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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: 1069156-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP1) punched a vulnerable adult (VA), which resulted in the VA sustaining an abrasion on his/her left upper arm, and that SP1 called the VA a “liar.” Allegation Two: It was reported that a staff person (SP2) left the VA unsupervised in the community. Date of Incident(s): Allegation One: November 28, 2022 Allegation Two: Prior to December 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), clauses (1) and (2); and subdivision 17, paragraph (a): 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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 6, 2022; from documentation at the facility and law enforcement records; and through eight interviews conducted with the VA, the VA’s two case managers (CM1 and CM2), a facility management staff person (P1), SP1, SP2, and two facility staff persons (P1 and P2). The VA lived at the facility with one other client. The VA’s Contact Information Sheet showed that some of his/her diagnoses included anxiety, depression, and hypertension. The VA was not subject to guardianship. The VA’s Support Plan showed that s/he enjoyed riding bike and going to movies, and that s/he had a pet. The plan further stated that the VA, who had one to one staffing, had concerns related to mental health. Facility documentation showed that P1, P2, SP1, and SP2 were each trained on the reporting of maltreatment of vulnerable adults act and the VA’s specific care plans. Allegation One: It was reported that SP1 punched the VA, which resulted in the VA sustaining an abrasion on his/her left upper arm, and that SP1 called the VA a “liar.” Although the VA said that s/he did not know the date, the VA said that s/he and SP1 were in the community and while SP1 was driving, SP1 became lost and began “yelling” at the VA and said, “You’re not going to see Jesus.” SP1 then stopped the car and told the VA to get out, but the VA did not get out. After that, SP1 hit the VA’s upper left arm and said, “I will find my own way.” After that, SP1 resumed driving and brought the VA home. The VA did not remember the details but said that on a different occasion, SP1 called him/her a liar and s/he did not know why SP1 said that. A law enforcement report, dated November 29, 2022, provided the following additional information: · When the VA was interviewed by law enforcement, s/he initially stated that SP1 hit the VA’s right arm, but when questioned by law enforcement as to how that could be possible considering that SP1 was in the driver’s seat and the VA was in the passenger seat, the VA stated that SP1 hit the VA’s left arm. The VA told law enforcement that although s/he did not have “any pain,” the VA thought it was “wrong” that SP1 hit him/her. · When P2 was interviewed, P2 said that when SP1 and the VA returned from the community outing, the VA told P2 that SP1 had hit the VA while SP1 was driving. P2 also stated that s/he “observed” SP1 yelling at the VA that morning because SP1 thought that the VA took SP1’s phone and called the VA a liar. · There was no documentation within the report to show that the VA was injured or had bruising. P1 and P2 provided the following information: · P2 provided information to this investigator that was similar to the information provided in the law enforcement report, but added that when SP1 and the VA returned to the facility, the VA stated that s/he had a bruise so P2 looked and noticed a “little bit of discoloration” on his/her “right arm” that looked like a “bruise” was “starting to form,” but a bruise did not form. · P1 stated that on November 29, 2022, P2 told P1 that on November 28, 2022, SP1 “punched” the VA’s left upper arm while SP1 was driving because the VA wanted to see his/her significant other and SP1 said that s/he could not bring the VA to see that person at the time. In addition, P2 notified law enforcement so the VA could make a report. P2 also told P1 that s/he heard SP1 call the VA a “liar” when SP1 and the VA argued because SP1’s phone had been misplaced.
