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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: 1070488-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a staff person (SP) pushed a vulnerable adult (VA) onto the floor then dragged him/her across the floor causing the VA to sustain a rug burn. Date of Incident(s): July 21, 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 (1): 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. Summary of Findings: Pertinent information was obtained during site visits conducted on August 8 and 16, 2022; from documentation at the facility, law enforcement records, and medical records; and through nine interviews conducted with the VA, two supervisory staff persons (P1 and P2), an administrative staff person (P4), the SP, two of the VA’s day program staff (DPS1 and DPS2), the VA’s case manager (CM), and the VA’s guardian (G). The facility was a split level home with a living room upstairs and the VA’s bedroom downstairs. The facility had a long gravel driveway and was surrounded by woods. During the time of the incident, P1 was on vacation and P2 provided supervisory coverage. Consistent information was provided that the SP put in his/her notice and his/her last day of work was July 22, 2022 (the day after the incident). The VA was diagnosed with a moderate developmental disability. According to the VA’s Coordinated Service and Support Plan (CSSP) Addendum, the VA preferred to know what was expected of him/her and needed consistency from one staff person to another. The VA preferred to talk through struggles and wanted space from others. According to the VA’s Self-Management Assessment of Risks: · The VA was not allowed to be unsupervised including while at the facility. The VA historically threatened to leave the facility but had not acted upon the threats. The VA may not have informed staff persons before leaving an area and may not have taken reasonable precautions with strangers or demonstrated consistent street safety skills. · The VA was vulnerable to self-abuse, including banging his/her head against the floor when upset; had a history of suicidal threats and broke glass windows; and a history of drinking hand soap when upset. According to the VA’s Individual Abuse Prevention Plan (IAPP): · The VA was susceptible to physical abuse. The VA was unable to identify potentially dangerous situations; had inappropriate actions with other persons; was not able to defend him/herself; and provoked other persons physically and verbally. Staff persons visually monitored the VA and “encouraged” the VA to “report accurate information” and “avoid confrontation” with other persons. · The VA had a history of seeing his/her view point as the only option and did not consider other person’s input which led to “frustration” for the VA and the other person. The VA was encouraged to not say things “under [his/her] breath” about other persons or comment on situations to avoid provoking other persons. Staff persons used “graduated guidance” to support the VA in situations that were potentially harmful to the VA. Staff persons monitored the VA for any signs or symptoms of abuse such as bruises, crying, and/or unexplained injuries and reported them “immediately” following the facility procedures. The VA stated on a previous occasion, s/he was in the living room with the SP and another client (C1). The VA fought with C1 and C1 bit the VA on his/her left arm. The SP pushed the VA down onto the floor which caused the VA to land on his/her right side. The SP then grabbed the VA’s legs and dragged him/her across the living room floor which resulted in a rug burn on the VA’s right side. The SP and C1 left the facility and because the VA was “really upset,” s/he also left the facility so another client (C2) called 9-1-1. Later on, the VA told P2 “what [the SP] did and everything” but was not able to provide specific information regarding what s/he told P2. According to a law enforcement report dated July 21, 2022, at 6:55 p.m., the VA left the facility unsupervised and headed west bound on 240th Street. The caller described the VA’s clothing and gave a call back number for the SP. At 7:13 p.m., law enforcement was with the VA requesting an ambulance because of a cut on the VA’s head. The VA was then brought to the hospital. There was no information provided on who was the initial caller but law enforcement spoke to the SP at one point. According to the VA’s medical records dated July 21, 2022, the VA had injuries to his/her forehead, left forearm, and right flank. The VA told the emergency room doctor that s/he was “frustrated” with another client who kept telling the VA to break up with his/her significant other. The VA then hit his/her head on a wall but did not have a headache or lose consciousness. The VA also said that s/he had a recent altercation with the other client which resulted in the bite mark on his/her left forearm. The VA stated s/he was “dragged” across carpet and hurt his/her right flank. The medical record did not say who dragged the VA across the floor. DPS1, DPS2, and the CM provided the following information: · The VA did not attend the day program from July 21 to 25, 2022, and the facility did not notify the day program of the VA’s absence. On July 25, 2022, when the VA returned to the day program, DPS1 and DPS2 asked the VA why s/he missed so many days in a row. The VA said s/he had some issues at the facility, left without staff supervision, and ended up in the hospital. DPS1 saw the bandage on the VA’s left forearm so asked him/her about it. The VA said that s/he got into a fight with C1 and C1 bit the VA. · The VA said that a staff person (the VA did not provide the staff person’s name) “pushed” the VA down, “drug” the VA across the floor, and tried to push the VA down the stairs. The VA was “frustrated” so s/he hit his/her head against a wall. The staff person took C1 and left the facility so the VA then left the facility and walked down the driveway so C2 called 9-1-1. The VA said s/he had a mark on his/her right side but refused to show DPS1 and DPS2 at that time. · On July 25, 2022, P1 contacted and notified the CM about the information that the VA provided about the incident. The CM then called and notified an administrative staff person (P4) about the incident and P4 responded that s/he would do an