|
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: 1068856-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at a vulnerable adult (VA), walked away when the VA fell on the floor and would not assist the VA, and grabbed the VA by the neck and shirt and forced the VA to his/her bedroom. Date of Incident(s): Prior to January 13, 2023 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); 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 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. Pertinent information for this investigation was obtained remotely, including documentation from the facility and through five interviews conducted with a management staff person (P1), two facility staff persons (P2 and P3) and a community person (CP). According to P1, the VA was primarily non-verbal, only answered yes/no questions and was unable to provide information in an interview. However, the VA provided some information to P3 so that information was included below. The facility provided residential services to the VA and three other clients. The VA’s Support Plan showed that the VA was “compassionate, caring, patient” and “helpful.” The VA’s Support Plan Addendum stated that the VA had a moderate developmental disability and engaged in behavioral concerns, some of which included physical and verbal aggression toward others. As a result, staff persons were trained to talk to the VA “about alternative ways [s/he] could have dealt with the situation.” The plan further showed that staff persons were to “lead [the VA] by the hand away from the area or the person if necessary” when the VA was attempting to be physically aggressive toward another person. Also, the plan showed that the VA had “impulse control disorder.” The CP provided the following information to this investigator: · Because the VA had some behavioral concerns, the facility contracted the CP to come in and talk to various staff persons to see how they interacted with the VA to see if alternative programming could be considered to lessen the amount of physical aggression the VA exhibited to others. · On January 13, 2023, the CP contacted the SP by phone. The SP told the CP that when the VA came out of his/her bedroom, the VA would “try to hit me.” As a result of that, the SP had to “grab” the VA by his/her shirt or “neck” and bring the VA back to his/her bedroom. · The SP also told the CP about an incident in which the VA fell on the floor and when that happened, the SP said “absolutely not” when the VA motioned to the SP that s/he needed assistance. The SP did not tell the CP how long the VA remained on the floor. · The CP described the SP’s tone of voice as being “elevated” and said that although the SP was not “yelling on the phone,” the SP was “talking very fast” and “was very stern.” When the CP asked the SP if that was how the SP talked to the VA, the SP said, “Yes, [s/he] needs to understand.” P1 stated that no other clients or staff brought concerns forward regarding the SP’s interactions with them, but the SP typically did not work with other staff persons. P2 stated that the SP and the VA “clashed,” and that “they just didn’t really get along that well” with one another. When P2, who worked with the SP a couple of times, was asked to describe the SP’s tone of voice with a “10” being that the SP talked very loudly to the VA and a “1” being that s/he talked quietly to the VA, P2 said that the SP was a “7.” P2 said that the SP talked that way to the VA for “awhile.” The SP also told P2 that s/he “hates” the VA and “ignores” the VA, but P2 did not have specific information related to that. P3 said that s/he saw the VA “take down other staff [persons]” just to get to the SP so the VA could hit the SP and when that happened, the SP verbally redirected the VA. On an unspecified date, the VA told P3 that the SP was “mean” to the VA and “hurts” the VA, but the VA did not provided specific information. As a result, P3 decided to talk privately to the VA. When that happened, the VA stated that s/he “hated” the SP, but the VA also said that it was “funny” and that the VA laughed when the VA hit the SP. When P3 asked the VA if the SP “was ever mean” to the VA, the VA started “crying” and told P3 about an incident in which the VA fell on the floor and the SP would not assist the VA. The VA also told P3 about an incident in which the SP tried to hold the VA on his/her bed but the VA did not provide details and told P3 that the VA tried to “bite” the SP. (A review of the VA’s case notes from October 2022 to February 2023, did not show a time that the VA tried to bite the SP.) P3 said that the other clients had not brought concerns forward to P3 about the SP and that P3 had not observed any bruising or red marks on the VA. When the SP was no longer employed at the facility, the VA was a “completely different person” and was “happy.” The facility’s Internal Review provided the following information: · When the SP talked to the CP on the phone, the SP “admitted to several types of abuse,” such as “forcefully” moving the VA from one place to another and “not helping” the VA when the VA was on the floor. · When the facility contacted the SP regarding the allegations, the SP “only denied calling [the VA] a monster.” The SP provided the following information to this investigator: · When the SP typically worked with the VA, the VA was physically aggressive toward the SP. When that happened, the SP tried to verbally redirect the VA, but that was often times not successful. When the VA was physically aggressive, the SP took the VA’s arm or shirt and “put” the VA in his/her bedroom. The SP stated that s/he would “nicely” tell the VA that s/he was doing something and that the VA needed to return to his/her bedroom. The SP denied forcing the VA to move from one place to another. · When the SP was asked about the incident in which the VA fell, the SP said that before s/he began mopping floors, s/he told the VA to stay in his/her bedroom, but the VA did not listen to that. When the VA came out of his/her bedroom, the VA fell on the floor and the SP did not assist the VA for a “few seconds,” but then the SP assisted the VA. · When the SP was asked to describe his/her tone with the VA on a scale of one to ten, the SP said that his/her tone was “a four.” The SP described his/her tone of voice as being “real strong.” When the SP was asked to elaborate on that, s/he stated that s/he told the VA, “Stop hitting me, I don’t hit you,” and “I don’t like it when you hit me.” The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to January 13, 2023. Relevant Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection-related rights include being treated with courtesy and respect. Conclusion: On January 13, 2023, the CP contacted the SP on the phone. During the discussion, the SP stated that when the VA was physically aggressive, the SP “grabbed” the VA by his/her shirt and/or “neck” to bring the VA back to his/her bedroom. The SP also told the CP that the SP did not provide assistance to the VA when the VA fell on the floor. Concerns were also raised that the SP yelled at the VA but there were no details regarding this other than that the SP had a “stern” voice at times. Regarding neglect: The SP acknowledged that s/he did not assist the VA when the VA fell on the floor, but stated it was only a matter of seconds until s/he assisted the VA. When P3 asked the VA, the VA only said that the SP did not help the VA and some time the VA tried to bite the SP. The VA did not provide information regarding whether or not the SP helped the VA in a timely manner. Given this, there was not a preponderance of the evidence whether the SP failed 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). Regarding physical abuse: According to the SP, the VA was very physically aggressive toward the SP and when that happened, the SP verbally redirected the VA. According to P2, a personality conflict existed between the VA and the SP. P3 stated that the VA was physically aggressive toward the SP and when that happened, the SP verbally redirected the VA. However, the SP told the CP that s/he “grabbed” the VA by his/her shirt or “neck.” The SP told this investigator that when the VA was physically aggressive, the SP would take the VA’s arm or shirt and “put” the VA in his/her bedroom, but did not “force” the VA to go there and told the VA “nicely” to go to his/her bedroom. The VA did not have any injury, bruises, or marks. “Grabbing” the VA to “put” the VA in his/her room, even if the SP did not “force” the VA to do so, was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that there were no witnesses or additional information, that the VA was not injured, and that the SP stated that s/he attempted to verbally redirect the VA, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or could be reasonable expected to cause the VA physical pain or emotional distress. 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 determined that although policies and procedures were adequate, they were not followed by the SP. The facility provided additional training to staff persons and the SP was no longer at the facility. Action Taken by Department of Human Services, Office of Inspector General: The facility took immediate corrective action so a Correction Order was not issued for the violation outlined in this report.
|
