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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: 1090539-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux Suspected Maltreatment Reported: It was reported that on an unknown date, a staff person (SP) yelled at a vulnerable adult (VA), forced medications with water into the VA’s mouth and held it shut, told the VA that s/he was “just a blind [guy/girl],” and referred to the facility residents as “retards” (referred to as the r-word throughout the remainder of the report). It was also reported that on September 6, 2022, the SP grabbed the VA’s stomach, causing a bruise. Date of Incident(s): Ongoing prior to September 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), clauses (1) and (2): 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. · 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 15, 2022; from documentation at the facility; and through seven interviews conducted with facility staff persons (P1, P2, P3, and the SP), the VA, a facility resident (R1), and a community person (CP), who was the VA’s friend. P3 and the SP were supervisory staff persons at the facility. Five staff persons (P4, P5, P6, P7, and P8) who also worked at the facility, were contacted by phone for an interview, but did not respond. No other staff persons were employed at the facility in September of 2022. Two individuals (R2 and R3) also resided at the facility, but they were non-verbal, and according to the VA, did not witness the incidents. The VA had impaired eyesight, was diagnosed with diabetes, had neuropathy in his/her hands, and received daily insulin injections in his/her lower abdomen. The quality of the VA’s vision might vary from day to day. However, the VA’s vision was getting worse over time, and s/he would eventually be blind without surgery, which s/he had declined to have. It was important for the VA to do as much for him/herself as s/he could, and s/he used a wheelchair for mobility at the facility and in the community. Spending time with his/her friends was important to the VA and s/he was usually easy going, but was sometimes upset about recent declines in his/her health, which frustrated him/her. When the VA was upset or angry, s/he might yell or raise his/her voice while advocating for him/herself. The VA required assistance with many activities of daily living, including medication administration and took several prescribed medications, including tablets/capsules that s/he swallowed with water. The VA had a history of wanting his/her needs met immediately and did not like to wait for assistance, but no documentation in the VA’s plans at the facility showed whether the VA had a history of providing inaccurate information. The VA was not subject to guardianship, and s/he was determined to be resilient by adapting to his/her physical limitations with little assistance from staff persons. Information from the CP, the VA, R1, the SP, P1, P2, and P3, provided the following information: · The VA said that that on a date s/he could not recall, the SP yelled at him/her, suddenly forced medications into his/her mouth, and held his/her mouth closed for a few seconds. The VA did not remember what the SP said and swallowed the medications placed in his/her mouth, but was upset because the SP’s actions were unexpected and s/he was unable to see the details of events occurring around him/her. The SP sometimes referred to the VA as blind, but the VA did not hear the SP use the r-word at the facility. The SP was “rough” when s/he assisted the VA with personal cares and recently grabbed the VA’s stomach, which caused bruises. On the date of the site visit, the VA had light yellow/green bruises with irregular edges on each side of his/her lower abdomen. However, the VA received daily insulin injections from staff persons in his/her lower abdomen in the same area in which the bruises were located and staff persons alternated sides when they gave the injections. The VA stayed in his/her bedroom when the SP worked to avoid contact with him/her because s/he was afraid of the SP. · Photographs taken on September 7, 2022, by an unspecified staff person and provided by the facility, showed that the VA had two faint yellow/green quarter sized bruises with irregular edges, on his/her lower abdomen. There were no observable injuries to the VA’s face or head. · The CP said that s/he did not have firsthand information regarding the allegations in this report. However, the VA provided a similar account of the SP’s actions to him/her and told the CP that s/he was afraid of the SP on a date that the CP could not recall. · P1 said that s/he could not recall the specific dates, but on two occasions since June of 2022, s/he saw the SP approach the VA, place one hand on the VA’s forehead, push his/her head back, and “dump” pills into the VA’s mouth. The VA was upset because s/he did not expect the SP to place medications in his/her mouth. The SP gave the VA water to assist him/her to swallow the medications, but the SP put the glass of water in the VA’s hand without verbally communicating his/her actions to the VA. P1 did not intervene in the SP’s interactions with the VA because s/he was a newer employee at the time and the SP was a seasoned staff person, and did not tell anyone about the SP’s actions. · According to P1, the SP often complained about the VA and about staff persons at the facility, and had an aggressive/outspoken approach. The SP told staff persons to “fuck off,” used other inappropriate language directed at staff persons at the facility when the VA and the Rs were at the facility and often discussed his/her personal matters there, but P1 did not witness the SP call the VA, R1, R2, or R3, the r-word. The VA once told P1 that s/he “feared” for his/her life at the facility when the SP worked because s/he did not know what to expect. · P2 said that the VA was short tempered at times and s/he had occasionally heard the SP