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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: 1067984-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Sarah Schumacher and Marie Tierney Suspected Maltreatment Reported: It was reported that a staff person (SP) "beat up" a vulnerable adult (VA), slapped the VA, and pulled the VA's ear. The VA had a black eye and scrapes on his/her left ear. Date of Incident: September 4 – 5, 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 September 29, 2022; from documentation at the facility, law enforcement records, and medical records; and through five interviews conducted with the VA, the SP, and three facility staff persons (P1 –P3), including a supervisory staff person. The facility’s records about the VA documented that the VA was a "helpful" person who enjoyed fishing, keeping his/her home tidy, and spending time with others. The VA's diagnoses included moderate intellectual disability, schizophrenia, and bipolar disorder. The facility’s Incident Report and Internal Review dated September 6, 2022, was completed by an administrative staff person (P4) and documented that on September 5, 2022, at 8 a.m., staff persons noticed bruises on the VA's left eye and ear. When asked what happened, the VA provided conflicting information to P4 and other staff persons including that s/he did not know, that s/he fell, and that the SP hit him/her. Photos of the VA taken on September 6, 2022, documented the following: · The VA had dark purple bruising around his/her left eye and extending approximately one inch down from his/her eye onto his/her left cheek. · There were two parallel red marks, approximately 3/4 inch long each, on the VA's left upper jaw, beginning where the jaw met the VA's left ear lobe and extending away from the VA's left ear. · There were multiple red and purple dots and irregularly shaped spots on the VA's left ear. · There was a dime sized round purple bruise on the outside of the VA's right elbow. · There was a quarter sized round purple bruise on the back of the VA's right thigh. The VA's medical records showed that the VA was seen in a clinic on September 6, 2022, and was diagnosed with facial bruising. No treatment was ordered. The VA provided the following information during his/her interview with the DHS investigator: · The VA was in his/her bedroom by him/herself during the daytime when the SP "punched" the VA and tried to throw the VA on his/her bed. When asked to demonstrate the SP’s actions, the VA showed an open hand striking the side of the VA's face. The VA said, "[The SP] shouldn't hit me." · The DHS investigator asked the VA whether the SP said anything to him/her during the incident, and the VA said, "I want to get a tape player." · The VA had a bruise on his/her stomach from falling off his/her bicycle. · The VA said, "I fall down all the time." The VA's guardian (G) said the VA was able to provide accurate information. However, the VA was susceptible to leading questions and often answered the way s/he thought someone wanted him/her to answer. The following is a summary of information from law enforcement records; facility documentation; and interviews with the SP, P1, P2, and P3: · P1 and P2 each worked at the facility on the night of September 4, 2022. P1 said the VA displayed increased anxiety that night, so P1 put the VA’s weighted blanket on the VA when s/he went to bed, and the VA fell asleep “within minutes.” P1 and P2 each said the VA had no bruises when they left the facility at 10 p.m. · The SP was the only staff person working at the facility during the overnight of September 4 to 5, 2022. · On September 5, 2022, P1 and P2 returned to the facility at approximately 8 a.m. and observed that the VA had a bruise on his/her eye and the facility was “a mess” with a kitchen chair tipped over and a plant spilled on the floor. The SP told P1 that s/he had a “terrible night” and something “must have” happened to the VA before the SP’s shift began, because the VA had a bruise on his/her eye. When P1 told the SP the VA did not have a bruise the previous night, the SP said, “Well I don’t know what happened, [the VA] tore down the curtains, it was a bad night.” P1 said the SP said, “I’ve got to go, I’m in a hurry,” and needed prompting to complete his/her job duties and document the VA’s bruise before s/he left the facility. · The SP told P1 that s/he made multiple attempts to contact P3 about the VA’s behavior and injury during the night of September 4 – 5, 2022, but that the SP was unable to reach P3. However, P3 told the DHS investigator that s/he did not receive any calls or texts from the SP that night. · The VA provided conflicting information to P1, P2, P3, P4, and law enforcement regarding how s/he sustained his/her injuries. The VA’s accounts included that s/he did not know, that s/he tripped, that s/he fell, that the SP slapped the VA, that the SP hit the VA, and that the SP “jumped” the VA on the VA’s bed. · The SP provided consistent information to staff persons, in documentation, and to the DHS investigator that: - During the night of September 4 – 5, 2022, the VA woke up around midnight and was awake and moving around his/her bedroom and other areas facility for several hours repeating, “Where am I, I am in the wrong room, the wrong house.” During this time, the VA pushed over a chair, knocked a plant over, and pulled down curtain rods and curtains. - The SP reassured the VA that s/he was in the right house and tried to help the VA calm and go back to his/her bedroom. Twice, while the VA was in his/her bedroom, the SP heard a “thud.” Each time, when the SP checked on the VA in his/her bedroom, s/he found the VA on the floor and it looked as though the VA had fallen. The SP asked the VA if s/he was hurt and observed visible