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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: 1085988-CRS (Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Christine Henne Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at and pushed a vulnerable adult (VA) and gave the VA Tetrahydrocannabinol (THC) gummy bears. Date of Incident(s): Prior to September 23, 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 October 17, 2022; from documentation at the facility; and through seven interviews conducted with four facility staff persons (the SP, P1, P4, and P5), two supervisory staff persons (P2 and P3), and the VA’s guardian (G). This investigator met the VA, but the VA was not able to provide information for this investigation due to his/her diagnoses. Documentation from the facility showed that the VA enjoyed walks in the community, video games, van rides, racquetball, Legos, and YouTube videos. The VA’s diagnoses included mild intellectual disability, autism, obsessive compulsive disorder (OCD), and anxiety. According to the VA’s Individual Abuse Prevention Plan, the VA was susceptible to physical abuse because the VA was not able to identify potentially dangerous situations or inappropriate interactions with others. The VA also had an “inability” to deal with verbally and physically aggressive persons. Staff persons were to visually monitor the VA for any signs that the VA was being physically or verbally abused and to report all suspicions right away to the appropriate individuals. Regarding the SP’s verbal and physical interactions with the VA: P2 said that at some point, s/he saw the SP “push” the VA down a hall to his/her bedroom and onto the VA’s bed. P2 also said that when the SP wanted the VA to sit down on the facility couch, the SP “scream[ed]” at the VA, “Sit down. Sit down.” On another occasion, P2 saw an incident where the VA stood in front of the couch and the SP “pushed” the VA onto the couch. The VA then said an “ugh” noise and, “Be nice.” P2 had seen the SP do this at least five or six other times, but never noticed any injury to the VA. According to P2, multiple staff persons, including P4, had also seen the SP “push” the VA. At some point, P4 told P2 that s/he saw two different types of “abuse” from the SP to the VA, but P4 did not provide additional information to P2. P2 directed P4 to talk to P3 about the incidents of “abuse.” On September 18, 2022, P2 emailed P3 and another supervisor and stated that s/he felt that the SP’s behavior towards the VA was “unacceptable” and the “yelling” and “pushing” of the VA was not what s/he would “consider professional.” P2 also stated in the email that s/he felt that s/he was “being harassed,” “attacked,” and “physically threatened” by the SP. At the closing of the email, P2 requested that s/he would like to further discuss the situation. P4 said that the SP was sometimes “a little bit impatient” when the VA had “high behavior days,” but P4 had never heard any staff persons yell or verbally abuse the VA. P4 was told by a former supervisor to “be firm” with the VA and that sometimes staff persons had to “raise [their] voice” for the VA to “listen.” When asked by this investigator if P4 had ever seen the SP push the VA, P4 said, “Not like hard.” P4 said that the VA was a “very high behavior client” and could be “very aggressive,” and that sometimes staff persons had to “not like push [the VA] away from [staff persons].” However, P4 said that the SP “[did] it a little bit more than other staff.” P4 was not aware of any injuries to the VA from the SP. P1 said that s/he did not witness any staff person forcefully push the VA, but heard from other staff persons that the SP was a “little rougher” with the VA. P1 stated that the VA responded “very well” with “yelling” such as “a mom voice” or when staff persons were “very direct” and said things such as, “You need to go sit down” or “You need to relax.” P5 said that s/he observed the SP be a “little too aggressive” with the VA when the VA did “something [s/he] shouldn’t be doing” such as “ripping” his/her clothing. On an unspecified date, P5 saw the SP “aggressively” pull clothing off of the VA when the VA was “ripping” his/her own clothing. According to P5, if staff persons saw the VA start to rip his/her clothing, staff persons were trained to be “stern” with the VA and say, “Give me your clothes.” But if the clothes were already ripped, then staff persons were trained to just let the VA rip them until the VA was “over” his/her “fixation” of it. P3 stated that s/he received an anonymous text on September 22, 2022, regarding concerns that the SP was verbally and physically aggressive towards the VA. When P3 talked to the SP about the concerns, the SP denied the allegations. P3 was only at the facility where the SP worked about once a month. The SP stated that s/he did not “physically” push the VA, but rather s/he would put his/her hands up (bent at the elbows) and that the VA “push[ed]” off of the SP’s hands him/herself and fall back onto the couch. The SP said that the VA would then “flop back like a fish out of water” onto the couch to “act dramatic.” The SP denied yelling at the VA, but said that s/he raised his/her voice to the VA because “that’s what [persons] have to do in order to make [the VA] listen.” The SP also stated that “everybody raises [his/her] voice” to the VA. The G had no concerns with the SP and stated that s/he trusted him/her “implicitly.” The G said s/he could understand how someone might think that a staff person could be “too aggressive,” but indicated that persons had to be “direct” with the VA.