· When P1 saw the VA on November 29, 2022, the VA stated that SP1 “punched” him/her, but the VA did not provided more detailed information and P1 did not see any injury or bruising. When P1 talked to SP1, SP1 stated that when SP1 told the VA they would need to schedule a time to see the VA’s significant other, the VA began “yelling swearing” and using racial slurs toward SP1. SP1 denied any physical contact toward the VA and P1 did not have previous concerns related to SP1’s employment history. P1 did not talk to the VA about being called a liar but talked to SP1. SP1 told P1 that s/he did not call the VA a liar. SP2 stated that the VA had a history of yelling at staff persons, that s/he had not seen any interactions between SP1 and the VA that were concerning, and that s/he had not seen any injuries or bruising on the VA and the VA had not mentioned anything to SP2 about the alleged incident with SP1. P3 stated that s/he had not observed many interactions between SP1 and the VA, but P3 did not have any concerns related to the interactions that s/he had observed. P3 also stated that the VA previously told P3 that s/he “really liked” SP1. The VA also told P3 that if staff persons did not give the VA money or buy him/her cigarettes, the VA became “irritated” with the staff person. P3 had not observed bruising or injuries on the VA. When CM2 talked to the VA in person on an unspecified date, the VA stated that a staff person hit him/her, but the VA did not identify the name of the staff person. CM2 did not see any bruising or injuries on the VA, and the VA did not mention anything of that nature, but the VA was “totally clothed” so CM2 would not have been able to see anything. The VA did not mention anything to CM2 about SP1 saying that the VA was a liar. In addition, CM2 stated that the VA had a history of making “false” accusations in the past if the VA did not “like” someone.
SP1 provided the following information: · On the day of the incident, the VA asked SP1 to take him/her to a veterinary clinic in a different city because the VA wanted to get medications for his/her pet. After the VA picked up the medication, the VA asked SP1 to take him/her to where the VA’s significant other lived, which was close to the veterinary clinic. When SP1 told the VA s/he could not do that and that it would have to be pre-planned, the VA became upset with SP1 and used racial slurs toward SP1. · While SP1 drove, the VA continued to be agitated and made racial slurs toward SP1 so SP1 decided to stop the vehicle and ask the VA to calm down. After a few minutes, the VA calmed down so SP1 continued driving back to the facility. · Later that day, SP1, who was preparing food in the kitchen, noticed that his/her cell phone, which previously was on a couch in the living room, was gone. A few minutes later, the VA came out of his/her bedroom holding SP1’s phone. Although the VA initially refused to give the phone back to SP1, s/he returned the phone within a few minutes. · SP1 denied punching or hitting the VA and denied calling the VA a liar. The facility’s Internal Review of an Alleged Maltreatment Report provided information that was similar to the information provided by staff persons, but added that although the VA had a “small mark on [his/her] upper shoulder,” it “seemed consistent with a scratch rather than a punch.” Conclusion for Allegation One: Regarding the allegation that SP1 hit the VA and caused an abrasion: Information showed that the day of the incident, SP1 was driving with the VA. When they returned to the facility, the VA told P2 that SP1 “punched” his/her left arm, which caused a bruise. P2 looked at the VA’s arm and s/he noticed a “little bit of discoloration,” but the VA did not have a bruise. P2 then assisted the VA with contacting law enforcement and when the VA was interviewed by law enforcement, the VA stated that although SP1 hit the VA, the VA did not have pain and the law enforcement report did not document any injuries or bruising. The next day, the VA told P1 that the SP punched him/her but did not provide further details. P1 did not see a bruise on the VA’s arm. The facility’s Internal Review of an Alleged Maltreatment Report stated that the VA had a “small mark on [his/her] upper shoulder” that “seemed consistent with a scratch.” SP1 stated that while driving, the VA was upset and used racial slurs toward SP1. SP1 denied punching the VA. CM2 stated that the VA told him/her that SP1 punched the VA, but did not mention a bruise and that the VA had a history of making “false” accusations in the past. Although the VA told this investigator, P1, P2, law enforcement, and CM2 that SP1 punched the VA, given that the VA provided varying information whether s/he had a bruise; that P1, P2, and law enforcement noted that the VA did not have a bruise; that SP1 denied punching the VA; and that there was no further information to confirm or refute SP1’s or the VA’s information, there was not a preponderance of the evidence whether SP1 engaged in conduct that was not therapeutic and could be expected to cause pain. 