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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: 1071168-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that after a vulnerable adult (VA) left the facility without supervision, a staff person (SP) dragged the VA back to the facility, which resulted in the VA hurting his/her hip and sustaining abrasions. Date of Incident(s): September 13, 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 October 3, 2022, from documentation at the facility and through six interviews conducted with the VA’s family member (FM) who was also the VA’s guardian, a facility management staff person (P1), two facility staff persons (P2 and P3), a facility health care professional (HCP) and the SP. Although this investigator met the VA and attempted to conduct an interview, the VA was unable to provide information for the investigation due to his/her disability. The facility had a two car attached garage. Inside the garage, there was a carpeted handicapped accessible ramp and a small hallway that led to the inside of the home. Part of the driveway was made of cement and the other part was made of asphalt. There were grassy areas on each side of the driveway. At the time of the incident, the SP was the only staff person working at the facility. The VA’s Support Plan showed that s/he enjoyed attending his/her day habilitation program and accessing the community. The VA was diagnosed with attention deficit hyper disorder, hearing loss (the VA used a hearing aid), and had a moderate developmental disability. The VA’s Self-Management Assessment showed that s/he had a history of leaving without supervision and that staff should “remain with [the VA] anytime [s/he] wants to go into the community.” The facility’s Internal Investigation Report, a handwritten Incident Report written by the SP, and interviews with P1, P2, P3, the HCP and the FM provided the following information: · On September 13, 2022, the FM said that s/he took the VA to a medical appointment and when they returned to the facility that afternoon, the FM assisted the VA inside the facility. The SP told the VA that s/he would get the VA’s medications and the FM stated that s/he was going to leave. The VA “grabbed” the FM and “followed” the FM outside, while the SP remained inside. · The FM said that once outside, the VA “pounded” on the FM’s vehicle so the FM went back inside, while the VA remained outside. The FM asked the staff person working, identified by a physical description and determined to be the SP, to come outside and get the VA, but the SP stated that s/he was the only staff person on duty at the time and could not leave the facility. The FM then went back outside and the VA “grabbed” hold of the FM again and “dropped to the ground.” The FM was “eventually” able to free him/herself from the VA. At some point, the SP came outside and the VA was “lying in the grass.” The SP picked up both of the VA’s ankles and told the FM to “pick up” the VA’s wrists so they could “carry” the VA into the facility. The FM said, “No,” and that s/he could not carry the VA. The FM then got in his/her car and left while the SP “just stood there” outside holding the VA’s ankles. After the FM left the facility, s/he called P3 because the VA refused to go in the house and the SP needed help. · P2 stated that s/he received a phone call from the SP, after the incident, because the SP needed help writing an incident report. The SP told P2 that while the SP was cooking, the VA “walked out of the house” and that s/he “dragged” the VA back into the facility. When P2 got to work the next day, s/he found a handwritten note from the SP. P2 then notified P3 and the HCP about the contents of the note. · On September 13, 2022, the SP hand wrote an Incident Report that said: [The VA] ran outside because [s/he] was not allowed to use the house phone & refused to come in for about an hour [s/he] walked down the street & I had to chase after [him/her] & drag [him/her] back in the house but [s/he] refused to come in & keep running out. At 4:15 p.m., I had to drag [him/her] back inside as I was alone with 4 residents. In the process of dragging [him/her] in the house [s/he] hurt the side of [his/her] butt from me dragging [him/her] inside the house. I notify PC. · When the SP was interviewed by facility management, s/he stated that when the FM brought the VA home, “s/he” did not want to come inside, but it was not determined who the SP was referring to (the FM or the VA). The SP stated that the FM and the VA were “wrestling on the ground” and that the VA “grabbed” the FM “hard” and that the FM was “very upset.” The SP also stated that s/he had to “hold [the VA] down” as the FM drove away. After the FM left, the VA “ran to the end of the street,” but when management showed the SP a map of the area, the SP stated that the VA “ran about three houses down” and that the VA “eventually” came back to the facility on his/her own after the SP “pleaded” with the VA to return. Later, the VA was “upset” that s/he could not use the phone, even though the SP told the VA that s/he could “maybe” use it later and the SP saw the VA leave again and “run through the garage.” When the SP followed the VA into the garage, the VA “sat down” and then “scooted” his/herself from the garage to the end of the driveway, but did not leave the property. “Initially,” the SP stated that the VA returned inside on his/her own, but when facility management showed the SP the note s/he had written, the SP “confirmed” that s/he wrote the note. Later, the SP “changed” his/her story to say that the VA, who was at the end of the driveway, “scooted” on his/her butt from the end of the driveway to the garage and that once the VA was in the garage, the SP “dragged [the VA] through the garage into the house and a side hallway.” The internal investigation did not identify how far the SP dragged the VA. The SP also said that when s/he called P2, the SP told P2 that s/he had dragged the VA and P2 told the SP that was not an allowed practice. · The SP was also asked to describe how s/he dragged the VA. The SP stated that s/he put his/her hands around the VA’s “ankles and calves and pulled” the VA. When asked how the VA responded, the SP, who was “afraid” that the VA would “run off and get hit by a car,” said that the VA “did not complain until later” and kept “pointing” to his/her “hip/butt.” The SP saw a “red rash” on the side of the VA’s buttocks. A photograph, taken on September 13, 2022, by an unknown facility staff person, showed a number of red scabbed over abrasions. (Note: Although the picture did not identify the side of the VA’s hip that was injured, the internal investigation stated it was on the VA’s left hip). On September 14, 2022, P1 documented that the VA had a “circular abraded area on [his/her] left hip about the size of a lemon. This is consistent with the accident report completed earlier this week. Photo was taken of this area for reporting purposes.” The SP told this investigator that while the VA was in the garage sitting on his/her buttocks, the SP held both of the VA’s feet and “pulled” the VA about three inches. The SP also stated that when s/he called P2, after the incident, P2 told the SP to rewrite the incident report and to not use the word dragged. (Note: P2 denied telling the SP to change the wording in the incident report.) The facility’s Emergency Response, Reporting & Review Policy had specific procedures staff were to follow if a client was missing, but the procedures did not specifically outline what staff persons were to do in the event that a client left the facility without supervision. P1 stated that the VA did not have a history of leaving the facility without supervision and that staff were trained to call 911 if a client left and the staff person was the only staff person on duty. The facility’s training records showed that all staff interviewed for this investigation, including the SP, were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to September 13, 2022. In addition, the SP received training related to emergency procedures on May 12, 2022. Conclusion: A. Maltreatment: On September 13, 2022, the FM and the VA returned to the facility. The FM stated that the VA became upset when the FM was about to leave the facility, dropped to the grass and refused to go inside. The SP grabbed the VA by the ankles and asked the FM to assist him/her with carrying the VA into the facility, but the FM declined that and left the facility while the VA remained outside and the SP held his/her ankles. The SP later documented that s/he “dragged” the VA back into the facility. The SP provided conflicting information when interviewed for the Internal Review. The SP initially denied dragging the VA and stated that the VA scooted, but then when shown the note, the SP acknowledged dragging the VA during the incident. The SP told this investigator that s/he dragged the VA three inches. After the incident, the VA had abrasions on his/her left hip. The SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were not accidental or therapeutic conduct. Given that dragging the VA was not accidental or therapeutic conduct, and that the VA sustained an injury on his/her left hip and later complained and pointed to his/her left hip, there was a preponderance of the evidence that a staff persons actions produced physical pain or injury. 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, the VA’s specific care plans, and the facility’s emergency procedures. The SP documented and acknowledged dragging the VA into the facility and stated that s/he saw an injury on the VA. 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 maltreatment for which the SP was responsible was not “recurring” maltreatment because it was a single incident. However, it was “serious” maltreatment because the VA sustained an abrasion/tissue damage from the incident. Action Taken by Facility: The facility completed an internal review. All staff persons were retrained on “positive support strategies” and “completion of accident/incident report.” P1 and P2 were retrained on “accident/incident reports that result in suspected maltreatment and the necessary urgency and escalation of such reports.” The facility developed “an agency wide protocol on elopement with specification on steps to take when it occurs in a single staff situation as well as when multiple staff are present.” 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.
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