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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: 1100393-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kimberly Anderson/Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) and a staff person (SP) had a verbal and physical altercation and the VA’s eyeglasses were broken during the altercation. Date of Incident(s): October 27, 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 subdivision2, 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 16, 2022; from documentation at the facility; and through five interviews conducted with facility staff persons (P1, P2, P2, P3, and P4) and the vulnerable adult (VA). Several attempts to contact the SP through various means: telephone, email, and mail, to set up an interview were unsuccessful. The facility was one half of a two story duplex with a shared basement with laundry and access to the other side of the duplex. On the main level of the home was a living room and a kitchen. The VA’s bedroom, a bathroom, and an office were up a steep set of stairs. The front outdoor entry of the home had two doorways for both sides of the duplex and four large cement stairs. There was a small section of grass between the home and a sidewalk near the road. There were bushes in the yard near the house. The VA’s Admission Form and Behavior Support Plan stated the VA enjoyed being outside and was working toward the goal of having his/her own apartment. The VA was diagnosed with post-traumatic stress disorder, bipolar disorder, and a neurodevelopmental disorder. The VA required two caregivers at all times. Staff persons were to keep the VA engaged in activities and provide structure and predictability. Staff persons were also to provide the VA space within sight and sound and avoid being confrontational and model calming behavior. The VA provided the following information: · When s/he was agitated, staff persons were to leave him/her alone and s/he told them when they were to do so. · On October 27, 2022, the VA and the SP got into an argument and the SP would not quit and “kept going on and on.” The VA threw the SP’s belongings onto the yard. The SP called P1 and this made the VA upset so s/he grabbed the SP’s phone from the SP. Then the SP “kind of” hit the VA in the face knocking off his/her eyeglasses. The temple of the VA’s eyeglasses broke so the VA was wearing a spare pair of glasses that s/he owned. The VA the left to walk around the block and the SP left the home. The VA was unsure if the hit was accidental as the SP was trying to grab the phone. The VA said s/he sustained no injuries. The facility’s General Event Report stated the following information: · The VA and the SP engaged in a verbal back and forth regarding the VA’s medicated toothpaste before the incident. This exchange escalated and the VA began to throw items in the house. · At approximately 9:30 p.m., the VA was on the front porch when evening staff persons began to arrive. At that time, the SP was gathering items to leave and asked where his/her things were. One of the staff persons pointed towards the door. The SP went outside and found that his/her items had been thrown onto the front lawn. The SP asked the VA to pick up the items and the VA yelled at the SP and said, “No.” · The SP used his/her cell phone to call P1 and inquire about what to do with the damaged items. The VA then grabbed for the SP’s cell phone and other staff persons heard the VA say that the SP hit the VA and broke the VA’s eyeglasses. · The VA then threw the SP’s cell phone and ran down the street. Staff persons followed the VA and the VA returned home. The VA said, “I should not have done that. I am going to get in trouble.” The VA watched television for about 30 minutes and then went to bed. Staff persons did not report seeing any scratches, swelling or bruising the day of the event or the following days after.
P1 provided information consistent with the General Event Report but also added that the VA’s first instinct would be to blame the other person and then state that s/he over reacted. P1 also said that the VA initially stated that the SP “punched” him/her but when retelling the story to a family member stated that her eyeglasses got hit off his/her face as s/he and the SP were tussling over the cell phone. P2, P3, and P4 provided the following consistent information: · On October 27, 2022, P2 was working with the SP. P3 arrived at the home at 9:00 p.m. and P4 arrived later. · P2 and P3 stated on the day of the incident, the VA and the SP were both in different than usual moods. The VA was not understanding things and asking more questions than usual and the SP did not have patience and was “short” with the VA. · Before the incident, the VA was downstairs and the SP was upstairs and they were yelling at each other and calling each other “lazy” because neither the VA nor the SP liked to climb the stairs and it was time for the VA to use her medicated toothpaste. The SP was in the bathroom upstairs on the cell phone talking to P1 and this caused the VA to become upset. The VA took the SP’s belongings and threw them onto the lawn. P3 stated that the SP talking with P1 was a trigger for the VA and it made him/her think s/he was “in trouble.” · At this time, the SP was unaware that the VA threw his/her belongings out on the lawn. The SP and the VA met each other halfway on the stairs to exchange the medicated toothpaste and the VA hit the medicine knocking it onto a chair in the living room. P2 decided that the interaction to get the VA to use the toothpaste “was not worth the fight” so s/he took the toothpaste back upstairs and this upset the SP. P2’s shift had ended approximately ten minutes prior so s/he was preparing to leave as P4 was arriving. P2 walked out the front door and saw the SP’s belongings on the front yard and began picking things up. · The SP came downstairs and inquired about his/her belongings and P3 pointed to the lawn. The SP walked out the front door, the VA followed the SP, and P3 followed the VA. All three remained at the top of the outdoor stairs and P3 could see the VA but the VA blocked P3’s view of the SP. P3 stated the VA moved towards the SP and was reaching for the SP’s cell phone when both of their hands began “flying.” At this time, P3 heard the VA say, “You hit me,” and the SP respond, “Well you grabbed my phone.” The VA had the SP’s cell phone and threw it into the bushes before s/he walked away. · P4 had arrived, but was still inside his/her car on the street, when s/he saw the VA and the SP “tussling.” P4 heard the VA yell that the SP hit him/her and broke his/her eyeglasses. The SP responded that the VA should not have thrown his/her cell phone. P4 parked his/her car, retrieved the SP’s cell phone, and followed the VA down the sidewalk then P3 followed the VA around the block to the back of the house. P3 talked with the VA in an attempt to calm him/her and then helped the VA find an old pair of eyeglasses. · P2 stated that s/he did not see the SP hit the VA and believed the VA’s eyeglasses were broken while the VA was reaching for the SP’s cell phone. · P3 asked the VA again if the SP had hit him/her. The VA said, “Yes,” and made a motion that resembled a slap and not a punch. P3 did not see the SP hit the VA but saw “tussling” and their arms moving. P3 did not see any marks on the VA’s face. · Once the incident was over and the VA was calm, P4 asked the VA if s/he was sure the SP hit him/her and the VA replied, “Yes I am 100% sure s/he hit me.” The VA described it as a push to the face that knocked the glasses off his/her face. P4 was unsure if the eyeglasses broke when they fell or if they were stepped on and broke. · P2, P3, and P4 believe that the SP escalated the incident by engaging in a power struggle with the VA. P1, P2, P3, P4, and the SP received training on the VA’s Coordinated Services and Support Plan Addendum and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: On October 27, 2022, the SP and the VA were in a verbal and physical altercation in which the VA’s glasses were broken. Although the VA said that the SP hit him/her, given that neither P2, P3, nor P4 saw the SP hit the VA, that the VA had no marks on his/her face after the incident, and that the VA told this investigator that s/he was unsure if the SP intended to hit the VA’s face, there was not a preponderance of the evidence whether the SP’s contact with the VA was anything other than accidental during the incident. 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, and could not determine that policies and procedures were adequate and followed. The SP was removed from the VA’s home and received Positive Supports Rule re-training. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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