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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: 1098135-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a staff person (SP1) grabbed, hit, and restrained a vulnerable adult (VA), which led to the VA sustaining bruising on his/her forearms and left shin. It was also reported that SP1 threatened to physically assault the VA and his/her family. During the investigation, it was reported that another staff person (SP2) physically abused the VA. Date of Incident(s): November 4, 2022, and ongoing prior to November 7, 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 November 15, 2022; from documentation at the facility, from law enforcement records, and the VA’s medical records; and through eight interviews conducted with the VA, SP1, SP2, a hospital nurse (HN), a facility management staff person (P1), the VA’s guardian (G), the VA’s case manager (CM), and a facility staff person (P2). The VA’s Support Plan showed that the VA enjoyed knitting, having a “routine,” and going into the community. The VA was diagnosed with major depressive disorder, anxiety disorder, post-traumatic stress disorder, and a moderate developmental disability. The plan further stated that the VA “often times” had two staff working with him/her due to behavioral incidents, which included: physical abuse to self and others, property destruction, and leaving without supervision. When the VA engaged in behavioral incidents, specifically leaving without supervision, staff were trained to follow the VA and encourage him/her to relax and return to the facility. The VA had a “high risk for making false calls to 911 during behavioral episode.” As a result, a rights restriction was in place to “restrict [the VA’s] use of the phone” and “monitor” the VA when s/he used the phone. The VA’s Individual Abuse Prevention Plan/Self-Management Assessment provided information that was similar to the information provided in his/her Support Plan, but added that the VA would “scratch [his/herself] to blood.” Information from the investigation showed that the facility’s phone was to be locked in the staff office at all times. The VA was the sole client at the facility. The HN and the VA’s medical records provided the following information: · On November 4, 2022, the VA was in the emergency room (ER) because s/he was “overwhelmed/having a nervous breakdown” and threatened to kill/harm him/herself and anyone in the house if s/he was not taken to the hospital. While in the ER the VA stated that SP1 “punched” the VA’s left arm that day, told the VA that s/he “was lucky” that SP1 did not break the VA’s jaw, and that SP1 was “going to kill” the VA’s family. · The VA had “bluish” bruises with some about the size of a “quarter” or “half dollar” on his/her left shin, left forearm, and right forearm. The HN thought that the bruises looked a “day or two old.” However, the VA’s medical records stated, “Skin: Negative for wound,” and the ER did not take pictures of any injury. · The VA was admitted for “observation” and released a couple days later. The VA provided the following information: · On a date the VA did not remember, SP1 “was hitting” both of the VA’s wrist “really hard” because the VA was trying to calling law enforcement. As a result, the VA had “black and blue” marks on his/her “left wrist.” The VA did not call law enforcement during the incident. · At about 5 p.m. the following day, SP2 worked, the VA, who described him/herself as “sneaky,” obtained the phone from the staff office. After the VA got the phone, s/he went to his/her bedroom and “quietly” told law enforcement that SP2 was hitting him/her. When SP2 realized that the VA was using the phone, SP2 took the phone from the VA. The VA then ran outside and SP2 followed. Once outside, SP2 received a phone call from law enforcement “following up” on the VA’s call. SP2 told law enforcement that everything was “ok.” After the call, SP2 “pushed” the VA to the ground. When that happened, the VA hit his/her head “on the ground.” Initially, the VA stated that his/her head “hurt a little,” but later said “not really.” The VA returned to the facility, but did not remember how long s/he and SP2 were outside. · At about 11 p.m. that night, law enforcement came to the facility while P2 was working. P2 told law enforcement that the VA was “fine,” but law enforcement took the VA to the hospital because the VA had “suicidal thoughts.” · The VA did not remember anyone telling him/her that they were going to threaten his/her family or that they were going to break his/her jaw. The law enforcement report, dated November 4, 2022, provided the following information: · Law enforcement received a call from the VA at 5:09 p.m., saying, “Staff had been hurting [him/her] and that [s/he] was suicidal.” At 9:47 p.m. law enforcement went to the facility and talked to the VA. The VA told law enforcement that earlier in the day, s/he called law enforcement because s/he was “feeling anxious” and when SP2 “tried to speak with [the VA] about using the phone,” the VA “ran outside.” While outside, SP2 “grabbed” the VA’s arm and took the phone away. The VA also stated that when SP2 grabbed the VA, the “grabbing” caused the VA to fall. · The VA showed law enforcement “a lightly discolored bruise” on his/her left forearm and a “small scuff” on the inside of his/her left hand. When the VA was asked about the injuries, the VA stated that the “scuff” mark was from an earlier fall in the driveway, but then “revised” his/her statement to say that the “discoloration” on his/her left forearm was from a “previous incident” in which SP1 grabbed the VA. · The VA requested that law enforcement take the VA to the hospital, but was told that it “was not an emergency” and that staff could take the VA to the hospital the next day. When the VA heard that, s/he began scratching and biting his/her arms, stating that s/he was “suicidal.” Law enforcement transported the VA to the hospital. SP1 stated that on November 3, 2022, when s/he worked, the VA had “some anxiety,” but that was “pretty common.” SP1 denied any type of physical altercation with the VA, denied telling the VA that s/he would break his/her jaw, and denied stating that s/he would kill the VA’s family. SP1 did not see any bruising on the VA on November 3, 2022. SP1 did not work on November 4, 2022, but that night, received a call from P2 telling him/her that law enforcement came to the facility. When the VA returned to the facility after being hospitalized, the