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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: 1081784-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 staff person (SP) placed their hand over a vulnerable adult’s (VA) mouth, roughly placed the VA’s legs on the couch, and spoke to the vulnerable adult in a demeaning way. Date of Incident(s): November 19, 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 December 12, 2022; from documentation at the facility; law enforcement records; and through seven interviews conducted with a facility staff persons (P1), facility management persons (P2 and P3), the SP, the VA’s case manager (CM), and the VA’s guardians (G1 and G2). Attempts were made to contact and interview another staff person (P4), but P4 did not respond to the requests. G1 requested that the VA not be interviewed regarding this incident because the VA would not be able to provide accurate information due to his/her brain injury. According to the facility’s Admission and Data Form, the VA had a good sense of humor and enjoyed outings with his/her family that included restaurants and parks. The VA was diagnosed with a brain injury and a major neurocognitive disorder, was blind, and had physical difficulties. The VA required two staff persons for 16 hours of each day. The VA showered four times each week with a specific schedule of Monday mornings, Wednesday evenings, Friday mornings, and Sunday evenings. The VA’s Individual Abuse Protection Plan provided the following information: · Staff persons verbally prompted the VA before performing personal cares so that the VA may be prepared. The VA was able to verbally communicate with staff persons if s/he was not ready or to ask any questions. · The VA was able to advocate for him/herself. If the VA did not like how someone spoke to him/her, the VA could express that s/he did not want to see or speak with them again. If someone was being verbally and/or physically aggressive toward the VA, the VA was able to speak up or shout. · If staff persons saw the VA being a target of verbal and/or physical abuse, staff persons were to stop the abuse by removing the abuser or assisting the VA in moving. Staff persons were trained on de-escalation techniques. The facility’s General Events Report stated that on November 19, 2022, P1 observed the SP standing over the VA. The SP was telling the VA to be quiet and pressing his/her hand “hard” over the VA’s mouth, causing the VA’s eyes to “bulge.” When the SP took his/her hand away from the VA’s mouth, the VA had a red mark on his/her upper cheeks. G1 and G2 provided the following consistent information to this investigator and law enforcement: · On November 20, 2022, P1 told G2 s/he did not like the way the SP treated the VA. P1 said that the previous day, November 19, 2022, s/he saw the SP place his/her hand over the VA’s mouth and was “scolding” him/her. The VA’s eyes “bulged out of their sockets” due to the pressure the SP applied to the VA’s face. · On November 23, 2022, G1 called the facility and spoke with P1. P1 told G1 s/he had been in the bathroom and when s/he came out, saw the SP with his/her hand over the VA’s mouth and the VA’s eyes were “bulging” out. · After the incident on November 19, 2022, the VA was less happy and less vocal than before the incident. · On November 24, 2022, G1 contacted law enforcement. The CM stated the VA was verbal but needed assistance with most things. The CM did not speak to the VA regarding the incident but G1 and G2 stated since the incident the VA seemed down and was not laughing and joking. The CM also stated the VA had a medicine change in December that could affect his/her behavior. The CM did not recall G1 mentioning concerns regarding the SP in the past. P1 provided the following information to this investigator and law enforcement: · On Saturday, November 19, 2022, P1 was in the kitchen and the SP and the VA were in the living room. P1 heard the VA say s/he wanted a shower that evening and the SP told the VA, “No,” and that the VA would shower the following day. P1 stated this continued and the SP began to speak to the VA in a “demeaning tone” and was “harassing” the VA. P1 could not remember the exact words the SP used, but the SP was repeatedly telling the VA to “be quiet.” · P1 was cleaning dishes in the kitchen and then walked to the bathroom to wash his/her hands. When P1 came out of the bathroom, s/he heard the SP yell to the VA, “Shut up,” and saw the VA lying on the couch and the SP had his/her hand over the VA’s mouth. The SP “was applying so much pressure in a downward motion that [the VA’s] eyeballs were popping out of [the VA’s] head.” When the SP heard P1 enter the room, the SP backed away from the VA and walked away. · P1 was unsure how long the SP had their hand over the VA’s mouth but stated it was long enough to leave a mark. P1 checked the VA for injuries and observed “two indentations” on either side of his/her face and a “small red mark” on the VA’s upper lip. P1 did not take a picture of the mark on the VA’s face because s/he did not want to further upset the SP. · On another unknown occasion in November 2022, the VA was lying on the couch and wanted to get up. The VA swung his/her legs off the couch and the SP picked up the VA’s legs and “threw” them back on the couch. P1 texted P2 about the incident. · P1 