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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: 1085988-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a staff person (SP) pushed a vulnerable adult (VA) down onto a couch, yelled at the VA, and slapped the VA in the face when the VA attempted to leave the facility. Date of Incident(s): February 4, 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), 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 March 1, 2023; from documentation at the facility, law enforcement records; and through four interviews conducted with three facility staff persons (SP, P1, P2), and the VA’s guardian (G). This investigator met the VA, but s/he was nonverbal and unable to provide any information about the incident. The facility was a single level home with a large open living room area. The living room had a large bean bag chair, two couches, a small trampoline, and an ottoman. The VA was diagnosed with developmental disabilities and autistic disorder. The Positive Behavior Support Plan provided the following information: · The VA displayed target behaviors including ripping clothing or other fabrics, property destruction (breaking or throwing items), pushing staff persons out of the way to gain something s/he wanted, and throwing things out of the windows. · The VA was non-linguistic only using limited words and sign language but was able to understand directions given to him/her. · When the VA displayed target behaviors, staff persons gave prompts and redirected the VA to an alternative activity. If the VA attempted property destruction, staff person attempted to move the item or put themselves between the VA and the item. If the VA pushed staff persons, staff persons asked the VA to stop and to have “nice hands.”
P1 provided the following information: · The SP and P1 worked together on the day of the incident. Sometime after lunch the VA became fixated on something and got more and more aggressive towards the SP and P1. The SP, P1, and the VA were all in the living room near the couch. The SP yelled at the VA to sit down but the VA would not sit down and kept getting up off the couch. The SP got mad and hit the VA on the left side of the VA’s face above his/her eye. The VA did not respond but then sat down on the couch and did not move. The VA had a red circular mark the size of a golf ball on his/her forehead that went away a few hours later. · The SP yelled and screamed at the VA often and said things like, “You are dumb,” and “You are effing annoying.” P1 had never seen the SP be physical before but there was “talk” among other staff persons that the VA had “mysterious marks” after a shift with the SP. · When the VA had unwanted behaviors, staff persons were trained to redirect the VA with van rides, movies, Legos, or some physical activity. All staff persons used a “firm” voice when redirecting the VA saying something like “Sit down and please wait.” P1 felt the SP’s voice was more than a firm voice. P2 said s/he had never seen the SP be rough or physical with the VA and had no concerns with the SP’s interactions. The VA was “very difficult” and often got physical with staff persons. Staff persons were trained to block and redirect the VA. The VA became obsessed with things such as food and times that s/he could break so staff persons might have to stand and block a doorway or other area to keep the VA away from something. The other staff person then tried to get the VA’s focus on something else. Staff persons might hold out a hand and say, “Come with me.” Many times, the VA might then grab the staff persons hand and direct the staff persons where the VA wanted to go. The SP provided the following information: · When the VA was upset and trying to destroy property, staff persons redirected the VA by holding his/her hand, asking the VA to sit down on the couch, watching a movie, playing LEGOS, going for a walk, or going for a van ride. The VA was usually easily redirected. · When the VA did not get his/her way, s/he threw him/herself down on the couch and made noises. The SP never pushed the VA. The VA weighed over 100 pounds more than the SP and the SP would not be able to push the VA if s/he wanted to. The SP had never slapped or hit the VA on the forehead. The SP worked with the VA for years and considered him/her family. · On the date of the incident the VA had a great day, and the SP did not remember needing to redirect the VA at any point. The SP felt other staff persons were trying to get the SP fired so they could take the SP’s position. · The SP never yelled or screamed at the VA unless the VA ran outside, and the SP had to chase the VA. If the VA left the facility, the SP might yell “come back inside” while running after the VA. The SP had never said anything like, “You are dumb,” or “You are effing annoying.” The law enforcement report provided the following information: · P1 said the SP yelled and pushed the VA down on the couch. The VA did not stay on the couch, so the SP slapped the VA on his/her forehead. The VA stayed sitting down after that and had a red mark on his/her forehead that disappeared after a few hours. · The SP said the allegation that s/he slapped the VA was false. At times, the SP did have to physically help the VA sit down due to his/her autism. Staff persons had to physically redirect the VA when s/he got physical with staff persons. · The G did want to pursue charges against the SP and the case was closed. The G had no previous concerns with the SP or the facility. The VA was a larger person and it worked best for staff persons to be direct with him/her when s/he was super focused on something. The G and/or staff persons often said, “Sit down,” and might put their hands on the VA’s arms and say sit down to “break the cycle.” All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans prior to the incident. Conclusion: P1 said that on the day of the incident, the SP yelled at the VA to sit down and hit the VA on the left side of the VA’s face above his/her eye. P1 said that the VA had a red circular mark the size of a golf ball that went away a few hours later. The SP also yelled and screamed at the VA and said things like, “You are dumb,” and “You are effing annoying.” The SP said s/he never pushed the VA or hit the VA on the forehead. The SP said s/he had not yelled or screamed at the VA unless the VA ran outside, and the SP had to chase the VA. The SP might yell, “Come back inside,” while running after the VA. Although P1 said the SP yelled at the VA, pushed him/her down onto the couch, and hit the VA in the forehead, given the SP denied hitting the VA, pushing the VA, and yelling at the VA, that the VA did not sustain any injury, and that there was no further witnesses or information 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 were adequate but not followed by the SP if the allegation was found to be true. The SP no longer worked at the facility. All staff persons were retrained on the VA’s plan, the vulnerable adult policy, and individual rights. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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