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). Regarding the allegation that SP1 called the VA a liar: The VA and P2 each said that SP1 called the VA a liar. The VA did not provide further details and P2 stated that this occurred when SP1’s phone was misplaced and SP1 thought the VA took it. SP1 denied calling the VA a liar and stated that the VA took SP1’s phone but eventually gave it back. Although the SP had reason to minimize his/her actions and calling a VA a liar was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, given that the VA did not provide further details or context; and that there was no information that SP1 used the word liar more than one occasion, there was not a preponderance of the evidence whether all of SP1’s conduct was accidental or therapeutic and whether SP1’s conduct could be expected to cause emotional distress. 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). Allegation Two: It was reported that SP2 left the VA unsupervised in the community. The VA’s Support Plan showed that s/he enjoyed riding bike, going to movies, and that s/he had a pet. The plan further stated that the VA, who had one to one staffing, had a history of leaving without supervision and “attention seeking behavior” at appointments. The plan further stated that when the VA attended church, bible studies, and community meetings staff persons were expected to “be on site to care for [his/her] needs and supervision while [s/he] is involved with these activities” and “staff [persons] will remain on the premises while [the VA] attends these activities.” The VA could be without supervision in the community or at home for a “few minutes” so staff persons could use the restroom. The VA’s Intensive Services Assessment stated that the VA did not have any unsupervised time in the community “at this time.” P1 stated that s/he did not know the date, but on one occasion, SP2 took the VA to a court hearing and waited in the parking lot while the VA attended the hearing with CM1, but then left. P1 did not know how long the VA, who was not harmed as a result of the incident, was left unsupervised by SP2. When P1 talked to SP2 about the incident, SP2 thought that leaving the VA without supervision at the courthouse was similar to the VA being left without supervision to participate in church. CM1 provided the following information: · Prior to the December 5, 2022, hearing, CM1 prearranged with the VA to meet him/her at the court house at 2:15 p.m. · When CM1 got to the court house at about 2:05 p.m., the VA was sitting on a chair on the second floor of the court house and no staff persons were with the VA. When the VA saw CM1, the VA was “relieved” s/he did not have to go through the hearing alone. The VA did not tell CM1 how long s/he was without supervision, but told CM1 that the staff person (the VA did not name the staff person) “dropped [him/her] off” because the staff person “knew” that CM1 was going to be present for the hearing with the VA. · When the hearing was over, CM1 took the VA back to the facility.
The VA stated that a staff person dropped him/her off at the courthouse at about 1:45 p.m., but the VA did not know the name of the staff person who took him/her to the courthouse. The VA waited about 20 minutes before CM1 got there for the 2:15 p.m. hearing. The VA did not express any concern when asked about having to wait without a staff person. Although this investigator interviewed SP2 for allegation one, allegation two was reported later and when this investigator contacted SP2 to provide information related to that allegation, SP2 did not respond to requests to provide additional information. Conclusion for Allegation Two: Information showed that on December 5, 2022, SP2, who did not provide information, dropped the VA off at the courthouse at about 1:45 p.m. for the 2:15 p.m. hearing. When CM1 got there at about 2:05 p.m., the VA was “relieved” that s/he would not need to do the hearing alone. When the hearing was over, CM1 brought the VA back to the facility. Although the VA typically did not have unsupervised time in the community, the VA’s Intensive Service Assessment stated the VA did not have unsupervised time in the community but the VA’s Support Plan stated that when the VA attended certain community activities, staff persons were to remain “on the premises” while the VA attended the activities. When P1 questioned SP2 about leaving the VA unsupervised, SP2 thought it was ok to leave the VA as it was like the other community activities and CM1 was going to be with the VA. There was no information that the VA was harmed. Although SP2 did not follow the VA’s supervision plans and there was a discrepancy in the VA’s supervision requirements, given that the VA was not harmed, and that the VA was with CM1 most of the time s/he was without staff persons there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility’s Internal Review of an Alleged Maltreatment Report for allegation one showed that although policies and procedure were adequate, the “maltreatment of vulnerable adults reporting policies and procedures, employee conduct, and disciplinary policies” were not followed, but no information was provided in terms of what was not followed. The facility provided additional training to SP1. For allegation two, the review stated that although policies and procedures were adequate, SP2 did not follow the VA’s “level of supervision.” The facility provided additional training to SP2. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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