internal investigation and get back to the CM. The CM did not hear back from P4. · On July 26, 2022, at approximately midnight, P2 sent out emails to the VA’s team, including DSP1 and the CM, with incident reports from July 10 to 21, 2022. · During the day on July 26, 2022, DPS2 and the CM met with the VA who said that s/he was “mean” to C1. The SP was “mean” and dragged him/her across the floor which resulted in rug burn on the VA’s right side. The SP then left with C1 and the VA did not like being without staff persons at the facility so s/he also left. · On July 29, 2022, the CM went and met the VA at his/her day program. The CM took photos of the injury on the VA’s right side. · The VA was able to provide accurate information and DPS1 and DPS2 talked to the VA multiple times about the incident and s/he provided the same information during every conversation. DPS1 said the VA’s ability to retell an incident was “pretty high.” DPS2 said the VA “never” made false reports previously. The CM did not have concerns with the VA’s ability to provide information and historically reported on him/herself when s/he did something wrong. A photo taken by the CM on July 29, 2022, showed multiple small abrasions on the VA’s lower right side with bruising under the abrasions. Incident reports and the VA’s progress notes completed by the SP provide the following information: · On July 10, 2022, at 7 p.m., the VA came upstairs “complaining” of diarrhea and the SP tried calming him/her. The VA went outside, lay on the driveway, and then left without supervision. The SP offered the VA over the counter medication and tried to deescalate the situation by calling the facility’s non-emergency line. · On July 19, 2022, at 6 p.m., the VA came upstairs, “complained” to another client (the SP did not provide information on which client), and they “got into it.” The VA fell down and “got scraped up.” There was no information provided where on the VA’s body s/he was scraped up. · On July 20, 2022, at 6:30 p.m., the VA came upstairs and “interrupted” the other clients including “verbally antagonizing” one of them which started a fight. “Scrapes and bruises” was the only thing documented for the injuries and there was no information where the scrapes and bruises were on the VA’s body. The SP separated the VA and other client to calm them and then called 9-1-1. · On July 21, 2022, at 6:15 p.m., the VA came upstairs, “complained” that s/he could not find the remote, and then asked to talk outside. Staff persons “tried to guide [the VA] back downstairs to play a game.” The VA then fell, yelled at the other clients, “wailed” on the floor, and then left without supervision. The SP tried calming the VA by asking him/her to go downstairs and the VA was “unresponsive.” The SP called 9-1-1 after the VA left. The VA’s progress notes completed by the SP, provided the following information: · On July 20, 2022, the VA arrived at the facility and ate a snack and dinner. The VA then had an “anxiety attack,” was “very hard to communicate with,” and “belligerent.” There was no information provided about an incident with C1 or injuries. · On July 21, 2022, the VA arrived at the facility and had a snack. The VA then went downstairs and came up for dinner before returning back downstairs. At approximately 6 p.m., the VA had a “classic [the VA] anxiety attack” because s/he could not find the remote. The VA then left without supervision and went to the hospital. There was no information provided about an incident with C1 or injuries. There was no entry in the VA’s health notes for July 20 and 21, 2022. The SP provided the following information: · Early in the interview, the SP could not recall the specifics of the night of the incident and stated his/her last day working at the facility was August 4, 2022. During the last few days of the SP working, the VA ate dinner, went downstairs to his/her bedroom, and then return upstairs “complaining” of an ailment. The SP tried redirecting the VA which sometimes made the VA “worse”, the VA began fighting with the other clients, and the VA eloped. · The SP stated that on either July 20 or 21, 2022, while on the front porch at the facility, C1 bit the VA and threw a can of paint. C1 then kicked and punched the VA so the SP removed C1 from the situation. At some point, the VA fell down. The SP did not recall if the SP or C1 called 9-1-1 because the VA was “wailing.” · On July 21, 2022, the VA and C1 fought over the remote. The SP needed to assist another client (C2) in the bathroom downstairs. During that time, C1 and the VA got into a physical fight but the SP could not provide specifics on what happened during the fight but later in the interview, the SP said it could have been when C1 bit the VA but stated s/he was “pretty sure” C1 bit the VA on the porch. · When this investigator asked the SP about what took place in the living room, the SP stated C1 was “upset” because the VA woke C1 up from having the TV loud. When this investigator asked about a rug burn on the VA’s back, the SP stated it could have been from either when C1 and the VA were fighting or when the SP was “intervening” to try and get the VA away from C1. The SP pushed the VA and C1 apart and “usually” grabbed C1’s arms and pulled C1 away from the situation. · The SP said that at one point, s/he walked up to the VA and grabbed the VA on his/her shoulders and told the VA to “get ahold of yourself” but denied pushing the VA and stated that the VA “fell” down because s/he was “belligerent.” The SP asked the VA to stop yelling but the VA continued which resulted in C1 getting more agitated. The VA was near the top of the stairs, hitting his/her head against the wall but did not intervene since s/he was dealing with C1. The SP denied dragging the VA across the floor and stated the VA might have been confusing the incident with what happened with C1. When asked if s/he ever left the facility with C1, the SP stated s/he possibly took C1 outside on the driveway to calm C1 and C2 possibly called law enforcement. · The SP did not recall if s/he was trained to put his/her hands on the VA’s shoulders to calm him/her but staff persons tried to move the VA away from a situation in a way that made sense without hurting the VA. P2 provided the following information: · On July 23, 2022, P2’s first day back at the