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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: 1097300-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth Suspected Maltreatment Reported: It was reported that a staff person (SP) grabbed a vulnerable adult’s (VA’s) wrists and forcefully removed the VA from a car. The VA sustained red marks and indentations on both wrists and forearms following the incident. Date of Incident(s): July 18, 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 a site visit conducted on August 24, 2022; from documentation at the facility; and through six interviews conducted with two facility staff person (the SP and P1), a supervisory staff person (P2), the VA’s case manager (CM), the VA’s guardian (G), and a staff person (S1) from the VA’s school. Attempts were made to contact and interview two additional staff person from the VA’s school (S2 and S3) but the attempts were not successful. This investigator met the VA but the VA did not provide information regarding this investigation due to his/her diagnoses. The VA was diagnosed with autism spectrum disorder. The VA enjoyed puzzles and going to pet stores. The VA attended a school program during the day and typically received transportation to the school from a transportation company (that was separate from the facility and school). The VA’s school was approximately 23 miles from the facility. The VA’s Individual Abuse Prevention Plan said that the VA had a history of behaviors including hitting him/herself, “banging” his/her head, and biting his/her hand if the VA was “elevated.” If staff persons observed self-injurious behaviors, they were to “intervene” to ensure the VA was safe. The VA’s Coordinated Service and Support Plan Addendum said that the VA had two to one staffing during awake hours and when in the community. If the VA displayed behaviors, staff persons were to reinforce appropriate behaviors and speak calmly. Staff persons could also “calm or comfort” the VA by placing a hand on the VA’s arm or shoulder for less than 30 seconds to ensure the VA was “safe.” Staff persons could physically intervene if the VA was attempting to hurt him/herself or others by blocking the VA with their body and if needed, preform a two person escort to remove the VA from the area or object. The [VA’s] School Transportation Plan developed April 5, 2022, said that two staff persons were to accompany the VA to the transportation vehicle and do a “hand to hand transfer" with transportation staff. The VA should never walk to and from the vehicle unaccompanied. If the VA’s transportation was running late or did not arrive, staff persons were to notify supervisory staff persons and contact the VA’s transportation company. S1 provided the following information: · On July 18, 2022, the VA missed his/her usual transportation to school so two staff persons from the facility drove the VA to school. S1 did not know their names but said that one staff person was the same gender as the VA and the other staff person was the opposite gender (Note: This was later determined to be the SP and P1). · Around 8:50 or 9 a.m., S1 was in an office within the school with the windows open when S1 saw a car arrive in the school parking lot that was going the “wrong way.” This “caught” S1’s attention so S1 began watching. The car “pulled up” to the school and S1 saw the VA in the backseat. S1 said that the car was likely going the “wrong way” because the SP and P1 did not typically drop the VA off and did not know which door to enter. · S1 said that because the VA was in the car and S1 was inside the school and “watching from a distance,” S1 “did not know for sure” but it “looked like” the VA did not want to get out of the car so the SP then “grabbed” or “tugg[ed]” the VA’s wrists with both hands and “forcefully began removing [the VA] from the vehicle.” After 10 to 15 seconds, the VA “complied” and began getting out of the car. · Once the VA was out of the car, the SP continued to “restrain” the VA’s hands “right above [the VA’s wrists]” in front of the VA’s body and the VA and the SP “stood stationary” until P1 put a snack in the VA’s pocket. At this point, the VA was “not resisting at all.” The SP then turned and started to “pull” or “drag” the VA towards the school. S1 “radioed” S2 and S3 who were already outside near the VA so that they could assist the VA inside. S2 and S3 then “took over” and the SP let go of the VA. S2 and S3 “held” the VA’s hands and walked the VA inside the school. · It was “really quick” regarding how long the SP held the VA’s wrists/hands and S1 said that the entire incident was about 30 to 45 seconds in total. S1 did not hear the SP or P1 say anything to the VA during this incident but S1 was “watching from a distance.” S1 did not have any concerns with P1’s interactions with the VA during the incident. · When this investigator asked S1 if S1 felt that s/he needed to intervene, S1 said that the incident “happened so fast.” However, if S2 and S3 did not assist, S1 “probably” would have ran outside to assist with bringing the VA inside. · Once the VA was inside, S2 and S3 observed “red marks” and “indentations” on both of the VA’s wrists and “forearms.” Staff persons did not observe any bruising. The marks started at the VA’s wrists and ended near the VA’s mid-forearm, which S1 said was where the SP was “holding” the VA. S1 said that it was “really concerning” regarding how the VA got the “marks.” However, according to S1, there was “no way” the VA sustained the marks