out of his/her catheter bag. · P1 stated that it was standard practice for the VA to clean up his/her own urine if the staff felt s/he did it on purpose. · P3 witnessed the SP push the VA’s head back and that the VA grabbed the SP’s arm and told him/her to get his/her hands off of the VA. The VA was then forced into his/her bedroom and when the VA tried to come out, the SP pushed him/her back inside. The G provided the following information: · The VA said s/he was not hit over the head, but was kept in his/her bedroom. · The VA said the SP was “bossy” and “pushy.” The G said the SP was “firm,” but not out of line. · The G stated that the VA “exaggerates a lot” and “guessed” s/he was not an accurate reporter. The CM provided the following information: · When the CM talked to the VA it sounded like s/he was not hit on the head, but locked in his/her bedroom. · The VA said s/he loved it at the facility one day and then said s/he hated it there the next day. The VA’s perception was based on his/her mental health and sometimes s/he had significant behaviorism. · The VA did not report to the CM about issues with the staff. · The CM said there was an incident where the VA’s catheter bag leaked and the staff told the VA to mop it up. The CM talked with staff about that not being an appropriate response even if the staff encouraged helping in activities of daily living (ADL) so the VA was not bored. · The VA told the CM that the SP was “mean,” but did not give specifics. P1 provided the following information: · In the past when the VA got angry and pulled off his/her catheter or colostomy bag and smeared feces on the wall, the previous supervisor allowed the VA to help clean up. P1 did not know of the VA doing that now. · P1 said staff cooked and cleaned and the VA asked if s/he can help mop, clean, and sweep. P1 told the VA “thank you, we are okay.” P1 said the VA did not help on his/her shifts. · P1 had no knowledge of the VA being shut in his/her bedroom or hit. P1 said “we do an awesome job taking care of residents here.” · P1 said the VA would “spit on staff, try to run into staff with his/her wheelchair, cuss you out, [use] racial slurs, and threaten to harm him/herself.” When that happened P1 engaged the VA in conversation to divert his/her mind from whatever s/he planned on doing. P2 said s/he did not know about the VA being hit on the head, barricaded in his/her bedroom, or being made to clean up his/her urine. P2 did not see the VA hit by a staff person. P2 said some staff speak “naturally loudly,” but the staff did not directly yell at the clients. P2 felt like the clients were “our” parents and staff were respectful. The VA provided the following information: · The VA said staff “treat me good.” The VA said nobody had locked or barricaded him/her in his/her bedroom. · The VA said the staff made him/her clean up his/her urine when there was an accident with the catheter bag. The staff gave the VA a “bleach rag” to clean it up. This happened a couple of times. The VA said the SP made him/her scrub a shower chair. · The VA said the staff talked to the VA “good.” Staff raised their voices “a little bit.” The SP provided the following information: · The VA was “never” forced to go to his/her bedroom. The SP did not know anything about the VA being hit on the head. · The VA asked for things to do like mopping, taking out the recycling, and cooking. The VA was the only client who asked to help, the staff did not force him/her to help. · The SP said the clients did not make him/her upset. The SP described his/her tone of voice as polite and respectful. · The SP said the VA has had “mood swings-extreme.” The SP, P1, and P2 were trained on the Reporting of Maltreatment of Vulnerable Adults and the Conclusion: The VA said s/he was not hit on the head or barricaded in his/her bedroom. The SP, P1, and P2 were not aware of the VA being hit. P1 and P2 were not aware of the VA being shut in his/her room and the SP said the VA was “never” forced to go to his/her room. Given that the CM and the G stated that it sounded like only part of the reported incidents were true, and that the G said the VA “exaggerates” a lot, there was not a preponderance of the evidence whether the VA was hit or forced to remain in his/her room. In terms of the VA having to clean up his/her own urine, given that there was differing accounts of what happened, or when it may have happened, and that information showed it was no longer practiced, there was not a preponderance of the evidence whether the VA was required to clean up any spilled urine. In terms of the SP speaking inappropriately to the VA, given that the VA said the staff talked to the VA “good” and without further information to support or refute this, there was not a preponderance of evidence whether the SP engaged in language that would be considered to be disparaging, derogatory or harassing. It was not determined whether physical or 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: 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). Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures adequate and followed by the staff. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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