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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: 1071114-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux Suspected Maltreatment Reported: It was reported that there were multiple concerns regarding a staff person’s (SP’s) interactions with vulnerable adults (VA1, VA2, VA3, and VA4) including name calling, punishment, forced work, and locking up possessions. Date of Incident(s): Ongoing, and prior to August 10, 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 (2); and subdivision 9, 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: 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property 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 facility staff persons (SP and P1), VA1, VA2, VA1’s case manager (CM), and VA1’s guardian (G). Another staff person (P2), and VA3 and VA4, did not provide information to this investigator. However, this investigator used information provided by P2, VA3, and VA4 in the Internal Review, to complete this report. VA1, VA2, VA3, and VA4, resided at the facility and had various diagnoses. The SP was the staff person who worked most often with the VAs and s/he spent large parts of each day with them. The VAs had jobs in the community and used public transportation to travel between the facility and their respective places of employment. VA1, VA2, VA3, and VA4 were each subject to guardianship. At the facility, the VAs were expected to clean their respective bedrooms and help keep the common areas of the facility neat. Facility documentation showed the following: · VA1 had Asperger’s syndrome, attention deficit hyperactivity disorder, and bipolar disorder, and had a history of “fixating” on the SP. VA1 benefitted from having a structured environment that allowed him/her time to talk through things that bothered him/her and was susceptible to physical abuse as s/he might not identify potentially dangerous situations or be able to deal with aggressive persons. · When VA1 was upset, s/he might call others names, aggressively say that s/he wanted to be left alone, call community persons, businesses, family members or staff persons to leave threatening messages, threaten to harm him/herself, call 9-1-1, or leave the facility without supervision. VA1 had a pattern of making demands regarding his/her care, but not following through with plans that s/he helped develop. · VA1 might have difficulty comprehending all that was said to him/her or be unable to follow multi sequence tasks. Repeating the same message calmly and frequently to VA1 was helpful, and communicating with him/her via text or email was also beneficial. VA1 did not want others to impose limits or conditions on him/her and attempted to pressure others to change their actions when s/he did not agree with them. According to VA1’s plans, s/he had a history of “creating chaos” by encouraging housemates to become upset, which might cause issues for him/her and others. VA1 wanted to be as independent as possible. · VA2 had difficulty recognizing boundaries and had a history of providing inaccurate information/changing his/her account of events based on his/her audience. Arguing with housemates or staff persons, then engaging in property destruction and calling a law enforcement agency to voice his/her concerns, were behaviors VA2 might have when s/he was upset. VA2 did not understand the consequences of his/her actions and used poor decision making skills at times. · VA2 was sensitive to his/her environment, and when it was chaotic, his/her anxiety level increased. Staff persons were to spend one to one time with VA2 daily so that s/he could talk about issues that concerned him/her and s/he liked having “closure” when issues were resolved. · VA2 needed assistance managing his/her financial matters and frequent contact with his/her family members was important to VA2, who enjoyed staying busy. · VA3 had no unsupervised time in the community because s/he might take items that were not his/hers in the community and at the facility, where s/he could be unsupervised for 30 minutes. If VA3 was upset or excited, s/he might yell at others or become physically aggressive, but s/he was usually laid-back and walked away from others when s/he felt anxious. VA3 might not recognize dangerous situations and was vulnerable to all types of maltreatment. · VA3 was friendly and outgoing and loved spending time with his/her family members. Working toward achieving more independence was one of VA3’s goals, and s/he thought that others underestimated his/her abilities. · VA4 had epilepsy, schizophrenia, and had diminished hearing, memory, and cognitive issues related to a cancerous brain tumor and the treatment s/he received for it. VA4 declined to wear hearing aids. However, VA4 expressed his/her needs/preferences as well as s/he could and liked spending time outside when the weather was good. · VA4 might become upset then hit or push others. Spending time with family members and community persons was important