said that the SP was “domineering and argumentative” and when tired and exhausted, was “mean” to the VA and other staff persons. P2 provided the following information: · The VA had a specific showering schedule and two staff persons were required to assist the VA with showering. The staff persons asked the VA about showering and the VA rarely refused. The VA would not ask for a shower. · Whenever P2 observed the SP and the VA together, the VA was cheerful and joked with the SP and the SP interacted with the VA in a therapeutic manner. · P2 was not working November 19, 2022, but received a text message from P1 stating that s/he had seen the SP place his/her hand over the VA’s mouth. P2 instructed P1 to complete a T-Log. P2 said s/he had no reason not to believe P1 was being truthful. · On November 21, 2022, when P2 asked the SP about the incident, the SP denied placing their hand over the VA’s mouth. · P2 asked the VA about the incident and the VA said s/he did not remember the SP putting his/her hand on the VA’s face. · P2 believed there were personal conflicts between the SP and other staff persons due to a language barrier. P2 had received previous concerns about the SP from staff persons, including an incident when P3 told P2 that the SP had been rough with the VA’s legs while putting them on the couch. The facility’s T-Logs for the VA provided the following information: · On November 19, 2022, no T-Log entry was created. · On November 20, 2022, a T-Log entry created by P1 included the VA was given a shower, was agreeable and in a good mood. · A second log on November 20, 2022, stated that the VA was lying on his/her back on the couch and had been coughing and his/her face was “very red.” This episode “scared” the VA and s/he was withdrawn afterwards. · Subsequent T-Logs dated November 23, 2022, December 2, 2022, December 6, 2022, indicated the VA’s mood was “great.” P3 did not have concerns regarding the SP prior to the incident but spoke with other staff persons about the SP. P4 told P3 there was an incident where the SP was being “short” with the VA when providing cares and P4 told the SP that s/he would finish with the VA so the SP could take a break. P3 spoke with the SP about the incident on November 19, 2022, and the SP denied the incident and stated staff were “lying.” The SP provided the following information: · On the evening of November 19, 2022, the SP asked the VA if s/he wanted to shower and the VA said, “Yes.” At that time, the SP was eating dinner in a chair near the couch. The SP told the VA that when s/he was finished, s/he assist the VA to shower. P1 was eating dinner at the dining room table and P1’s back was to the SP. When the SP was done eating, the VA no longer wanted a shower. The VA was not upset. · The SP denied placing his/her hand over the VA’s mouth. The SP denied forcibly putting the VA’s legs on the couch. The SP stated the VA’s legs were heavy and one needed to be strong to carry the legs. · The SP denied being verbally aggressive toward the VA. · The SP had worked with the VA for approximately five years and “loved” the VA. The VA was friendly to the SP and the SP was friendly to the VA. The LEO report stated that during the SP’s interview with the LEO, the SP became agitated and defensive when speaking with the LEO. The SP stated P1 “was lying” and s/he never physically placed his/her hand over the VA’s mouth. Law enforcement closed their case without any further action. Facility documentation showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. The SP was trained on the VA’s Coordinated Services and Supports Plan and Individual Abuse Prevention Plan. The SP was most recently trained on the Reporting of Maltreatment of Vulnerable Adults Act on August 29, 2022. Conclusion: According to P1, on November 19, 2022, the VA wanted a shower and the SP told the VA to wait until s/he had finished dinner and an exchange began between the SP and the VA. At some point, P1 walked into the living and saw the SP holding his/her hand over the VA’s mouth with enough force to cause the VA’s eyes to bulge. P1 said that s/he then saw “two indentations” on either side of the VA’s face and a “small red mark” on the VA’s upper lip. P1 also stated that on an unknown occasion, the SP roughly handled the VA’s legs and spoke to the VA in a demeaning way. The SP denied placing his/her hand over the VA’s mouth, moving the VA’s legs in a forcible way, or using demeaning language directed toward the VA. Given the conflicting information provided by P1 and the SP, that the VA told P2 that s/he did not remember the incident, and there was no information to support or refute either P1’s or the SP’s account of the incident, there was not a preponderance of evidence whether the SP’s conduct produced or reasonably expected to produce physical pain or injury or emotional distress. It was not determined whether 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 and 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.) Action Taken by Facility: The facility completed an internal review, and determined that policies and procedures were adequate but not followed. P2 has received additional job duty training and retrained on the Vulnerable Adults Act and Maltreatment of Minors. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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