from the SP holding the VA for 30-45 seconds. S1 had photos of the marks which were taken around 9 a.m. (Note: The photos showed red lines on the VA’s left wrist and forearm close to the VA’s hand. There were also linear red lines and various sized indentations on the VA’s lower right arm). · The VA turned his/her hands “up and down” and looked at the marks but then “moved on with [his/her] day.” The VA “did not seem concerned” and the marks “slowly got better” as the day went on. The marks were gone the following day. · The VA was not able to provide information about the incident due to his/her diagnoses. The VA had a history of being “destructive” and “rip[ping] things up” in cars including head rests, the gas tank, license plates, and the interior liner. When this occurred, staff persons “block[ed]” the VA or redirected the VA to “stop” in a “firm” voice and “guided” the VA. The VA then “usually complied.” At times, school staff persons also had to do a “restraint” or “hold.” Additionally, the VA displayed some self-injurious behaviors including “squeezing” his/her head if his/her head hurt, slapping his/her head, or “squeezing” his/her “fists.” · The VA typically did not have any issues wanting to go to school and did not typically miss his/her transportation. However, the transportation company only waited five minutes and left if the VA was not “ready.” When that occurred, it could have thrown the VA’s routine “way off.” · S1 did not have any other concerns with staff persons or the facility. An email sent from the VA’s school to the facility on July 18, 2022, said that the VA was transported to school by the facility and unlike the VA’s typical transportation to school, there was “no divider” in the car (Note: P2 said that some of the VA’s transportation companies had vehicles with “barriers” or “dividers” between the back and front seats.) When the VA arrived to school, an unknown staff person (later determined to be the SP) got out of the car and held the VA’s wrists together to “pull” the VA out of the car. However, it was not in an “overly forceful way as if [the VA] was resisting.” The SP continued to hold the VA’s wrists together and began walking the VA towards the front doors of the school. At that time, school staff came out and then held the VA’s hands and walked the VA into the school. School staff then noticed “red marks” on the VA’s wrists. The VA “did not seem bothered” by the marks but did look at his/her wrists. School staff monitored the VA’s wrists and “later in the day,” the marks had “disappeared.” P2 provided the following information: · On July 18, 2022, P2 received an email from the VA’s school stating that the VA had some “red marks” on his/her arms. P2 saw photos of the marks and described them as an “indent” on the VA’s skin similar to a “pillow mark” from “sleep.” P2 had “no idea” what the marks were from but said they could have been from clothing or the VA’s backpack. P2 was not aware of the VA having the marks prior to the incident but had not worked with the VA on that date. The email noted that the “marks” did not “bother” the VA and that they “disappeared” by 3 p.m. · When this investigator asked P2 if s/he was aware of the SP “forcefully” grabbing or pulling the VA out of the car, P2 said that the email from the VA’s school stated that it was “not in a forceful manner.” · P2 then spoke to the SP about the incident. The SP said that the VA’s typical transportation did not wait longer than five minutes and left so P1 and the SP drove the VA to school. On the way, the VA was trying to open the car door while they were on the highway so the SP held the VA’s wrists so the VA could not “grab” the door until they got to a “safe spot.” · There had been prior times where the VA missed his/her transportation to school. On some of those occasions, the VA had been “escalated” so staff persons did not drive the VA as it would be “too much of a risk.” However, on the date of the incident, the SP and P1 said that they drove the VA to school because the VA asked to go. · P2 was not aware of the VA trying to open the car door while driving prior to this incident. However, the VA had a “pretty big increase” in property destruction as of late, including in vehicles. P2 did not know why the VA had an increase in behaviors but said that the VA had an upcoming doctor’s appointment to see if any “med adjustments” would help. The facility and the VA’s team had also been trying to find “adaptations” to keep the VA “safe” and to also find out what was “triggering” the VA. The facility was “brainstorming solutions” to keep the VA “safe” in the community and to continue to allow the VA “access” to the community. · The VA had two staff persons due to his/her behaviors and because the VA was a “risk of elopement.” When this investigator asked P2 what staff persons should do if the VA was not getting out of a vehicle, P2 said that staff persons should stay near the VA in case the VA was causing harm to him/herself. However, P2 would “direct” staff to wait for the VA until s/he was calm and “deescalates a little.” This could be done with verbal cues and “comfort.” If the VA continued to “escalate,” staff persons could do a “two person hold” if the VA was at risk of hurting him/herself. However, staff persons typically did “escorting or blocking.” · P2 was not aware of any other concerns with the SP or P1. The SP was typically “very calm” and “very quiet.” P2 had seen the SP “redirect” the VA with prior behaviors. P2 had never seen the SP be upset