to VA4 and s/he wanted to have his/her wishes respected. VA4 was friendly and was a great story teller. Facility documentation; information provided by VA1, VA2, P1, and the SP, in interviews with this investigator; and information from P2, VA3, and VA4 in the facility’s Internal Review, showed the following: · VA1 said that the other VAs usually provided inaccurate information to get the SP “in trouble,” but information s/he provided was the “truth.” The SP tried to “make conversation” with VA1, which made him/her feel “down,” especially when s/he was made to feel that s/he had no friends or had not accomplished much. The SP had previously told the VAs to “come at” him/her or “punch” him/her so that the SP could restrain them, but the SP was unable to restrain VA1 because s/he “defended” him/herself against the SP. · VA1 was concerned about the SP’s word choices/actions with him/her and the other VAs, but said that the SP did not refer to him/her or the other VAs as “fucking stupid” or make anyone scrub the floor. However, VA4 sometimes had to mop the floor when s/he missed the bus that took him/her to work. VA4 had thrown VA1’s laptop and computer bag in the garbage bin outside when VA1 left the laptop unattended in the living room, but VA1 and staff persons became aware that the laptop was missing, and VA1 quickly retrieved it from the garbage. After that, if VA1 and other VAs left their cell phones/electronic items unattended in common areas of the facility, the SP might place the items in the office and notify P1 that the items had been left in a common area, before returning them to their owners. According to VA1, the SP said that s/he used the aforementioned phrases and actions to make VA1 a “better person,” but it just made the VAs argue among themselves because the SP’s actions encouraged the VAs to talk about each other to the SP. · VA2 said that several years ago, s/he attempted to injure the SP with a “sharp knife” and hit the SP with it. VA2 then “escalated,” called the SP names, and told the SP that s/he would not use the knife to hurt anyone. The SP took the knife from VA2 and the police were called. VA2 said that the SP should avoid him/her because s/he was not a person to “mess with,” and would push the SP down if s/he “pissed” VA2 “off.” In a prior incident, VA2 had hit the SP on the temple, causing him/her to fall. VA2 thought that the SP was a “bully” and felt that the SP should not ask the VAs to clean toilets, sweep floors, clean the sink, or do other household chores. · VA3 and VA4 had general concerns regarding their personal items being temporarily placed in the facility office, but did not provide information regarding the SP’s other interactions with the VAs. · The SP stated that s/he did not say that VA1 or the other VAs were “fucking stupid, did not tell the VAs to “come at” him/her, and did not do anything to “amp” the VAs “up.” The SP told VA1 that s/he had a lot of potential and asked him/her if s/he had friends, suggested that VA1 go on fun community outings with his/her friends, and encouraged VA1 to think about all the good things that s/he had accomplished. The SP had recently become aware that VA1 felt that the SP was “picking on” him/her when the SP offered suggestions to VA1. The SP restrained VA2 several years ago when VA2 obtained a butter knife which s/he attempted to use to stab the SP, but immediately released VA2 after s/he dropped the knife. VA2 then called 9-1-1 and law enforcement officers came to the facility, but they took no further action. · The SP might ask the VAs to help clean the common areas of the facility. However, the VAs chose whether to complete the requested tasks and were not required to do specific tasks such as “scrubbing” the floor, but might be asked to sweep or mop it. The VAs often declined to complete chores they were requested to do, and the SP recently learned that s/he should better explain why s/he made requests of the VAs, going forward. The SP denied that s/he said anything to intentionally hurt the VAs’ feelings and thought s/he should teach the VAs about completing tasks to contribute to the operation of the household, especially if learning how to complete the task would benefit them if they lived independently. · Information was consistent from the SP, P1, and P2 that the VAs were asked to keep their personal items in their bedrooms or with them at all times for safekeeping because there had been instances when personal items were stolen or broken when left unattended in common areas of the facility. The VAs and their guardians were aware of the practice and knew that keeping items out of the common areas of the facility lessened the likelihood of potential arguments and accusations between the VAs. If personal items were observed unattended for more than a few minutes in common areas, the item might be temporarily placed in the office for safekeeping, and later returned to its owner. The VAs did not have rights restrictions that prevented them from having access to