|
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: 1072124-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that on several occasions, a staff person (SP) yelled at, threatened, and called a vulnerable adult (VA) names. On one occasion, the SP also spit on the VA and shoved the VA. Date of Incident(s): Prior to January 2023 and ongoing 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 February 2, 2023; from documentation at the facility and law enforcement records; and through five interviews conducted with three facility staff persons (SP, P1, P2), the VA’s case manager, and the VA. The facility was a two-level home with an open concept living area on the first floor. The individual’s bedrooms were located on the second level. The VA was diagnosed with post-traumatic stress disorder, depression, anxiety, and borderline personality disorder. The VA enjoyed spending time with friends and family. The MnChoices Support Plan indicated that the VA may become physically aggressive and had difficulty regulating his/her emotions. The VA was easily agitated and suffered from daily anxiety. The Individual Crisis Plan indicated that the VA might display verbal or physical aggression towards others. Staff persons encouraged the VA to take a break from the situation and separated the VA from any others involved in the situation. Later, staff persons facilitated a conversation with the VA and those involved to come up with positive strategies for the future. The VA provided the following information: · On the date of the first incident (determined to be December 6, 2022), the VA had purchased some groceries on his/her own. The SP came in the facility and did not wash his/her hands, went into the refrigerator, and started touching items. The VA asked if the SP could wash his/her hands and told the SP that the food was the VA’s so the SP did not need to do an inventory. The VA got in-between the SP and the refrigerator but did not touch the SP and said “do not touch my stuff.” The SP then started pushing the VA and called law enforcement to say the VA was preventing the SP from walking around. Law enforcement told the VA and the SP to stay away from each other. · A couple weeks later (determined to be January 3, 2023), the SP came to the facility. To avoid any arguments, the VA grabbed his/her things, “ignored” the SP, and went to the VA’s bedroom. The SP then started beating on the VA’s bedroom door. The VA did not answer and then the SP tried to force the VA’s door open, so the VA got up and put his/her body weight on it. The SP said the oven was on and the VA had forgot to turn it off. The SP screamed at the VA and yelled to “get your ass down here” and turn off the oven. The SP would not leave the VA alone, so the VA called law enforcement. · During a third incident (determined to be January 7, 2023), the VA did not remember what the argument was about but the SP was upstairs yelling at the VA. The SP said the VA was spitting on the SP. The VA said that s/he was not spitting and that s/he was talking while the SP was yelling. The SP then spit on the VA. · The SP triggered the VA’s post-traumatic stress disorder when the SP screamed at the VA. P1 and P2 provided the following information: · P1 said the VA did not like supervisory staff persons. Many times, staff persons started working at the facility and then experienced verbal abuse from the VA and wanted to work at a different facility or quit. The VA was not happy at the facility and sent threatening texts to P1. P1 told the VA that s/he would not respond to texts unless they were respectful. · P2 said that the VA was at times aggressive and could be very angry and violent. When the VA got upset, staff persons kept quiet, and the VA calmed down. Many staff persons did not want to work at the facility because the VA was aggressive. The SP provided the following information through an interview with this investigator and through the Incident/Injury/Crisis Report Forms: · On December 6, 2022, the SP arrived at the facility and walked into the kitchen. The VA jumped up and was very aggressive and loud. When the SP went to the fridge to look at the amount of food the facility had, the VA blocked the SP from going into the kitchen and told the SP not to go into the fridge as all the food in the fridge was the VA’s. The VA swore and yelled at the SP. · On January 3, 2023, the VA made a pizza and took it to his/her bedroom. The VA had left the oven on, so the SP went to the VA’s bedroom and asked the VA why s/he left the oven on and why s/he was eating pizza in his/her bedroom. The VA yelled at the SP that s/he could do whatever s/he wanted and swore at the SP. The SP asked the VA not to swear and the VA said s/he could talk to the SP anyway the VA wanted. Law enforcement arrived later to talk with the SP and the VA. · On January 7, 2023, the SP arrived at the facility and saw broken glass and a red sauce on the kitchen floor. At the time, the VA was coming out of his/her bedroom but went back when s/he saw the SP. The SP asked the VA who broke the jar and the VA did not answer the SP. The VA put his/her middle finger up at the SP and said the SP should clean up the mess. The SP did not respond to the VA at that time. Later the SP went upstairs and knocked on the other individual’s bedroom door. The SP came out of his/her bedroom and yelled at the SP. The VA continued to yell at the SP and spit came out of the VA’s mouth and landed on the SP. The SP said s/he would call the police if the VA continued to yell. The VA went back into his/her bedroom and called law enforcement. Law enforcement advised the SP to leave the facility until things quieted down. · The SP never had any physical contact with the VA. The VA yelled at the SP, but the SP never yelled or screamed at the VA. Law enforcement reports showed the following: · On December 6, 2022, law enforcement arrived at the facility for a possible domestic dispute. The VA said that the SP came to the facility and went to the fridge to do an inventory of food. The VA had his/her own personal food in the fridge and told the SP not to touch the VA’s food. The VA got between the SP and the fridge so the SP could not access the fridge. The VA admitted to raising his/her voice and yelling but said s/he never threatened the SP or put his/her hands on the SP. The SP said the VA got in the SP’s face and yelled and provided an audio recording in which the VA could be heard yelling that staff persons did not care for him/her properly and telling the SP not to touch his/her food. · On January 3, 2023, the VA called 911 to report the SP was harassing the VA and trying to get into the VA’s bedroom. The SP said that the SP and the VA had a dispute when the VA left the oven on. When the SP tried to talk to the VA, the VA started yelling at the SP. The VA said the SP yelled at the VA for no reason and the VA went to his/her bedroom to avoid a confrontation. Both the VA and SP agreed to stay away from each other for the rest of the night. · On January 7, 2023, law enforcement arrived and spoke with the VA who said that SP came to the facility and blamed the VA for a broken salsa jar. The VA and the SP got into an argument and the SP spit on the VA. The SP showed the law enforcement officer a video that showed the SP going upstairs and knocking on one of the individual’s bedroom doors. The VA stepped out of his/her bedroom and started yelling in the SP’s face. The VA cursed at the SP and became so upset that spit started to fly out of his/her mouth and got on the SP. All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: Information was consistent that on three different occasions, the VA and the SP had verbal arguments. The VA said the SP screamed and yelled at the VA during each incident triggering his/her post traumatic stress disorder. On one occasion, the VA got in-between the SP and the refrigerator, and the SP pushed the VA. On another occasion, the SP spit on the VA. The SP said s/he never had any physical contact with the VA. The VA yelled at the SP, but the SP never yelled or screamed at the VA. While it was possible that not all of the SP’s interactions with the VA were entirely therapeutic, given the VA did not sustain any injury and that there was no further witness to corroborate or refute the allegations, there was not a preponderance of the evidence whether any of the incidents could be reasonably expected to produce emotional distress or physical pain. It was not determined whether physical or emotional 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; or 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 and followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
