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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: 1068721-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) sustained unusual bruises and scratches on her body. There was also concerns of possible sexual abuse. Date of Incident(s): October 2 or 3, 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); and subdivision 2, paragraph (c): 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. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility, law enforcement records, and medical records; and through seven interviews conducted with two supervisory staff persons (P1 and P2), two staff persons (P3 and P4), the VA’s case manager (CM), and the VA’s guardians (G1 and G2). Attempts were made via telephone and certified mail to contact and interview a staff person (SP), but the SP did not respond to the requests. Law enforcement interviewed four staff persons (P3-P5 and the SP) and their information was included below. The VA was diagnosed with autism, had limited verbal communication, and required staff person’s assistance with showering. According to the VA’s documentation, the VA wore adult undergarments. Staff persons verbally reminded the VA to use the bathroom and assisted with toileting including wiping. Staff persons monitored the VA every one to two hours while sleeping. The VA had a history of “various scratches and bruises” where the origin was unknown. The VA had a history of biting her fingers when upset or anxious, approximately twice per week. The VA also had a history of displaying physical aggression toward other persons but after a medication change, it “significantly” decreased. The VA enjoyed listening to music on a music player. There were four clients, including the VA, who resided at the facility. Two of the clients were quadriplegic and the other client (C) was autistic, legally blind, and small in stature. The C had a bedroom on the lower level of the facility and the VA’s bedroom was on the upper level. P3 provided the following information to a law enforcement officer (LEO): · On October 3, 2022, P3 started work at 9 a.m. The VA woke up and ate breakfast. At approximately 11:15 a.m., P3 assisted the VA with a shower and saw bruising on both of the VA’s breasts and her nipples looked “red.” The bruises were identical on each breast and each was a straight line approximately one half inch in length that resembled “tooth marks.” There was also a red mark next to the bruise on the VA’s right breast. · P3 turned the VA and saw a scratch and a bruise on the VA’s back on her right rib cage. There was also an abrasion on the upper part of her left thigh approximately the size of a quarter and two bruises on the VA’s left thigh. There were three additional marks near the VA’s buttocks, one of which was approximately three inches long and the thickness of a “finger” that was starting to bruise and possibly another bruise on the other side near the VA’s right buttocks. There were three to four circular bruises on the VA’s left knee cap. Some of the bruises were still “fresh” because there were red marks surrounding them. · After the shower, P3 went and checked the VA’s bruise chart and none of the bruises were documented. P3 worked at the facility for seven years and these injuries were not “normal” for the VA. Typical bruises for the VA were on the back of her legs from getting in and out of the facility van but majority of the time she did not have any bruises. · The C was “very small” in stature and did not go to the upper level of the facility during the night. The C used a radio to communicate with staff persons during the night. On October 3, 2022, the C told P3 that at approximately midnight the night before, s/he heard a “loud noise” from upstairs. The C radioed to the SP asking what the noise was. The SP responded that s/he fell while mopping the floor. (Note: The LEO did not interview the C because s/he had “very high anxiety” and likely would pull out his/her eyebrows.) · If someone “picked on” the VA in the past at school, she typically fought back. The VA typically sat in her chair during the day and was “very stationary” in that spot. Prior to the incident, the VA had been at the facility for approximately five straight days and had been “quiet.” P4 provided the following information to the LEO: · P4 worked on October 2, 2022, until 8 p.m. when the SP arrived. When P4 arrived at the facility the following morning at 8 a.m., the SP stood at the sink washing dishes. The SP’s right eye lid was “puffy” but P4 did not ask the SP about it. P4 asked the SP how the overnight shift went and the SP responded it was “good.” The SP said the VA went to sleep at approximately 10 p.m. · P4 went about the morning and provided cares for the clients. P4 noticed the VA wore the same pajamas as the night before and acted “the same as usual” that morning. While the VA was in the shower, P3 called P4 and showed him/her injuries on the VA. P4 saw reddish, blue bruises approximately the size of a quarter on the VA’s breasts; one of the VA’s nipples appeared inflamed; a bruise approximately the size of a quarter on the VA’s abdomen; two “really big” marks on the VA’s right side one of which had a scrap that was approximately one inch long and the other was on the VA’s rib cage approximately the size of a quarter; multiple bruises on the VA’s inner thigh near her genitals one of which was a couple inches long and other smaller ones; a bruise on the VA’s left knee which appeared “fresh” because it was reddish in color. · Later that morning, P4 went to make the VA’s bed and saw what appeared to have been blood on the VA’s pillow case. There was “one little smear” of blood on one side of the pillowcase and darker red marks that appeared to have been blood on the other side of the pillow.