their property, but the practice of placing unattended items in the office was an accepted well known facility procedure. · During the past few years, the VAs had frequently called 9-1-1 when they were upset, when they misplaced their personal items, or when they did not receive expected pieces of mail. According to P1, the city of Richfield gave VA4 a “repeat nuisance order” because s/he repeatedly called 9-1-1 for issues that did not warrant a call to 9-1-1. There were no concerns regarding 9-1-1 calls made by staff persons or concerns regarding the SP’s work at the facility. P1 and P2 were aware that VA2 had been restrained when s/he had a knife at the facility and no information showed that the permitted restraint was done inappropriately. · P1 and P2 provided this investigator with copies of emails showing that VA1 often wrote to them and other members of his/her team expressing dislike for the SP and asking to be moved to another facility. In some of the emails, VA1 said that s/he would “run away” from home, asked to be “kicked out” of the facility and said that s/he thought that the SP was withholding his/her mail. P1, P2, and other team members attempted to redirect VA1 and encouraged him/her to think positively. 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 VAs’ plans. Conclusion: VA1 and VA2 provided consistent information that there were concerns regarding the SP’s statements/actions at the facility. VA1 thought that the SP used language/took actions that made others feel “down” including asking VA1 whether s/he had friends, questioning his/her accomplishments, telling the VAs to complete chores at the facility, and placing their unattended personal items in the office. VA2 said that the SP was a “bully” and thought the VAs should not be asked to do household chores. VA1 also said that VA3 placed VA1’s laptop/computer bag in the garbage bin outside without telling anyone prior to doing so, which led to the facility practice of placing unattended items in the office, notifying P1, and then returning the items to their owners. The SP denied that s/he used language/took actions to “amp” up the VAs, but had told VA1 that s/he had potential, had asked VA1 if s/he had friends then suggested that s/he go on activities with them, had restrained VA2 when s/he attempted to stab the SP with a butter knife, asked the VAs to complete household chores, and placed their unattended personal items found in common areas of the facility, in the facility office for safekeeping. Items were later returned to their owners and only temporarily placed in the office to prevent the item from being taken or broken. P1 and P2 were aware of the VAs concerns and the SP’s actions, but had no immediate concerns regarding the SPs work, and were working with the SP to change his/her word choices to improve the VAs’ perceptions of the SP’s comments. P1 and P2 also planned to visit the facility more frequently to stay in better contact with the VAs and the SP. Regarding emotional abuse: VA1 and VA2 had concerns about the SP. However, VA1 had a history of targeting the SP, might misinterpret verbal communication, and provided conflicting information regarding the SP’s actions, and VA2 stated that s/he previously verbally and physically aggressed toward the SP, who then restrained VA2. Given this, that the SP provided a full context of his/her statements to VA1, that the SP denied that s/he attempted to upset the VAs, that no information showed the VAs were forced to complete household chores, and that there were no witnesses to the incidents described by VA1, there was not a preponderance of the evidence whether the SP engaged in conduct that caused or could reasonably be expected to cause emotional distress to the VAs. 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). Regarding financial exploitation: Information was consistent that it became an accepted facility practice to temporarily place items in the facility office for safekeeping that were left unattended in the common areas of the facility after some items were broken or taken, and then return them to their owners. VA1 said that VA3 had previously placed VA1’s laptop/computer bag in the outside garbage bin. Given this, and that no information showed that placing the items in the office benefitted the facility or its staff persons, there was not a preponderance of the evidence whether in the absence of legal authority items that belonged to the VAs were willfully used, withheld, or disposed of. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property 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. P1, P2, and the SP discussed times when the SP’s word choices or phrases could be changed to improve the VAs’ perceptions of the SP’s comments and how communication might be improved between the SP and the VAs. P1 and P2 planned to visit the facility more often, including making unexpected visits. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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