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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: 1072229-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at a vulnerable adult (VA1) for “several minutes” about a board game they were playing. It was reported that on “several occasions” the SP grabbed a vulnerable adult’s (VA2’s) face, told him/her to “shut up,” and yelled at him/her. The SP also told others not to help VA2 with walking or use VA2’s gait belt and to, instead, let VA2 fall. Date of Incident(s): August 21, 2022, and other dates unknown 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 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: 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. 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 September 12, 2022; from documentation at the facility; and through interviews conducted with VA1, VA2, VA1’s guardian (G1), VA2’s guardian (G2) who was also VA2’s family member, a facility staff person (the SP), and a supervisory staff person (P2). (Note: More than one attempt by telephone was made to reach another staff person (P1); however, P1 did not respond by the completion of this investigation.) The facility was a side-by-side duplex. VA1 lived on one side of the duplex, and VA2 lived on the other side with two other residents (R1 and R2). The facility provided 24 hour staffing to both sides of the duplex. (Note: This investigator met R1 at the time of the site visit; however, due to R1’s limited communication skills, s/he was not interviewed for this investigation. R2 was not home at the time of the site visit, and there was no information that R2 had ever said anything to staff about concerns with the SP. R2 was not interviewed for this investigation.) Facility documentation stated that the staff persons interviewed for this investigation received training on VA1’s and VA2’s support plans and support plan addendums, and on the Reporting of Maltreatment of Vulnerable Adults Act. Regarding VA1: VA1’s support plan and support plan addendum provided the following information: · In 2002, VA1 moved into the facility seeking supports and services relating to his/her diagnoses, including traumatic brain injury and paraplegia. · VA1 was susceptible to abuse by others and had a history of provoking others. VA1 had a history of misinterpreting situations, which might cause him/her to overreact and engage in verbal aggression toward others. Staff persons intervened in abusive situations and reported abuse on behalf of VA1. At the outset of this investigation, P1 provided information that on August 21, 2022, the SP yelled at VA1 for “several minutes” about a board game they were playing together. P2 said that the SP had a history of having a “rude” tone of voice, and that the facility had spoken with the SP about this in the past. P2 also heard the SP call VA1 “a liar” before; however, P2 never witnessed the SP yelling at the residents. VA1 told this investigator that the SP did not yell at him/her, and that s/he did not hear the SP yell at the other residents. VA1 added that the SP had called him/her “a liar” before; and that the SP had, on occasion, lifted VA1’s chin so that s/he was looking at the SP when s/he was speaking. VA1 said that s/he liked living at the facility. The SP provided the following information: · The SP was not scheduled to work with VA1 on August 21, 2022, and therefore, would not have been playing a board game with VA1 on this date as was alleged. · The SP and VA1 “teased” each other back and forth; however, the SP never yelled at VA1. G1 did not have concerns with the facility’s or staff persons’ overall care and supervision of VA1. Regarding VA2: VA2’s support plan and support plan addendum provided the following information: · In 2000, VA2 moved into the facility seeking supports and services relating to his/her diagnoses, including intellectual disability. · VA2 had moderate to severe hearing sensitivity. Staff persons spoke loudly and allowed VA2 to read their lips; and/or used written communication with VA2. · VA2 was susceptible to abuse by others. Staff persons intervened in abusive situations and reported abuse on behalf of VA2. At the outset of this investigation, P1 provided information that on “several occasions,” the SP grabbed VA2’s face, told VA2 to “shut up,” and yelled at VA2. The SP also stated that staff persons should not help VA2 with walking and instead, should let VA2 fall. VA2 told this investigator that the SP did not yell at, and was not mean to, him/her. However, based on VA2’s communication style and that VA2 had family members with the same first name as the SP, it was unclear to this investigator if VA2 was talking about the SP or someone else. VA2 said that s/he liked living at the facility. P2 said that the SP had a history of having a “rude” tone of voice, but that P2 never witnessed the SP yelling at the residents. P2 heard from other staff persons that the SP used to grab VA2’s face, but P2 never witnessed this. The SP provided the following information: · VA2 had a history of engaging in maladaptive behaviors, and when this occurred, the SP was trained to leave the area and give VA2 space, and communicate with VA2 by writing notes so that s/he understood what was happening around him/her. · The SP “never, ever, ever” told VA2 to “shut up;” and never yelled at VA2. · The SP said that VA2 needed assistance with walking, and that the SP always remained by VA2’s side when walking. “I’ve never made [him/her] walk by [him/herself].” If VA2 started to fall, the SP broke his/her fall, but did not try to catch him/her. The SP would guide VA2 “gently” to the floor, but did not want to catch him/her for fear of injury to VA2 and/or the SP. (Note: There was no information that VA2 ever sustained an injury as a result of a fall.) G2 said that VA2 had never said anything to him/her about being yelled at by a staff person. Regarding an additional concern: During this investigation, an additional concern was raised regarding the SP’s administration of VA2’s as needed (PRN) anxiety medication. The PRN was prescribed to be administered as “1 capsule by mouth four times daily as needed for anxiety.” Facility documentation, including VA2’s Medication Administration Records and a photograph of VA2’s PRN blister pack, showed that during June and July 2022, the PRN was administered seven times, and not all by the SP. There was an 8th capsule missing from the blister pack; however, this was consistent with G2’s account that on one occasion, the SP gave G2 one capsule when s/he was going on an outing with VA2. G2 threw the capsule away and did not give it to VA2. Given that facility documentation did not support misuse of VA2’s PRN medications, a licensing violation was not determined. Conclusion: It was reported that the SP yelled at VA1 and VA2. VA1 and VA2 each said that the SP did not yell at them, and P2 never witnessed the SP yelling at the residents. The SP also denied this allegation. Given the aforementioned and without additional information or witnesses to state otherwise, there was not a preponderance of the evidence whether the SP’s conduct, which was not an accident of therapeutic, produced or could reasonably be expected to produce emotional distress to VA1 and/or VA2, 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. 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). It was reported that the SP did not assist VA2 with walking, and instead, let VA2 fall. The SP denied the allegation, and said that in the event VA2 started to fall, the SP guided him/her “gently” down, but did not try to catch VA2 in order to avoid injury to him/herself and/or VA2. Given that there was no information of VA2 sustaining any injuries from falling, and without additional information or witnesses, there was not a preponderance of the evidence whether the SP’s conduct, which was not an accident of therapeutic, failed to supply VA2 with reasonable and necessary care to maintain VA2’s physical or mental health or safety. 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). Action Taken by Facility: The facility completed an internal review, and determined that policies and procedures were adequate but not followed. The facility provided additional training to all staff persons regarding the Reporting of Maltreatment of Vulnerable Adults Act. The SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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