|
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: 1071834-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Anna Parkin 651-431-6567 Suspected Maltreatment Reported: Multiple concerns were reported, including multiple occasions where a staff person (SP) did not change or reposition a vulnerable adult (VA) during the nights; the SP said inappropriate things to the VA; and while providing perineal cares (peri-cares), the SP touched the VA’s genitals for approximately 20 minutes. Date of Incident(s): Ongoing between July 13 and August 26, 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 (2); and subdivision 2, paragraph (c); 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: 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. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. 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 September 6, 2022; from documentation at the facility; and through seven interviews conducted with two supervisory staff persons (P1 and P2), three facility staff persons (P3-P5 and the SP), and the VA. The VA was diagnosed with Guillain-Barre syndrome and chronic obstructive pulmonary disease. According to the VA’s Risk Assessment Detail, the VA did not present a risk for emotional abuse and sexual abuse. According to the VA’s ISSA Assessment Detail, the VA was “fully mobile” and able to fully participate in all activities. The VA was not subject to guardianship. There was no information in the VA’s plans that required staff persons to check on the VA overnight. The VA was at transitional care until approximately July 13, 2022, and was dependent on a wheelchair for mobility since returning to the facility. The VA had a bell in his/her bedroom that s/he rang when s/he needed staff person’s assistance. According to the VA’s Medication Administration Record, staff persons repositioned the VA every two hours and provided skin care. This included changing the VA’s adult undergarment and bed pads. From August 10 to 28, 2022 (the day the documentation was requested), staff persons initialed that the cares were completed with the exception of four times. Staff persons completed the VA’s peri-cares twice daily on non-shower days and once on shower days. During that same period, there were staff persons initials all but two times. According to the staff schedule, the SP and P3 generally worked the overnight shift (10 p.m. until 8 a.m.), which were awake shifts and some days worked at the same time, while other days were single staffed. P2 generally worked during the day shift and P4 and P5 generally worked the afternoon shift. The VA provided the following information: · For approximately two months prior to the investigation, the SP did not reposition the VA every two hours, especially from 12 midnight until 6 a.m. “Sometimes” the VA lay in bed until approximately 8:30 a.m. waiting for the SP to clean the VA. On two unknown dates, the VA was awake the whole night and the SP did not reposition the VA at all. On more than two occasions, the VA rang for the SP to come into his/her bedroom but the SP did not respond. · On August 23, 2022, the SP and P1 were working. The VA reminded the SP to reposition the VA every two hours. The SP did not like the VA’s comment, was “sarcastic,” and the VA felt “bullied.” The VA told P1 about it and the SP told the VA s/he was lying. · On approximately five previous occasions, when the SP did the VA’s peri-cares, it felt “strange” and the SP was “not gentle” while touching the VA’s genitals. For approximately 20 minutes, the SP wiped the VA’s genitals and buttocks and put ointment and powder on the VA’s buttocks. The VA asked the SP to not “twerk” his/her genitals. · On previous occasions, the SP asked the VA if s/he “pissed” and “pooped” him/herself. The VA did not like how the SP phrased the questions to the VA. Other staff persons did not need to ask the VA as s/he told them if s/he had incontinence issues. · The SP also restricted the VA’s amount of water s/he drank at night possibly because the SP did not want to change the VA’s adult undergarments. The SP took the VA’s water and placed it on a table where the VA could not reach it. On a previous occasion, the VA asked the SP to move the water closer and the SP “put up an argument.” The SP had an accent and when s/he spoke fast the VA was not able to understand the SP so the VA was not able to provide information on what the SP said. The VA told P1 about the water but it did not improve. P1 provided the following information: · On a previous unknown date, the VA told P1 to tell the SP to be “calm” while doing peri-cares. That night, the SP started his/her shift at 4 p.m. and brought the VA into the bathroom to complete his/her peri-cares. P1 watched and “made a joke” about how long the SP took to complete the peri-cares. P1 watched the SP complete the VA’s peri-care an additional four times after that and reminded the SP to be “quick” in providing the cares. · The VA also told P1 that on one occasion, the SP began the VA’s peri-cares, left to assist another client, then return to finish the VA’s cares. The VA was “not happy” about it. The VA also told P1 that the SP was not polite in how s/he talked to the VA about incontinence during the night. · Approximately one to two weeks prior to August 23, 2022, the VA told P1 that the SP restricted the VA’s water at night. P1 discussed it with the SP and reminded the SP that the VA needs water near his/her bed at night as the VA had a “dry mouth.” Later on, P1 discussed this with the VA and the VA said the SP was “better” about the water situation. · On August 23, 2022, when P1 