VA had some bruising on his/her left wrist that was “yellow and very small.” SP2 provided the following information during his/her interview and in the facility’s Report Form, dated November 4, 2022, at 8 p.m.: · On November 4, 2022, the VA had a “good day.” At about 4 p.m., SP2 noticed that the staff office was unlocked and so SP2 checked the office and determined that the phone was gone. SP2 then went to the VA’s bedroom door and heard the VA talking. SP2 knocked on the door and when the VA opened the door, SP2 told the VA that s/he knew s/he was on the phone. When the VA handed the phone to SP2, SP2 ended the call without looking to see who the VA was talking to. · As SP2 was taking the phone back to the office, s/he noticed that the VA was leaving the facility so instead of putting the phone back in the staff office, SP2 took the phone and followed the VA outside. · When SP2 caught up with the VA, SP2 stood in front of the VA to prevent him/her from going further. When SP2 did that, the VA began hitting SP2 so SP2 put both of his/her hands toward the VA. While the VA hit SP2’s hands, the VA fell to the ground, which was typical behavior from the VA. · For about 30-45 minutes, SP2 tried to verbally redirect the VA, who remained on the ground. At some point, law enforcement called, and told law enforcement that everything was fine and the situation was under control. However, the VA tried taking the phone from SP2 and was “pretty mad” that SP2 was talking to law enforcement. At some point, the VA stood up and they walked back to the facility without further incident. SP2 described the rest of his/her shift as being “completely fine.” When SP2 left for the night at about 8 p.m., the VA was sleeping. · SP2 denied dragging, pushing, or hitting the VA. At some point, SP2 saw one bruise on the VA’s arm, but SP2 was not certain which arm. SP2 described the bruise as “dime” size and yellow. SP2 thought that it appeared to be two to three days old. P2 provided information to this investigator and in the facility’s Report Form that was similar. On November 4, 2022, at about 9:50 p.m., law enforcement came to the facility to follow up regarding an earlier call from the VA. When law enforcement arrived, P2 told them that the VA was sleeping, but as they talked, the VA woke up and came out to the living room. The VA then began to engage in self-injurious behaviors (SIB) including “scratching” his/her arms. At some point, the VA threatened to “kill” law enforcement and him/herself. When that happened, the VA was transported to the hospital by law enforcement. P2 stated that when law enforcement was at the facility, s/he could “barely see” any bruising on the VA’s left arm. The G stated that s/he talked to the VA when the VA was in the hospital and the VA told the G that staff “hit” him/her and caused some bruising, but the VA did not provide a name of any staff person. The G further stated that the VA had a history of “inaccurate reporting.” The CM stated that the VA had a “long history” of making “false accusations.” P1 said that the VA’s ability to provide information was “sketchy at best” and that the VA had a history of inaccurate reporting of events. P1 did not have concerns regarding SP1 or SP2 and their interactions with the VA. P1 said that there was video footage available from inside the facility, but the footage was not able to be saved in a format to be given to this investigator. P1 said that s/he reviewed the video from November 4, 2022, and P1 “was amazed at how calm [SP2] had kept the situation with [the VA] and the phone, never was in a hurry, didn’t display any stress, calmly followed [the VA] when [s/he] left the house, and normalized the relationship upon returning.” In addition, P1 provided the following timeline related to the November 4, 2022, incident: · At 5:08 pm, the VA discovered that the office door was unlocked. · At 5:13 pm, SP2 noticed that the phone was missing and the VA left the facility. · At 5:43 pm, the VA and SP2 return to the facility. · At 9:55 pm, law enforcement arrived to the facility. The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to November 4, 2022. Conclusion: Information obtained showed that on November 4, 2022, at 5:08 p.m., the VA accessed the phone and called law enforcement. When SP2 noticed that the VA was using the phone, SP2 asked for the phone back and when the VA returned the phone, SP2 ended the call and attempted to bring the phone back to the locked office, but the VA left the facility at 5:13 p.m. SP2 followed the VA outside and at some point law enforcement called back. When the VA heard SP2 say that everything was “ok,” the VA began to escalate. SP2 stated that the VA began hitting SP2, so s/he used his/her hands to block the VA from hitting and when that happened, the VA fell to the ground. Information showed that the VA and SP2 returned to the facility at 5:43 p.m. and at 9:55 p.m., while P2 was working, law enforcement arrived at the facility and when they talked with the VA, the VA began engaging in SIB and said that s/he was suicidal so they transported the VA to the hospital. While the VA was at the ER, the VA told the HN that SP1 “punched” the VA’s left arm, told the VA that s/he “was lucky” that SP1 did not break the VA’s jaw, and that SP1 was “going to kill” the VA’s family. SP1, who denied those allegations and did not work that day but worked the day prior. The VA told the G that staff hit the VA and caused bruising, but did not provide a name. Although medical records did not say the VA had any bruising or injury, the HN said that that VA had “bluish” bruises with some about the size of a “quarter” or “half dollar” on his/her left shin, left forearm, and right forearm. Although the VA may have had some bruising, the VA had a history of engaging in SIB and provided different accounts of how/when the bruises occurred so it was not able to be determined if the VA had bruises and if so, when or how the bruising occurred. SP1 and SP2 denied the allegations and P1 did not have any concerns regarding SP1’s and SP2’s interactions with the VA. Therefore, there was not a preponderance of the evidence whether SP1 or SP2 physically abused the VA. 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’s Report Form showed that policies and procedures were adequate, followed, and that no additional training was needed. Action Taken by Department of Human Services, Office of Inspector General: No action taken at this time.
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