with the VA. P1 was similar to the SP, but a “little more stern” regarding redirecting the VA and verbal prompts but nothing concerning. P1 provided the following information: · P1 did not recall the date of the incident but on that date around 8 a.m., P1 arrived to the facility for his/her scheduled shift. The SP told P1 that the VA’s transportation to school had “just left without saying anything.” P1 did not know why the transportation left as P1 had just arrived but the VA was ready for school. P1 and the SP then called P3 to see what to do and P3 said that the transportation would not come back. · The VA was in a “happy mood” and said that s/he wanted to go to school so P1 and the SP decided to drive the VA to school in P1’s car. The facility had a vehicle that staff persons typically used but at some point prior to the incident, the VA broke one of the side mirrors (and P2 also said that the VA broke the gas cap which caused gas to spill from the vehicle) so it was not “safe” for staff persons to use. · When P1 drove, the VA was in the backseat behind P1 and the SP was next to the VA behind the passenger seat. P1 was not from the area so did not specifically recall the route s/he took to get to the VA’s school but said that s/he used GPS and that it took about 35 minutes. Typically when the VA rode in vehicles, the VA was “so happy” when the windows were down and there was “fresh air” coming into the car, including while on the highway. As P1 was driving on the date of the incident, the car windows were down and the VA was initially “happy.” However, at some point when P1 exited the highway, the VA began “behaving funny,” including that the VA was moving “up and down.” The VA was “heavier” and the car was “shaking” so P1 stopped the car. P1 did not know why the VA began displaying these behaviors but thought it was due to exiting the highway and the VA no longer being able to “enjoy the breeze.” P1 also thought that the VA may have thought that they were going home, instead of to school. · P1 and the SP told the VA that they were not transporting the VA in the company vehicle and that it was P1’s personal car so the VA should “relax” and that the VA would be at school soon. The VA was “okay” so P1 began driving again. However, “just prior” to arriving to school, the VA began to “attack” or “reach out” towards P1’s head rest and P1. P1 was concerned for his/her “safety” and the VA’s safety. During this time, the SP began talking to the VA to assist the VA to “relax,” including stating that the VA would be at school in a “few minutes.” The SP also told the VA to have “safe hands, safe feet,” which is what staff persons were trained to do. At that time, the VA “gave” his/her hands to the SP to hold and the SP held the VA’s hands until they arrived to school. At no point was the VA resisting. P1 was driving so did not know exactly how the SP was holding the VA’s hands but said that it was “not too tight” and that the SP did not “grab” the VA. P1 did not recall how long the SP held the VA’s hands and said that his/her “concentration” was getting the VA to school before the VA “started acting up again.” · When they arrived to school, P1 opened the door for the VA and the SP so that the SP could walk the VA to school staff. The SP was still holding the VA’s hands during this time, including while getting out of the car. P1 did not observe anything that could be considered “forceful” to the VA, including when the SP assisted the VA out of the car. P1 did not see the SP pulling the VA towards the school and said s/he was “right there.” Additionally, shortly after they arrived, school staff “quickly” assisted the VA. The VA did not indicate s/he was in any pain during the incident. · P1 did not notice any “marks” during or prior to the incident. However later, P1 saw photos of the marks. P1 thought the marks could have been from when the SP was “holding” the VA’s hands when the VA was trying to reach for P1/P1’s head rest. P1 was not aware of anything on the SP’s or the VA’s wrists that could have caused the marks. · P1 did not have any concerns with the SP’s interactions with the VA. The SP took “good care” of the VA and was “naturally calm.” · Staff persons were trained to tell the VA “safe hands, safe feet” if the VA were to display behaviors in a car, which is what the SP and P1 did. Staff persons could also offer the VA a snack or talk about things the VA enjoyed, such as a pet store, car ride, or car wash. The SP provided the following information: · The SP did not recall the date of the incident but, around 7:20 a.m., the SP was at the facility with the VA and saw that the VA’s transportation for his/her school was leaving without the VA. The SP did not know why it was leaving and did not have their number. The SP then called P3 who said that s/he would call the VA’s transportation company. P3 then called the SP back and said that the transportation company would not come back. · The VA was “calm” and kept “repeating” that s/he wanted to go to school. The SP “did not know what to do” and was trying to find a way to bring the VA to school. The SP then spoke to P1 who “agreed” that they could drive the VA to school and that P1 would drive his/her car. The SP sat in the back next to the VA and the VA was seated behind P1, who drove.