arrived at the facility, the VA appeared “upset” and told P1 that the prior night, the SP used a flat sheet on the VA’s bedroom instead of a fitted sheet. The VA and the SP “exchanged words” including the VA saying “damn it” and it made the SP “angry.” The VA could not sleep well that night and did not remember the SP reposition him/her throughout the night or change his/her adult undergarment. P1 told the VA s/he would discuss the incident with the SP, who was with another client at the time. · A few minutes later, P1 heard the SP say to the VA, “Why did you lie behind my back when I am in the house?” P1 told the SP, “Stop.” The SP was upset, stopped talking to the VA, and told P1 that what the VA said did not happen. P1 and the SP went into the kitchen and P1 gave the SP the option to leave the facility, which the SP did. · Later that day, at approximately 4 p.m., P1 went to check on the VA. The VA told P1 s/he was worried about the SP returning to work. P1 called P2 and they agreed to take the SP off the schedule. · P1 stated s/he had never seen the SP angry with clients before and did not have concerns with the SP’s interactions with clients. The VA advocated for staff persons and when s/he was “wrong” was quick to apologize. The VA did not try to get staff persons in trouble, it was his/her way of building trust due to how vulnerable the VA was. P2 stated that during the internal investigation, the VA told P2 that the SP touched the VA’s genitals inappropriately. P2 asked if the VA felt it was sexual, and the VA responded that s/he did. The VA also told P2 that the VA did not change the VA’s adult undergarments or reposition the VA. The VA made it sound like it was ongoing and not just on August 23, 2022. The VA was “good” at self-advocating and did not have a history of exaggerating. P2 did not have previous concerns with the SP’s interactions with clients. P3 stated s/he worked multiple overnight shifts with the SP prior to this investigation. Sometimes P3 repositioned the VA; sometimes the SP repositioned the VA; and other times they both repositioned the VA during the night. P3 did not witness the SP say anything inappropriate to the VA. When P3 assisted the VA with his/her peri-cares, it sometimes took up to 45 minutes. P3 did not have concerns with the SP’s interactions with the clients, including the VA. The VA was accurate about reporting incidents and the VA did not previously discuss any concerns about the SP to P3. P4 was not aware of the allegations because s/he was on vacation at the time of the incidents. P4 did not have concerns with the SP and had a “good impression” of the SP. The VA had not discussed any concerns with P4 but had a “good ability” to provide information. P5 stated that a few weeks prior to his/her interview with this investigator, the VA told P5 that the VA and the SP had a “misunderstanding” and that the VA did not want to talk about it. The VA appeared “fine” when talking to P5 about it. When P5 worked occasionally with the SP, the SP repositioned the VA and assisted the VA with bathroom needs. P5 denied hearing the SP discuss “pissing and pooping” with the VA. When P5 assisted the VA with clean up after a bowel movement, it took P5 approximately 40 minutes. The SP stated s/he repositioned the VA and checked his/her adult undergarments every two hours during the night and asked the VA’s permission prior to checking. Most of the time if the VA had a bowel movement, s/he called for the SP to come assist so the SP did not need to ask him/her. The SP denied asking the VA if s/he “pissed or pooped” on him/herself. While the SP provided peri-cares to the VA early on, the VA told the SP to be gentle and “go slow.” When the SP provided peri-cares to the VA, it usually took around 10 to 15 minutes and the SP did what P1 trained him/her to do. The SP denied restricting the VA’s water during the night. Facility documentation showed staff persons, including the SP, were trained on facility policies and on the reporting of Vulnerable Adults Act prior to the incident. Conclusion: Consistent information was provided that the VA required additional cares since s/he moved back to the facility, including assistance with urinating and bowel movements while in bed and repositioning very two hours. The VA stated that when the SP worked overnights, s/he did not reposition the VA every two hours; restricted the VA’s water at night; did not like the way the SP spoke to the VA, including asking if s/he pissed and pooped him/herself; and when the SP did the VA’s peri-cares, it felt “strange” and it was “not gentle” while the SP wiped the VA’s genitals and buttocks and put ointment and powder on the VA’s buttocks. Although P1-P5 did not have concerns with the VA’s ability to provide information, given that P1-P5 also did not have concerns with the SP’s interactions with the VA; that the SP denied the allegations; and that there was no additional information to support or refute the VA’s information, there was not a preponderance of the evidence whether the SP failed to reposition the VA every two hours; restricted the VA’s water at night; spoke to the VA in an inappropriate manner; or touched the VA’s genitals or buttocks with sexual intent. It was not determined whether emotional abuse, sexual abuse, or neglect 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: 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. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. 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 but were not able to determine if they were followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
|