Regarding the Tetrahydrocannabinol (THC) gummies: The SP, P1-P5, and the G provided consistent information that the VA was previously prescribed and administered Cannabidiol (CBD) gummies (without THC).. According to an Order Detail Report, the CBD gummies were prescribed on April 27, 2022 for anxiety and discontinued on July 27, due to an “inadequate patient response.” The G said that s/he was not aware of anytime that the VA received THC gummies. Over two years prior, the VA’s doctor approved a THC prescription for the VA; however, since the VA’s insurance did not cover the cost, the VA was not able to afford the THC so the VA never had or took THC. The G “at no time” gave any staff persons permission to administer THC gummies from their personal products to the VA. After the CBD gummies were discontinued, P4 saw the SP give the VA THC gummies from the SP’s personal bag. This occurred three or four times from mid-August to mid-October 2022. The SP told P4 that the gummies had THC in them and that the G and “other people” or “higher ups” approved them to use for the VA’s high behaviors. P2 was asked by P3 if s/he knew anything about the VA being given THC gummies, which P2 did not. P2 was also asked to make sure there were not THC gummies at the facility, and to get rid of them if there were. However, P2 never found any THC gummies inside the facility. P5 said that s/he did not know anything about THC gummies being given to the VA. The SP denied giving the VA THC gummies. The drug and alcohol use policy said that the facility supported a workplace free from the effects of drugs, alcohol, controlled substances, and the abuse of prescription medications by an employee, subcontractor, volunteer, or other individual directly or indirectly responsible for individuals served in any program operated by the company. All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and facility policies prior to the incident. Relevant Rules and/or Statutes Minnesota Statutes 245D.04, subdivision 3, paragraph (a), clause (6), states that a person's protection-related rights include the right to be treated with courtesy and respect. Conclusion: Regarding verbal and physical interactions with the VA: P2 stated that s/he saw the SP “scream” at the VA and “push” the VA. However, P2 did not see any injuries to the VA. P4 said that the SP was “sometimes a little bit impatient,” but did not witness the SP yell at the VA. P5 observed the SP “aggressively” pull clothing off of the VA when the VA was “ripping” the VA’s clothing. The SP denied the allegations and stated that s/he put his/her hands up and the VA pushed him/herself onto the couch “flopping like a fish out of water” and that s/he raised his/her voice to get the VA to listen. Given that several staff persons provided consistent information that the SP was a “little too aggressive,” and “sometimes a little bit impatient” as well as “scream[ed]” at and “pushed” the VA, it was possible that the SP’s interactions with the VA were likely not entirely therapeutic and were a violation of Minnesota Statutes 245D.04, subdivision 3, paragraph (a), clause (6). In addition, information showed that staff persons were very direct, stern, and raised their voices in order to make the VA listen. However, without further information and given that the VA did not sustain an injury, there was not a preponderance of the evidence whether the SP or other staff persons engaged in behavior that produced or could reasonably be expected to produce physical pain or emotional distress. It was not determined whether physical or 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; or 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 the THC gummies: The G stated that two years prior the VA was prescribed THC but due to the cost the VA did not purchase or take THC. Although P4 stated that s/he saw the SP give the VA THC gummies from the SP’s personal bag, the SP denied the allegation and there was no other information to corroborate eithers account. Therefore, there was not a preponderance of evidence whether the SP gave the VA THC gummies. 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 completed an internal review and determined that policies and procedures were adequate and were followed. Staff persons were retrained regarding the drug and alcohol policy and the Vulnerable Adult Act. Action Taken by Department of Human Services, Office of Inspector General: On January 27, 2023, the facility was issued a Correction Order for the violation outlined in this report.
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