facility since prior to the incident, P2 read the VA’s progress notes completed by the SP. P2 then asked the SP about the incident and the SP was “vague with details” but said that the VA was “whiney” and had a “tantrum.” · P2 asked the SP if the VA had injuries or if the SP completed the VA’s health notes and the SP said s/he wrote everything in the incident report. Since the SP no longer worked at the facility, P2 did not continue the conversation further. · Later on, P2 spoke to the VA who was “upset” about the incident. P2 tried to get information from the VA but the VA escalated with being upset and was “loud” and repeated the same words. P2 saw the bite mark on the VA’s arm and someone (P2 could not recall who) told him/her that C1 bit the VA. The VA did not tell P2 that the SP pushed and dragged the VA causing an injury. The VA was independent with bathing so P2 only saw the bite on the VA’s arm and did not see any other injuries. P2 then spoke to P1 who was already aware of the incident. · The VA did not leave unsupervised when P2 worked and was not aware of concerns from other staff persons until the week of the incidents and the SP’s progress notes. The VA was able to provide some information about incidents but was also known to “make up stories” if P2 wanted to know something specific or if it benefited the VA. P2 did not have prior concerns with the SP’s interactions with the clients. P1 provided the following information: · On July 21, 2022, P1 called the SP to “check in” and the SP told P1 that the VA was “belligerent” and left the facility but things were “okay.” The SP did not tell P1 that 9-1-1 was called or that the VA went to the hospital and P1 did not talk to the VA. P1 later called and spoke to the overnight staff person (P3) who told P1 that the VA returned from the hospital during the night. · On a later date (P1 could not recall which date), while at the facility, P1 asked the VA about a bandage on his/her arm. The VA told P1 that C1 bit him/her so P1 looked at the injury and provided the VA with care instructions. P1 was not aware of any other injuries and the VA did not discuss any injuries. The VA did not tell P1 about the incident with the SP but P2 “might have” told P1 about the rug burn on the VA’s side. · On a later unknown date after the SP no longer worked at the facility, the VA told P1 that s/he did not like the SP but did not provide a reason why. The VA also told P1 that the SP left the VA and other clients alone at the facility. P1 did not look further into this information. · P1 stated the VA was “always truthful” about incidents. P1 did not have concerns with the SP’s interactions with clients but was aware there were issues between the SP and the VA multiple days in a row prior to the SP no longer working at the facility. P4 stated that there had been things going on with the VA including leaving without supervision but not maltreatment. When asked about the VA having injuries, P4 denied knowing of any injuries and referred this investigator to other supervisory staff persons, including P1 and P2. The G stated s/he received incident reports from the facility and the CM later contacted the G about the information that the VA provided. On July 29, 2022, the G talked to the VA and the VA discussed the bite on his/her arm from C1 and that the SP dragged the VA across the floor. The VA then showed the G the rug burn on his/her right side. The G did not ask additional questions since s/he was aware that law enforcement was already involved. The VA was “mostly accurate” when providing information but has left out pieces of information in the past. The facility’s personnel files and training records documented that staff persons interviewed for this investigation, including the SP, were each trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), stated that a client’s protection-related right included being treated with courtesy and respect. Conclusion: A. Maltreatment: The SP provided “vague” details of the incident to P2 and could not recall specifics of the night of the incident when talking to this investigator. In addition, the SP provided incorrect information regarding his/her last day of working at the facility. However, the SP stated on July 21, 2022, there was a fight between C1 and the VA while the SP was downstairs assisting C2. At one point, the SP walked up to the VA and grabbed the VA on his/her shoulders and told the VA to “get ahold of yourself.” When this investigator asked about rug burn on the VA’s back, the SP stated it could have been from either when C1 and the VA were fighting or when the SP was “intervening” to try and get the VA away from C1. The SP said that s/he pushed the VA and C1 apart and “usually” grabbed C1’s arms and pulled C1 away from the situation, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). The SP’s documentation from the incidents did not provide information as where on the VA’s body the injuries occurred. Although the SP denied pushing the VA down and/or dragging him/her across the floor, given that the VA provided consistent information to five persons at different times on different dates; that DPS1, DPS2, the CM, P1, and the G each stated that the VA had a history of providing accurate information; and that the SP had reason to minimize his/her actions for fear of repercussions, there was a preponderance of the evidence that the SP’s actions were not therapeutic conduct and that the SP pushed the VA onto the floor and dragged him/her across the floor which resulted in the VA sustaining rug burn on his/her right side. It was determined that 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). 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 the VA’s plans. The SP was responsible for maltreatment of the VA. 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 abuse for which the SP was responsible not recurring maltreatment but was “serious” maltreatment. It was a single incident during which the VA sustained an abrasion on his/her right side that was still visible eight days after the incident. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. On September 23, 2022, the facility was issued a Correction Order for the violations outlined in this report. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal.
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