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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: 1070619-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux Suspected Maltreatment Reported: It was reported that staff persons (SP1, SP2, and SP3) dragged a vulnerable adult (VA) on a driveway at the facility which caused a scrape to the VA’s buttocks. Date of Incident(s): July 30, 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); and subdivision 17, paragraph (a): 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 failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 10, 2022; from documentation at the facility; and through interviews conducted with facility staff persons (SP1, SP2, SP3, and P1), and the VA. The facility’s Program Abuse Prevention Plan and a facility tour completed by this investigator on the date of the site visit, showed that the vulnerabilities of the persons at the facility varied, but they each had access to 24 hour a day supervision with awake staff persons unless otherwise specified in their plans. The facility was located in a rural neighborhood in Hermantown, about 50 feet from Maple Grove Road also called County Highway 6, which had two way traffic that often traveled faster than the posted speed limit of 50 miles an hour. The facility had a wooden accessible ramp with metal railing for improved mobility connected to its paved driveway to the front main entrance of the residence. Facility documentation showed the following: · The VA’s diagnoses included a developmental disability, intermittent explosive disorder, and depression. If the VA had injuries on his/her skin, s/he might pick or pick at them, and s/he had a history of engaging in self-injurious behaviors. The VA might leave facilities without supervision, had near daily physically aggressive behaviors toward others, and might provide inaccurate information. The VA was mobile without assistance, enjoyed going shopping, liked helping others, and wanted to get a job in the community. · The VA disregarded his/her personal safety and was impulsive, which might put him/herself or others at risk of immediate harm. When upset, the VA could hit, kick, yell, make threatening statements/gestures, spit on, or attempt to stab law enforcement officers, bus drivers, security guards, health care professionals, staff persons, his/her family members, or other individuals. At times, several law enforcement officers were needed to restrain the VA when s/he physically aggressed. If the VA was aggressive at the facility, the emergency use of manual restraints were permitted to calm the VA and return him/her to a “safe” level. However, the VA’s weight was greater than the weight recommended by his/her physician for persons of his/her height, which made it difficult to use some approved restraints with him/her. · The VA might refuse to take medications to manage the symptoms of his/her mental illnesses. · The VA was to be supervised at all times in the community and at the facility for his/her safety and the safety of others. When the VA left facilities without supervision, s/he often entered community residences and asked that the police be called. The VA wanted to express him/herself positively and to successfully relay his/her wants and needs. Triggers for the VA included power struggles, “low quality” or no supervision, boredom, or the need for attention. “First” and “then” statements, taking breaks, and specific instructions worked well for the VA. It was hard to locate facilities that could provide services for the VA’s needs, and his/her team had discussed developing a single service site for the VA. However, the site had not yet been established and the VA was residing at the facility getting crisis services until the site was ready for him/her. · The VA was an avid cell phone user and often called 9-1-1 for nonemergency situations when s/he was unsupervised with cell phones. Facility documentation; information provided by the VA, SP1, SP2, SP3, and P1 in interviews with this investigator; and information provided by P2 and P3 in the facility’s Internal Review, provided the following: · The VA said that on the date of the incident, s/he went on a community outing with staff persons and then returned to the facility. The VA exited the van, but did not want to go into the facility and began spitting, hitting, kicking, and punching unspecified staff persons. According to the VA, s/he was lying on his/her back on the driveway when SP1 and SP2 dragged him/her by his/her arms up the ramp and into the facility, which caused a four by six inch red scrape on his/her left buttock. The incident was witnessed by SP3. Later that day, the VA took a shower and the water “burned” the scrape, so the VA told SP1, SP2, P2, and P3 about the scrape and SP2 put gauze and tape it. The VA did not require evaluation by a health care professional for the scrape. · SP1, SP2, and SP3 provided consistent information to this investigator and in the facility’s Internal Review, that on the date of the incident after the outing, the VA was wearing shorts and a hoodie. After the VA exited the van, s/he entered the facility, said that s/he was tired, and that s/he was going to lie down. However, the VA did not lie down, but opened the front door and began running toward a neighbor’s house. SP1 and SP3 blocked the VA from going onto the neighbor’s property which frustrated the VA, who then began hitting a car in the facility driveway with his/her fists. The SPs attempted to verbally de-escalate the VA, but s/he told the SPs to “shut up” and that s/he wanted to go to a neighbor’s residence to call the police. The VA then lay down on the driveway and began hitting the back of his/her head against it repeatedly. SP2 quickly placed his/her hand behind the VA’s head to prevent him/her from hitting it on the driveway and SP1 and