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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: 1068334-H_CRS (Home and Community-Based Services-Community Residential Setting) 1068333-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon/Danielle Morrison Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) and a staff person (SP) got into a physical altercation after the SP asked the VA to turn off the lights and the TV. Date of Incident(s): November 28, 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): 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 December 29, 2022; from documentation at the facility; and through five interviews conducted with two staff persons (SP and P1), two supervisory staff persons (P2 and P3), and the VA’s guardian (G). The VA declined to speak with investigators but provided information to law enforcement and the facility and that information is included below. The VA was diagnosed with fetal alcohol syndrome, bi-polar disorder, posttraumatic stress disorder, and mild developmental disability. The VA liked to crochet, go on walks, clean, read, and spend time with family and friends. The facility was a split level house. At the top of the stairs directly ahead was the kitchen and to the left was the first living room. In the far left corner was a dining room and through it was a second living room. Information obtained showed that on November 28, 2022, the day of the incident, the SP and P1 began work at 10:30 p.m. The VA provided the following information to a law enforcement officer (LEO) and in the Internal Review: · On November 28, 2022, around 10:30 p.m. the VA was upstairs and made food. The VA sat at the kitchen table and the SP was in the living room. The SP “yelled” at the VA to turn the TV and lights off to allow the other residents to sleep. The VA asked, “Why?” since the SP was in the room closest to the TV. The SP came over to the VA, put his/her finger in the VA’s face, and repeated his/her requested to the VA. The VA raised his/her voice and attempted to leave the situation by walking away. The SP followed the VA and continued to ask the VA to turn off the lights and TV. · The VA said that the SP started the physical interaction by yelling at the VA. The SP got close to the VA, put his/her hands on the VA’s arm, and the VA and the SP began shoving one another. The SP started “fuzzling” with the VA, which, the VA said, was “rough housing.” The SP and VA “fought” in the living room and dining room area. · At some point, the VA crossed his/her arms to create space between him/her and the SP and “accidently scratched [the SP] on the right side of [the SP’s] neck.” The VA pushed the SP away and threw the SP’s phone to “distract” the SP. The VA then went downstairs to get away from the situation. · P1 asked the VA to go on a van ride to calm. The VA then came upstairs and was approached by the SP. The SP again asked the VA to turn off the lights and the TV. The VA again brought “[his/her] arms up to cross then [sic], accidently scratch[ing] [the SP] on the left side of [the SP’s] neck.” The VA said that due to the length of his/her nails the scratches [the VA gave the SP] caused bruising [on the SP]. At some point, the SP bit the VA on the right inside forearm, but did not recall at what point this occurred. The VA denied that s/he grabbed the SP by the neck, but said s/he grabbed the SP by the shoulders. The VA got a “small scratch” on his/her right forearm area from the SP during the incident. The SP fell during the incident, landed on the dining room table, which knocked over a bowl and a coffee mug. The VA then agreed to go on the van ride with P1. · When the VA and P1 returned, the LEO was at the facility. The VA spoke to the LEO and photos were taken of his/her injuries. The Internal Review stated that the VA asked another staff person (P4) to take photos of the bite mark and scratches from the SP. (Note: P4 noticed a “very small scratch on [the VA’s] right hand” that the VA said was from the SP. P4did not take a photo of the scratch as “it was very small” and did not see any bite marks on the VA.) The SP and P1 provided the following information to investigators and to the facility’s Internal Review: · On November 28, 2022, the SP and P1 both began work at 10:30 p.m. At that time, the VA was in a “happy mood,” on his/her phone, and started preparing his/her dinner around 10:45 p.m. while the SP was in the first living room and P1 was in the second living room. At this time, the VA also turned up the volume on the TV and turned all the lights on in the living room, which prevented another resident from going to bed. (Note: Due to his/her disability, the resident was not able to provide information for this report.) The VA was at the kitchen table with an art project and asked the resident to join him/her. The SP asked the VA “politely” in a “calm” manner to “please turn volume down” on the TV or when s/he was done eating to “take art stuff to other parts of the house” so the other resident would be able to go to sleep. · The VA was verbally disrespectful towards the SP and said, “Why don’t you do your fucking job?” The SP asked the VA to calm and then the VA threw a mug, water bottle, and footstool towards the SP. The VA “lunged” at the SP and the VA fell on the couch. The VA rose, pushed the SP against a wall, placed his/her hands around the SP’s neck and “squeezed.” P1 came into the first living room and called P3 for guidance. (Note: P3 said s/he was told by P1 the VA was “squeezing” the SP’s throat. During the call P3 heard the SP “screaming” s/he was being choked and for the VA to let him/her go. P3 told P1 to call the police.) P1 asked the VA to calm and release the SP but the VA continued to choke the