areas of the VA’s skin. After the first fall, there was no sign of injury, and after the second fall the SP saw “a sliver of a bruise” under the VA’s left eye. The SP asked the VA if s/he hit his/her head, and the VA replied, “No I didn’t fall, I fell off the bike.” The bruise under the VA’s eye increased in size and darkened throughout the rest of the night. - Throughout the night, when the SP walked with the VA by putting the SP’s hand on the VA’s back, the VA said, “You’re hitting me,” and, “You guys are trying to kill me.” - The SP texted and called P3 at various points throughout the night, including after the VA fell the first time, when s/he first noticed the VA's bruise, and when the bruise appeared to be getting larger. However the SP did not hear from P3 until morning, when P3 called the SP and the SP told P3 what happened. - On an unspecified later date when the SP worked with the VA, the SP asked the VA, "Are we good, [VA]?" and the VA answered, "Yes." The SP then asked the VA, "Did I hit you?" and the VA answered, "No." The VA told the SP that s/he received his/her injuries from falling off his/her bike. - The SP denied hitting the VA or doing anything else to cause the marks on the VA's face and ears. · The VA’s mental illnesses caused anxiety, delusions, lack of insight, and paranoia. When the VA's mental illnesses were more symptomatic, s/he had difficulty regulating his/her emotions and became agitated easily. · The VA’s Behavioral Support Plan stated the VA's "target behaviors" included pulling at things with intent to destroy, hitting things with enough force to hurt him/herself, and throwing him/herself to the floor or into objects. When the VA was upset, staff persons were to coach him/her to use his/her preferred calming strategies; remind the VA that s/he was well-liked by staff and loved by his/her family; and remind the VA that s/he was a "good person" and "has done a good job." Precursor behaviors included obsessing and repeatedly saying the same thing. Staff persons were trained in therapeutic interventions and positive support strategies to use to help the VA calm and avoid aggression. · The VA did not always sleep through the night. During the month of September 2022, there were numerous instances documented where the VA was awake throughout most of the night, repeatedly walking to other areas of the home, carrying his/her blankets around the home, and stating repeatedly that s/he was in the "wrong room" or the "wrong bed." · The VA had a history of inaccurately alleging that staff persons pushed and hit him/her. · The VA had a history of rubbing his/her skin until there was a mark or bleeding; and pinching his/her thighs and arms, leaving small circular bruises. · The VA took medications that may cause dizziness. There were numerous instances documented in September of 2022 where the VA was unsteady on his/her feet. · The VA might not accurately report injuries or illness. Staff persons were to watch the VA for signs and symptoms of illness and injury and seek medical attention when needed. The facility’s Reporting of Maltreatment of Vulnerable Adults Policy and Procedures stated that it was the facility’s policy “to assure that all individuals receiving supports are protected from maltreatment.” The facility’s personnel files and training records documented that the SP, P1, P2, and P3 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s individualized plans prior to the incident. Conclusion: Information was consistent that during the night of September 4 to 5, 2022, the VA developed dark purple bruising around his/her left eye, two parallel linear red marks on his/her left upper jaw, and multiple red and purple dots and irregularly shaped spots on his/her left ear. On September 6, 2022, the VA also had a dime sized round purple bruise on the outside of the his/her right elbow and a quarter sized round purple bruise on the back of his/her right thigh. The VA told some individuals at some points in time that the SP caused the bruises and marks by hitting the VA, punching the VA, and/or “jumping the VA.” However, the VA also provided conflicting information that s/he sustained the bruises in a fall or trip, from falling off his/her bike, and that s/he did not know how s/he got the bruises, and the VA had a history of providing inaccurate accounts that a staff person hit him/her. The SP consistently denied harming the VA, and stated that during the night of September 4 to 5, 2022, the VA was awake, obsessed over being in the “wrong room” or “wrong bed,” fell twice, pulled down curtain rods and curtains, and overturned a chair and a plant. The SP’s account of that night was similar to multiple other nights documented during September 2022, when the VA displayed similar behavior; and was consistent with the VA’s known self-injurious behaviors as documented in the VA’s Behavioral Support Plan. Given the various and conflicting accounts of how the VA sustained his/her injuries, that the VA’s injuries were consistent with multiple accounts including that the VA caused the injuries him/herself, there was not a preponderance of the evidence as to whether the SP did anything to cause the VA’s injuries. 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 the incident was not similar to past events with the persons or services involved, policies and procedures were adequate but were not followed because internal reporting policies and procedures were not followed, there was no need for corrective action to protect the health and safety of persons receiving services, and there was a need for additional staff training on the facility’s vulnerable adult maltreatment reporting policies and procedures. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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