SP3 raised the VA to a sitting position by placing their arms under the VA’s arms. However the VA continued to hit/hit at the SPs, tried to spit on them, and said that s/he was going to grab their genitals. The SPs became concerned that the VA might run into road and get hit by oncoming cars or injure him/herself by hitting his/her head on the driveway so they thought it was necessary to take action to move the VA inside the facility. · The SP1, SP2, and SP3 attempted to raise the VA into a standing positon, then use a two person escort to prevent the VA from harming him/herself and bring him/her into the facility, but the VA resisted and “plopped” onto the driveway in a seated position. The VA’s weight and his/her continued physical aggression prevented the SPs from lifting/escorting him/her into the facility. The VA began scooting up the ramp toward the facility each time the SPs approached him/her and eventually entered the facility on his/her own. The VA’s aggressive behavior continued inside the facility and s/he threatened to leave the facility several times while making vague threats of self-harm. The VA later calmed and it was noted that s/he had scratches/red areas on his/her lower back, but there was no broken skin or bleeding. The VA also had small bruises at his/her armpits which might have been caused by attempted escorts, and had an indentation by her left eye where his/her eyeglasses had pressed against his/her face during the incident before the SPs could remove them. The entire incident lasted almost one hour and was documented by SP3 in the VA’s Progress Notes and on an Incident Report on the evening of July 30, 2022. The VA received first aid for the scratches on his/her back. · P1, a supervisory staff person, completed a Behavior Intervention Reporting Form (BIRF) regarding the incident when s/he became aware of it, and discussed the incident with the SPs, P2, and P3. According to the BIRF, the two person escort of the VA lasted less than one minute and was an approved escort that was consistent with the SPs’ training and facility policies and procedures. The VA said that SP2 escorted him/her, but according to the SPs and facility documentation, SP2 was not directly involved in the escorts and placed his/her hand behind the VA’s head to prevent him/her from hitting it on the driveway. The actual size of the VA’s injury was not documented in the information obtained by this investigator. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident and on the VA’s plans. Conclusion: Facility documentation showed that the VA had a history of disregarding his/her personal safety and was impulsive which might endanger the VA and others, and required supervision at all times inside the facility and in the community. Leaving facilities without supervision was one of the VA’s vulnerabilities and the VA’s team was planning a service location for him/her at which s/he would be the only resident, but the location was not ready when the incident occurred. The facility was about 50 feet from a busy road that was also a county highway, which was traveled by drivers who often exceeded the speed limit. There was a wooden ramp with metal railing that led from the facility driveway into the facility front door and there were several neighbors whose residences were close to the facility. Information was consistent from the VA, SP1, SP2, and SP3, that they were involved in a physical interaction on July 30, 2022, after a community outing. The VA said that s/he did not want to enter the facility and physically aggressed toward staff persons. The VA lay on his/her back on the driveway and was dragged up the ramp by SP1 and SP2, sustaining a four by six inch red scrape on his/her left buttock. SP2 gave the VA first aid for the injury but no further care was required. The SPs provided consistent information that during the incident, the VA had behaviors including running toward a neighbor’s residence, hitting a car at the facility, telling staff persons to “shut up,” hitting his/her head against the driveway, hitting staff persons, and spitting at them. The SPs thought they had to take action to escort the VA into the facility because of his/her escalating behavior and their concern for the VA’s safety. The SPs attempted to use a two person escort with the VA to assist him/her to stand, which was implemented correctly according to P1. However, the VA began scooting away from the SPs when they approached him/her, and moved up the ramp into the facility on his/her own. The VA continued to aggress, but after s/he calmed and was assessed for injuries, it was noted that s/he had scratches/red areas on his/her lower back with no broken skin or bleeding, small bruises near the armpits, and an indentation near his/her left eye. The VA was wearing shorts and a hoodie when the incident occurred. Although the VA sustained superficial scratches and small bruises during the incident and the SPs attempted to use a two person escort with him/her, given the level of aggression the VA showed during the incident, his/her impulsivity and history of disregarding his/her personal safety, and that s/he was also engaged in self-injurious actions when the incident occurred, there was not a preponderance of the evidence whether all of the SPs’ actions were therapeutic or whether the VA sustained the injuries by any means other than accidental. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). 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 which determined that its policies and procedures were adequate and were followed. Prior to the incident, staff persons received monthly and annual training on Effective and Safe Engagement which included permitted techniques for implementing manual restraints. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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