SP. The SP raised his/her hands in between the VA’s arms and attempted to create space between them. The SP then grasped the VA’s wrists and pulled them away. In the Internal Review the SP said s/he crossed his/her arms in front of his/her face and “brought then [sic] down pushing [the VA’s] arms down and to [his/her] sides.” The VA pushed the SP around the upstairs area and almost pushed down the stairs. The VA threw the SP’s phone and bag away from the SP. The VA pushed and threw various items at the SP which included a coffee mug, a water bottle, and a chair. · P1 continued to ask the VA to go outside to go on a van ride to calm the situation. The VA agreed and went outside. P1 encouraged the SP to phone the police and the SP called 9-1-1. P1 went outside and then P1 and the VA left in the van. P1 drove the VA around for about ten minutes during which they did not talk. When P1 and the VA returned to the facility, law enforcement was there. The VA spoke with the LEO and said the SP hit him/her first. P1 said that s/he saw the VA hit the SP and did not see the SP hit the VA at any time. After the VA talked with the LEO s/he went to bed. The following morning, P1 heard the VA say that s/he “beat [the SP] the fuck up” and “bragged” about the situation the previous night. · P1 did not see the SP bite or push the VA. The SP denied hitting, biting, and/or scratching the VA during the incident. The SP and P1 said the SP followed the facility training for the situation. P3 provided the following information: · On November 29, 2022, in the morning P3 went to the facility and met with the VA. The VA “bragged” about how s/he “beat the hell out of [the SP]” and how the VA “almost choked [the SP] to death.” The VA told P3 s/he was trying to help the resident and the SP asked the VA to not get involved. The VA said s/he “got mad and threw [the SP’s] phone.” During the conversation the VA did not say anything about the SP pushing or biting the VA to P3. P3 did not see any marks on the VA. · P3 said that the VA had recently gotten off of probation and was “scared of getting in trouble.” The VA had a history of changing stories, including to police, from what actually happened. In the past, the VA made threatening comments towards and physically gone after staff persons. P2 said s/he was not working during the incident and did not have any additional knowledge. P2 reviewed the incident details with P3 and saw photos of the SP’s neck. The photos showed marks on the left and right sides of the SP’s neck that were reported to have been caused by the VA. The G provided the following information: · The VA will “outright manipulate the system.” The VA will “make things up” such as “having 13 kids” when s/he did not and having unconfirmed medical conditions. The G did not believe the VA shared accurate information and in the past accused staff of things that did not happen such as taking his/her food, being mistreated, and “abused” by staff persons. The VA recently reported that s/he “was being abused, which [s/he] was not.” The G believed staff persons did not mistreat the VA, but the VA told others that they did. P3 did a “phenomenal job” with the VA, and it was a “good” and “safe” setting for the VA. · The VA had a history of physical aggression towards staff persons and other residents and made statements that s/he would “beat people up and stand up for [his/her] rights and if they need it [s/he] has no problem getting physical.” The VA was “proud of physical assaults.” The VA’s County Coordinated Service and Support Plan stated that the VA needed assistance to manage “physical aggression, verbal aggression” along with “law breaking and temper outbursts.” The facility staff persons were to provide emotional support and a space for the VA to calm. The VA’s Individual Abuse Prevention Plan stated the VA could “miss interpret [sic] things others say and falsely accuse others of acts against [him/her].” The VA “may resort to physical and verbal aggression when [s/he] is upset. [S/he] may become confrontational, swear, yell, threaten others, hit[,] scratch[,] or grab another person.” The VA’s Behavior Support Plan when Psychotropic Medication(s) are prescribed stated the VA “misrepresents the truth to people. [The VA] will make up false tragedies, [medical conditions], children, and other things that have not actually occurred.” The facility documentation showed that the SP and P1-P3 received training specific on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information was consistent that on November 28, 2022, about 10:45 p.m., the VA was making dinner and the SP asked the VA to turn off/down the TV volume and turn off lights so that another resident could sleep. The VA became upset and raised his/her voice, pushed the SP, threw the SP’s phone, and made contact with the SP’s neck. Eventually the VA calmed and P1 took the VA on a van ride. The VA said that the SP started the incident by yelling at the VA and that s/he sustained scratches and a bite mark from the SP. However, given that P1 and the SP provided consistent information that the SP did not hit, push, or bite the VA during the incident; that each stated the VA was physically aggressive towards the SP; and that the VA had a history of providing inaccurate information, there was not a preponderance of the evidence whether all of the SP’s interactions were therapeutic conduct or whether the VA sustained the injuries by any means other than accidental. 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 Program: The facility conducted an internal review and found the policies and procedures were adequate and followed by the SP. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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