raise his/her voice to the VA, who responded by raising his/her voice to the SP. Conflicts between the SP and VA usually occurred when the VA wanted to use the telephone or wanted something from staff persons, and the VA sometimes made statements that s/he intended to have the SP “fired” especially when the VA was unaware that P2 was in the room with the VA. P1 was one of the VA’s preferred staff persons and treated P1 more like a friend than a staff person. They did not like the SP. According to P2, the SP told staff persons to “do their jobs” when the VA and Rs were at the facility but his/her statements were not directed to the VA or Rs. P2 did not witness the incidents the VA described and did not hear the SP use the r-word, but the VA provided consistent information to P2 over time regarding the SP’s actions. · P3 provided information in the Internal Review that s/he did not have firsthand information regarding the allegations, but said that the VA might attempt to manipulate staff persons to get what s/he wanted right away or immediately take him/her on preferred community outings. The VA’s plans at the facility did not document the VA’s credibility, but P3 recalled that information from the VA’s previous residential facility showed that the VA had a history of providing inaccurate information. The VA often complained to P3 about various staff persons being “mean or aggressive” to him/her, but did not tell P3 that staff persons talked down to him/her. On May 20, 2022, the SP was given a verbal warning on a Corrective Action Plan because s/he was “rough” with the VA and did not take time to explain what s/he was doing to assist the VA before assisting him/her. It was also noted that the SP’s conversations with individuals and others that s/he had contact with in his/her role at the facility, were not “not always positive, professional, or respectful.” The SP was instructed that immediately and going forward, s/he was to show professionalism and be a positive role model, be mindful of his/her interactions with individuals when assisting them, and explain his/her actions to the VA and be gentle while assisting him/her with cares. · The SP said that when s/he administered medications to the VA, s/he told the VA that s/he would assist him/her, “gently” placed his/her left hand on the VA’s forehead, tilted the VA’s head back, and placed medications in the VA’s mouth with his/her right hand. The VA was unable to place medications in his/her own mouth because s/he often dropped them but the VA had not declined to take the medications when the SP offered them to him/her or expressed concerns to the SP about the way s/he assisted the VA. The SP was blind and s/he sometimes talked with the VA about blindness and how it might affect him/her if s/he lived independently in the community, but the conversations were “never negative.” It was possible that the VA overheard a phone conversation at the facility between the SP and his/her significant other (SO) during which the SP told the SO that the SO was not the r-word, but the SP did not call the VA or the residents the r-word. The VA had daily insulin injections that likely caused the bruising on the VA’s abdomen, which was common when an individual had diabetes. The SP denied forcing medications into the VA’s mouth and holding it shut, denied calling the VA blind or the Rs the r-word, and denied grabbing the VA’s stomach. The SP thought that the allegations in this report were “misconstrued, ridiculous, exaggerated, and insane.” · R1 did not recall information regarding the SP’s interactions with the VA that were investigated in this report, or the SP’s use of the r-word, and said that s/he had no concerns about his/her care at the facility. · The facility’s Service Recipient Rights Policy stated that the VA had the right to be free from maltreatment and the right to be treated with courtesy and respect. 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. The SP was trained on the facility’s Medication Administration Policy when s/he was hired, and had annual training on the facility’s policies and procedures in 2020 and 2021. The SP was most recently trained on the Reporting of Maltreatment of Vulnerable Adults Act on February 19, 2022. Relevant Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) stated that a consumer has the right to be treated with courtesy and respect. Conclusion: There were concerns that the SP was rough when s/he administered medications to the VA, grabbed the VA’s stomach leaving bruises, and referred to the VA as “blind” and to the Rs using the r-word. However, the VA was visually impaired and said that the SP did not refer to him/her or the Rs using the r-word. The VA and P1 each stated that on dates they could not recall, the SP placed the VA’s prescribed medications in his/her mouth without telling the VA that s/he planned to do so. In addition, the VA said that the SP once held his/her mouth shut for a few seconds when giving prescribed medications to him/her and P1 said that on two occasions, s/he saw the SP push the VA’s head back and dump prescribed medications in the VA’s mouth. The SP’s actions upset the VA because s/he was unable to see events occurring around him/her, and s/he stayed in his/her bedroom when the SP worked, because s/he was afraid of the SP. The VA also said that the SP grabbed his/her stomach, which caused bruises to the VA’s abdomen and photographs showed that on September 7, 2022, the VA had two small light irregularly shaped green/yellow bruises on his/her lower abdomen. However, the VA received daily insulin injections in his/her lower abdomen and the bruises on his/her lower abdomen were near the injection sites. P2 said that there were occasional conflicts between the VA and SP when they raised their voices to each other that usually began when the VA wanted something. The VA and P1 did not like the SP, the relationship between the VA and P1 was more like a friendship than