· The drive to the VA’s school took approximately 35 minutes and they were on the highway a majority of the time. On the way, the VA was initially “fine” but then “started to act up.” This included that the VA made a “noise” and was moving back and forth which caused the car to “shake.” The SP told the VA to “calm down” and the VA “agreed.” The VA was “okay for some time” but then was trying to “pull” P1’s head rest and open the car door which the SP then locked. The SP told the VA to “stop” and for the VA to have “safe hands,” which the VA did. However, the VA had a history of doing “anything [that] flashes in [his/her] mind,” so when the VA was “shaking” the car, the SP was “scared,” including for P1 who was driving. The SP was also “worried” because they were driving on the highway “pretty fast.” The VA then relaxed a “little” and the SP held the VA’s hands “not too hard.” The SP did know what the VA would do if s/he let the VA’s hands go, as the VA was “very fast” and “strong.” · Around 8 or 9 a.m., they arrived to the VA’s school but did not initially know where to park. The SP then saw two school staff persons walking towards him/her so the SP held the VA by the hands/wrists and walked with the VA to meet the staff persons. The VA was not resisting during this time. When this investigator asked the SP why s/he was holding the VA’s hands/wrists if the VA was not resisting, the SP said that the VA liked “red things” and P1’s car was red. Additionally, P1’s car was new and the SP did not want the VA to cause damage to it, which the VA had a history of doing with other cars. During this time, P1 was “very close” to the VA and the SP. The SP continued to “hold” the VA’s hands/wrists until the school staff persons took the VA inside. At that time, the SP saw “marks” on the VA’s hands/wrists which “surprised” the SP. The SP told school staff persons about the marks who said that they would “look at it.” · The SP held the VA’s hands/wrists for a total of 10 minutes on the date of the incident. The VA did not indicate s/he was in any pain during the incident. · The SP did not see the marks prior to dropping the VA off at school. The SP was wearing a watch and bracelet at the time of the incident which had “sharp edges” and could have caused the marks. The SP was holding the VA “not too tight and not too loose.” Additionally, the VA’s skin was “very sensitive.” The SP provided an example of the VA showering and said that the VA’s skin would get “very” red due to the hot water. The SP did not typically hold the VA in a similar manner but said that when the VA was in a “particular mood,” and staff did not “pay attention,” the VA had a history of displaying behaviors. · The SP worked with the VA later that day after the VA returned from school and did not see the marks. · The VA had a history of “ripping” things in vehicles, including fuel tanks, the lining in the car, and mirrors. The VA did things when staff “did not expect” it so the SP was a “little more careful” while in the car for both the VA’s safety and P1’s and the SP’s safety. · The VA also had a history of trying to open the car door which could “harm” the VA. However, the VA had “never” been successful in opening the car doors while the car was in motion. When this occurred, staff persons parked the car and talked to the VA until s/he was “calm.” The SP and P1 did that on the date of the incident but the VA continued to display behaviors. · When this investigator asked the SP if there were any times that s/he felt that s/he or P1 should have called a supervisor for assistance, the SP said that s/he and P1 felt that it was “manageable” as the SP was “holding” the VA. The facility Incident Report and Review said that the facility did not prohibit holding any clients wrists at any time. Law enforcement also investigated and determined that there was “no crime or abuse” as the SP had to secure the VA’s wrists. This was because for “most of the car ride,” the VA was “violently attempting to hit [P1] and hit [his/her own] head.” The CM said that the VA had been having “some behaviors” in vehicles during the summer of 2022. This included damage to the seats and mirrors. On one occasion, the VA’s transportation company called 9-1-1 due to the VA’s behaviors while driving to school. The VA’s team talked about “possibly adding modifications” to the facility car to prevent the VA from “destroying” it. The VA had “limited” communication skills. The G said that the VA had a history of “destroy[ing] vehicles.” The VA also had “elopement concerns” but not while in vehicles. The G said that the incident was a “crisis moment” and the G could “see” why staff persons held the VA’s wrist if the VA was attempting to destroy a staff persons car. The G did not have any concerns that the VA was being “abuse[d].” The G thought that the marks on the VA’s arms were caused by the staff person having a watch or bracelet on while they were holding the VA’s wrists. The G saw photos of the marks and did not think that the marks looked like handprints and said that they went away “fairly quickly.” Additionally, the VA’s skin was “so sensitive” and “everything leaves a mark.” The G said that staff persons should not be transporting the VA in their personal vehicles due to the VA’s history of “destroy[ing]” them but that it “warmed [his/her] heart” that the VA wanted to go to his/her day program and the staff persons took him/her. If the VA displayed behaviors while in a vehicle, staff persons could “distract” the VA or “block” the VA. The G did not have any concerns with the facility. The Emergency Use of Manual Restraints [EUMR] Policy said that emergency use of manual restraints could be used on an emergency basis when a person’s conduct posed an imminent risk of physical harm to self or others and less restrictive strategies had not achieved safety. This included “holding” someone in a seated position. The EUMR must be needed to protect the person or others from imminent risk of physical harm and must end when the threat of harm ended. Staff persons were not to use an EUMR when a client engaged in property destruction that did not cause imminent risk of physical harm. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies including emergency use of manual restraint, and on the VA’s plans prior to the incident. Conclusion: Information showed that the VA had a history of behaviors including damaging vehicles. This included ripping things in vehicles such as head rests, gas tanks, license plates, and the interior liner. P2 and the CM said that these behaviors had increased as of late. S1 said that at times, staff persons needed to do a “restraint” or “hold” the VA when this occurred. The CM said that in some of these incidents, 9-1-1 was called. The [VA’s] School Transportation Plan said that the VA should never walk to and from his/her transportation vehicle unaccompanied and should do a “hand to hand transfer" with transportation staff. On the morning of July 18, 2022, the VA missed his/her usual transportation to school so P1 drove the VA in his/her personal car while the SP rode in the back with the VA. On this date, the VA was calm and asked to go to school. However, on prior occasions, P2 said that due to the VA missing his/her transportation, it caused the VA to be “escalated” so staff persons did not drive the VA as it would be “too much of a risk.” S1 said that when the VA arrived to school, the SP “grabbed” or “tugged” the VA’s wrists with both hands and “forcefully began removing [the VA] from the vehicle.” However, S1 also said that s/he was “watching from a distance” and did “not know for sure.” An email from the VA’s school also said that when the SP “pull[ed]” the VA out of the car, that it was not done in an “overly forceful way.” Following the incident, school staff observed red marks and “indentations” on the VA’s wrists and forearms. The marks went away later in the day. On the drive, P1 and the SP said that the VA was initially happy but then began “moving up and down” which caused the car to shake. P1 and the SP each said that they spoke to the VA who then calmed. However later, the VA began to “attack” or “reach out” towards P1 and P1’s head rest. The VA also tried to open the car door. The law enforcement report also said that the VA was attempting to “violently” hit P1’s head and his/her own head. P1 and the SP were concerned, “worried,” and “scared” for their “safety” and the VA’s safety. When this occurred, the SP began talking to the VA and then told the VA to have “safe hands, safe feet” and the VA gave his/her hands to the SP to hold. P1 said that at no point was the VA resisting and that the SP did not hold the VA’s hands “too tight.” The SP said that s/he held the VA’s hands “not too hard.” At some point, P1 also pulled over and P1 and the SP talked to the VA. When they arrived to school, P1 did not observe anything that could be considered “forceful” to the VA, including when the SP assisted the VA out of the car. P1 did not see the SP pulling the VA towards the school and said s/he was “right there.” S2 and S3 were outside near the VA, the SP, and P1 but did not respond to this investigators attempts for an interview. On the date of the incident, the facility vehicle was not able to be used due to prior damage from the VA, including a missing mirror and gas cap. The G said that staff persons should not be transporting the VA in their personal vehicles due to the VA’s history of “destroy[ing]” them but said that it “warmed [his/her] heart” that the VA wanted to go to his/her day program and the SP and P1 took him/her. Although the VA had red marks and indentations following the incident and S1 said that the SP removed the VA in a “forceful” manner, the marks and indentations was gone shortly after the incident and an email from the VA’s school said it was not in an “overly forceful manner.” The VA also did not indicate s/he was in any pain during the incident. The VA likely obtained the marks and indentations during the incident given that no one was aware of the VA having them prior. However, the SP said that s/he was wearing a watch and bracelet during the incident which may have caused the marks. P2 thought they could have been from clothing of the VA’s backpack. The SP and the G each said that the VA had sensitive skin. Although it was unclear if a restraint was necessary throughout the entire incident, given the VA displayed behaviors during the incident and was at risk of hurting him/herself or P1, that the VA did not indicate s/he was in any pain, and that the marks and indentations disappeared shortly after the incident, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or whether the VA sustained the marks by any means other than accidental. 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. This included “authorization of personal vehicle,” “emergency use of manual restraint allowed policy,” and “incident response, reporting, and review policy.” The incident was not similar to prior events. However, the VA had an increase in property destruction the past six months, including while in vehicles. Staff involved were retrained on the above policies. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
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