· P4 stated that the VA had a history of hitting persons with a closed hand or grabbing onto persons “really hard” if she was upset or did not want to do something. Historically the bruises on the VA were smaller and typically on the VA’s legs, hands, or arms and P4 had not seen bruises “that bad” before on the VA. P4 “never” saw the VA pinch herself or bump into objects and “never” saw bruising on the VA’s breasts prior to this incident. P4 told this investigator that when s/he came to the facility on October 3, 2022, at 8 a.m., the floors had not been moped because there was dirt and crumbles in the kitchen and historically the SP did not clean the facility. P4 worked the evening prior and had not seen the VA’s body, including her chest, torso, and thighs. P5 told the LEO that s/he worked with the VA the previous day (October 2, 2022) and stated there was “nothing out of the ordinary.” During that time, P5 saw the VA without clothing and the VA had approximately six to seven marks that looked like a “pin top” on her upper thigh but no other marks or injuries. P5 left the facility at 8 p.m. when the SP started his/her shift. The VA had a history of biting her fingers when she was mad but no other self-harm causing bruises. The VA had “violent behavior” at times especially if someone turned her music player off. If the VA was violent, staff persons walked away from the VA and went into the kitchen. Photos provided by law enforcement that were taken on October 3, 2022, showed injuries to the VA that were consistent with P3’s and P4’s descriptions. On October 5, 2022, the VA was interviewed by a representative from a child advocacy center. When asked about injuries, the VA circled the front, back, and genital areas on a diagram of a person. The VA did not provide any verbal or written information about the incident. The SP provided the following information to the LEO: · The SP worked at the facility for approximately two months prior to this investigation and mainly worked the single staff overnight shift. During the overnight shifts, the SP cleaned the facility and assisted the clients as needed, including the VA’s bathroom cares every two to three hours. The SP woke up the VA by tapping her on the shoulder and walking with to the bathroom. The VA was independent with removing her clothing and sitting on the toilet but the SP assisted the VA with wet wipes and pulling the VA’s pants up. The SP then walked the VA back to her bedroom. · The SP “never” saw the VA mad and the VA had not been physically aggressive. The SP never saw the VA hurt herself and the other three clients would not have hurt the VA. The SP was trained that if the VA tried to hit staff persons, they were allowed to hold the VA “for a couple seconds” before letting go but the SP never had to do a hold on the VA. When the LEO asked the VA about his/her eye being injured on October 2, 2022, the SP said it was a sty or pimple. · On the night of October 2, 2022, the SP played games with the VA, folded laundry, and at 9 p.m. turned off the VA’s music player. The VA “paced around” until approximately 12 midnight or 1 a.m. when she went to sleep. · At one point, the SP was mopping in the kitchen, fell, and hit his/her right knee. The C woke up and asked the SP what the noise was and the SP responded that s/he fell. The SP did not have an injury to his/her knee. The SP forgot to log that s/he mopped the kitchen the kitchen floor in his/her daily notes. The SP denied anything happening between him/her and the VA. · On October 3, 2022, when the SP returned to the facility, P1 told the SP that the VA had bruises but the SP had “no idea” how the VA sustained the bruises. The SP told the LEO that s/he saw three to four yellow or green bruises on the VA’s inner thighs when assisting the VA in the bathroom on October 2, 2022, but forgot to document the bruises on the VA’s chart. P2 provided the following information to this investigator and in a written statement: · On October 7, 2022, P2 spoke to the SP and asked the SP about what took place on his/her recent shifts at the facility. The SP said s/he cleaned, swept, moped, washed dishes, washed laundry, and charted. On October 2, 2022, the SP turned off the VA’s music player and the VA went to bed at approximately 11 p.m. The SP played video games and checked on the VA every one to two hours. The SP spent approximately five to seven minutes in the VA’s bedroom when doing checks. P2 asked the SP if s/he noticed “any skin break down or anything else with the clients that was out of the norm” and the SP said that on September 28, 2022, s/he noticed marks on both of the VA’s thighs that were “greenish yellow” when changing the VA’s adult undergarment. P2 asked if the SP documented the marks and the SP said s/he “probably didn’t document it.” · P2 then asked the SP about a loud noise that the C heard during the night of the incident. The SP said when s/he moped the kitchen, s/he slipped because s/he did not have “good grip” on his/her shoes and s/he fell forward hitting his/her right knee on the floor. · P2 noted during the interview that the SP’s right top eyelid was “a little red in the corner and a little puffy.” According to the VA’s medical records on October 3, 2022, at approximately 6:35 p.m., the VA was seen at an emergency room. The doctor noted ecchymosis (purple bruises) on both of the VA’s breasts, her abdomen, each side of her back, and the back inside part of both thighs. The doctor noted the VA’s vaginal hymen was intact and there was no evidence of vaginal penetration with a “scant” amount of blood on the vaginal swabs. The doctor noted that the VA “never had menses.” A sexually transmitted disease test was conducted, which was negative, and a prophylaxis (preventative medication) was administered. A sexual assault exam was performed and the evidence was