VA/staff person, and the VA said that s/he intended to get the SP “fired.” P2 did not have firsthand information about the incidents the VA described but the VA provided consistent information over time regarding the SP’s actions. The SP said that s/he used the r-word when talking with his/her SO by phone, that might have been overheard at the facility, but denied that s/he referred to the VA or others using the r-word. When the SP gave prescribed medications to the VA, s/he told the VA that s/he was going to assist him/her, gently tilted the VA’s head back, and placed the medications in the VA’s mouth. The SP denied that s/he grabbed the VA’s stomach and denied that s/he forced medications into the VA’s mouth and held it shut. Regarding emotional abuse: The VA said that the SP yelled at him/her on a date s/he could not recall, and it was reported that the SP referred to the VA as blind and to the facility residents using the r-word. P1 said that the SP was outspoken, P2 said that the VA and the SP raised their voices to each other, and documentation showed that the VA might raise his/her voice when s/he was upset. The SP had a Corrective Action Plan regarding his/her communication with others and might have raised his/her voice to the VA, which was not therapeutic conduct, not consistent with the actions of a professional caregiver in a DHS licensed program, violated facility policies and procedures, and was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that it was unknown what the SP said with a raised voice, that there were no witnesses with firsthand information, that P2 heard the VA say that s/he wanted to get the SP “fired,” and that the VA was blind and said that s/he did not hear the SP use the r-word, 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 VA. 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 physical abuse: The VA said that on dates s/he could not recall, the SP forced medications into his/her mouth and held his/her mouth shut for a few seconds, and grabbed his/her stomach, which caused bruises to the VA’s lower abdomen. Photographs taken on September 7, 2022, showed that the VA had two light yellow/green quarter sized bruises with irregular edges on his/her stomach, but the VA received daily insulin injections in his/her abdomen which might have caused the bruises. The VA had no injuries to his/her face or head. P1 said that on two occasions since June of 2022, s/he saw the SP place a hand on the VA’s forehead, push the VA’s head back, and “dump” pills into the VA’s mouth, but the SP did not tell the VA of his/her intended actions prior to starting them. P2 did not witness the incidents described by the VA and said that the VA was sometimes short-tempered. The VA said that s/he wanted to get the SP fired. P1 and the VA did not like the SP and the relationship between them was more like a relationship between friends rather than a staff person and a facility resident. P3 had no firsthand information regarding the incidents, but said that the VA might attempt to manipulate others to get what s/he wanted and complained about staff persons at the facility. On May 20, 2022, the SP was given a Corrective Action Plan for being “rough” with the VA, and did not explain what s/he was doing to the VA before assisting him/her. The SP was instructed to show professionalism, be a role model, be mindful of his/her interactions with individuals, explain his/her actions to the VA before assisting him/her, and to be gentle while providing cares to the VA. The SP said that s/he was gentle when assisting the VA, and denied forcing medications into the VA’s mouth and holding it shut, denied calling the VA blind or the Rs the r-word, and denied grabbing the VA’s stomach. Although the VA and P1 each stated that that the SP suddenly placed medications into the VA’s mouth, which upset the VA, that the VA said that the SP held his/her mouth shut for a few seconds and also grabbed his/her stomach, and the VA had two light irregularly shaped yellow/green bruises on his/her lower abdomen, given that P2 said that the VA said s/he wanted to get the SP fired, that P3 stated that the VA had a history of providing inaccurate information, that the SP denied holding the VA’s mouth shut, that the SP denied doing anything to cause bruises on the VA’s stomach, and that the VA received daily insulin injections in his/her lower abdomen which might have caused the bruising, there was a not a preponderance of the evidence whether the SP engaged in conduct that produced or could reasonably be expected to produce physical pain or injury. 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 which determined that its policies and procedures were adequate but were not followed. On May 20, 2022, the SP was given a Corrective Action Plan when it was observed that s/he was “rough” when providing cares and did not “take time to explain” what was being done before assisting individuals. In addition, it was documented that the SP’s conversations and interactions with individuals and their guardians were not “always positive, professional, or respectful.” The SP was instructed to show professionalism, be mindful of his/her interactions, and explain what s/he would be assisting with when providing cares to the individuals. When the facility became aware of continuing concerns with the SP’s work in September of 2022, the SP was suspended, and at the time this report was written, s/he was no longer employed at the facility. The VA preferred to take medications in applesauce and his/her plans were updated to reflect his/her preferences for medication administration. Staff persons were instructed to verbally communicate their intended actions to the VA prior to touching him/her when providing cares. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action, the facility was not issued a correction order for the violation outlined in this report.
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