sent to the Minnesota Bureau of Criminal Apprehension. At the time of this investigation, those results were pending and law enforcement was still investigating the allegations. According to the VA’s Grooming Chart, the last time the VA’s bedding was changed was on September 27, 2022. According to the VA’s bruise chart, there was an entry on September 21, 2022, completed by P5, that there was a bruise on the VA’s lower left back that was “very faint” and “scratch marks.” An entry made on September 26, 2022, completed by an unknown person, stated that there were approximately five “pea size bruises” on the inside of the VA’s left thigh. According to the VA’s progress notes, the SP wrote on October 2, 2022, that s/he turned off the VA’s music player at 9 p.m. and the VA was awake walking around. She had a bowel movement and went to bed at 1 a.m. According to the facility’s Nightly Cleaning Schedule for the month of October 2022, there were no tasks documented as completed by the SP, including mopping. Facility documentation showed that staff persons, including the SP, received training on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Regarding physical abuse: P5 worked on October 2, 2022, and during that time, s/he saw the VA without clothing and the VA had approximately six to seven marks that looked like a “pin top” on her upper thigh but no other marks or injuries. P5 left the facility at 8 p.m. when the SP started his/her shift. On October 3, 2022, at 8 a.m., P4 arrived at the facility. The SP’s right eyelid was “puffy” and when asked about the night, the SP said that the VA went to bed around 10 p.m. P3 arrived at the facility at 9 a.m. At approximately 11:15 a.m., P3 assisted the VA with a shower and during that time, P3 and P4 each saw injuries on both of the VA’s breasts, back, upper left thigh, on the back of her thigh near the buttocks, and on the left kneecap. The bruises appeared still “fresh” because there were red marks surrounding them. P3 and P4 each stated that these were not typical injuries for the VA. P3 and the SP each stated that the other clients did not injure the VA. Although the SP denied causing the injuries to the VA, the SP’s credibility was diminished for the following reasons: · The C told P3 that s/he heard a loud noise during the night and radioed to the SP, who told the C that s/he slipped and fell while mopping the kitchen floor. The SP also told the LEO and P2 that s/he fell while mopping. However, P4 stated that when s/he arrived to the facility on October 3, 2022, it did not appear that the kitchen floor had been cleaned because there was dirt and crumbs on it the following morning. P4 also said that historically the SP did not clean the facility and according to the facility’s Nightly Cleaning Schedule for the month of October 2022, there were no tasks documented as completed by the SP, including mopping. · The SP provided conflicting information regarding what time the VA went to bed. o The SP told the LEO and wrote in the VA’s progress notes, dated October 2, 2022, that s/he turned off the VA’s music player at 9 p.m. and the VA was awake walking around until s/he went to bed at 1 a.m. o On October 3, 2022, when P4 arrived to the facility, the SP told P4 that the VA went to sleep at approximately 10 p.m. o On October 7, 2022, the SP told P2 that on October 2, 2022, at approximately 11 p.m., s/he turned off the VA’s music player and the VA went to bed. Given that the SP’s credibility was diminished; that P5 provided information that the injuries were not there the day prior; that when P3 and P4 saw the injuries the following morning, they appeared “fresh;” that the SP was the only staff person working during the time when the VA sustained the bruising; that there was unexplained blood on the VA’s pillow; that there was no information to support that any other clients or the VA caused the injuries; and that the bruises the VA sustained likely would not be accidental or caused during the course of therapeutic conduct, there was a preponderance of the evidence that the SP caused bruises and abrasions on the VA which were not accidental. 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). Regarding the sexual abuse: Consistent information was provided that the VA had injuries to his/her breasts and buttocks near his/her genitals, including bruising and possible tooth marks. On October 3, 2022, a sexual assault exam was completed on the VA and the doctor noted that the VA’s hymen appeared intact. There was no evidence of vaginal penetration with a “scant” amount of blood on the vaginal swabs. The results of the sexually transmitted disease tests were negative. Although the injuries to the VA were concerning, pending the outcome of the sexual exam results, there was no additional information to support or refute possible sexual abuse. Therefore, there was not a preponderance of the evidence whether the SP had sexual contact with the VA. It was not determined whether sexual abuse occurred (Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast). The evidence from the sexual assault exam was submitted by law enforcement to the Minnesota Bureau of Criminal Apprehension and the results were pending at the time of this investigation. Any new information obtained from the results of that exam may be reassessed by the Department of Human Services. 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 VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for physical abuse of the VA. C. 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 physical abuse for which the SP was responsible was not recurring because it was a single incident. However, it was serious maltreatment because the VA sustained multiple abrasions/bruises. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
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