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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: 1115738-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt scott.j.brandt@state.mn.us 651-431-6556 Suspected Maltreatment Reported: The following concerns were reported: · Staff persons took naked pictures of a vulnerable adult (VA) on their personal phones. · Staff persons did not regularly change the VA’s adult undergarments. · The VA’s head was injured when the VA was transferred using a Hoyer lift. · Staff persons did not consistently wash the VA’s hair. · Staff persons did not get the VA up in a timely manner due to being busy. · Staff persons did not give the VA his/her glasses, as needed, did not fix the VA’s glasses when they broke, and staff persons did not put on the VA’s coat when it was cold outside. · A facility staff person (P3) told the VA that s/he was tired of the VA’s “bullshit.” · Staff persons did not plan sufficient activities for the VA. Date of Incident(s): Prior to February 16, 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 (2); 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. 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 March 7, 2023, from documentation at the facility and through nine interviews conducted with the VA, the VA’s family member (FM1), the VA’s guardian (G), the VA’s case manager (CM), two facility management staff persons (P1 and P2) and three facility staff persons (P3-P5). Although this investigator contacted another family member (FM2) and another facility staff person (P6), they did not respond to requests to be interviewed. The VA’s Coordinated Services Support Plan showed that s/he enjoyed accessing the community to go shopping, playing BINGO, visiting with family members, and watching football. The plan further showed that the VA, who was diagnosed with Cerebral Palsy, used an electric wheelchair for mobility and had “limited use of [his/her] hands.” Staff persons provided assistance to the VA for all personal cares. The VA’s Support Plan showed that the VA had a history of refusing care and when that happened, “Staff [persons] made more attempts to assist [the VA] or sometimes have a different staff [person]” provide assistance. Regarding the concern that staff persons took naked pictures of the VA on their personal phones: FM1 and the G each had concerns that staff persons used their personal phones to take “naked” pictures of the VA. On February 15, 2023, P1 sent an email to the G that stated, “I have attached the picture that staff [persons] took of [the VA] today. The staff [person] did not take any naked pictures of [the VA]. Unfortunately, staff [persons] feel the need to take pictures as proof that they take care of [the VA] due to so many false allegations and reports that they don’t take care of [him/her]. I have coached staff [persons] to not take pictures like this.” (Investigator’s note: The G shared photos staff persons took of the VA with the investigator. The photos showed the VA with wet hair and wrapped in a towel appearing to be after the VA was showered. The photo showed a towel over the VA’s chest area with only bare neck, shoulders, and face.) The CM provided information that was similar to the information provided in the email from P1 to the G. The VA said that staff persons, specifically P2, P4, and P5, took photos of the VA and said, “they have to” do that because the VA’s family “doesn’t think they are taking care of me good.” P2-P5 provided consistent information that they took photos of the VA, but that none of the photos were naked and that the intent of taking the photos was to prove to the VA’s family that staff persons were providing reasonable care for the VA. P3 said that initially, staff persons began taking photos on their personal phones to show that care was provided. When photos were taken, they were sent to management and then staff persons were instructed to delete the photos from their personal phones. Within the last few weeks, the facility began using a facility owned iPad to take the photos. The CM told this investigator that s/he did not have concerns related to how staff persons interacted with the VA. The CM further stated that the VA was “very unhappy” living at the facility and that the VA wanted to live closer to his/her family. Regarding the concern that staff persons did not regularly change the VA’s adult undergarments: FM1 stated that on an ongoing basis, the VA brought up concerns to FM1 that when the VA needed to have his/her undergarments changed, staff persons did not assist the VA and/or told the VA that s/he would need to wait. The VA provided an example in which s/he asked P2 for assistance with changing his/her adult undergarment and P2 told the VA, “Okay, you have to wait a minute.” When the VA was asked how long s/he waited, the VA said, “Long time,” and that P2 said, “I’ll take you if I have time,” but P2 did not assist the VA. The VA also stated that staff persons change him/her “whenever I say.” P2 stated that there were times, specifically when the facility was single staffed, that the VA would be told that s/he needed to wait for assistance, but P2 denied telling the VA that s/he would assist the VA if s/he had time. P2 also stated that the VA became verbally aggressive to staff persons when the VA was asked to wait. P2 also stated that the VA was changed every two hours, or as needed. P3-P5 provided information that was mostly consistent with the information provided by P2. Regarding the concern that the VA’s head was injured when the VA was transferred using a Hoyer lift: The VA did not remember specific information about dates or the actual incidents but stated that there were two separate incidents involving P2 and P3 (the VA did not remember if P2 and P3 were both involved in both incidents or if each was involved in separate incidents). In those instances, they were transferring the VA with the Hoyer lift and in each instance, “I got hit with it and it hurt,” and the staff persons (the VA did not recall who) said, “I am sorry.” P2 stated that on an unspecified date, the VA told P2 that while P3 transferred the VA with the Hoyer lift, the VA’s cheek was bruised. P2 noticed a small dime sized bruise on the VA’s cheek that was yellow. P3 denied that an incident occurred with the Hoyer lift and the VA and also that s/he did not see bruising on the VA. P4 and P5 each stated that they did not see bruising on the VA. A review of the facility documentation did not show information regarding bruising on the VA’s cheek area. Regarding the concern that staff persons did not consistently wash the VA’s hair: FM1 stated that it was an ongoing concern that staff persons did not regularly wash the VA’s hair. The VA told this investigator that staff persons washed his/her hair three times weekly. P2-P5 provided mostly consistent information that they assisted the VA with washing his/her hair at least three times weekly and that there were times that the VA refused. When that happened, staff persons reapproached the VA a few minutes later to see if the VA was ready, but that there were times the VA continued to refuse.
Regarding the concern that staff persons did not get the VA up in a timely manner due to being busy: The VA stated that there were times that s/he would ask for help, specifically asking P4, and P4 said that s/he was assisting other clients with personal cares and the VA would have to wait. The VA provided an example in which s/he waited “two hours” for P3 to provided assistance to the VA. P3 denied that the VA had to wait two hours and said that there were times that staff persons, specifically if they were single staffed, told the VA that s/he would need to wait. P2 provided similar information and added that the VA once told him/her that the VA’s needs should come before other clients. P4 and P5 each said that the VA was assisted as quickly as possible, but that there were times that the VA got upset and began yelling at staff persons that s/he needed to wait. Regarding the concern that staff persons did not give the VA his/her glasses, as needed, and that his/her glasses were not fixed when they broke and that staff persons did not put on the VA’s coat when it was cold outside: FM1 said that when the lens fell out of the VA’s glasses on February 1, 2023, P2 fixed them, but FM1 told P2 that the VA needed to see a doctor to get them tightened and that did not happen. FM1 also stated that on at least one occasion, the VA told him/her that when staff persons put the VA’s coat on, they put it on backwards, but FM1 did not know who did that. The VA also told FM1 that P4 refused to put on the VA’s glasses one time and said, “You don’t need your glasses, you are just staring at four walls.” When the VA was asked about this concern, s/he stated that s/he would “holler” if s/he needed assistance with something, such as putting his/her glasses on the VA, and that staff persons provided that assistance to the VA. The VA did not have concerns with how staff persons put the VA’s coat on. P2-P5 each denied that they refused to give the VA his/her glasses. In addition, P2 stated that s/he overheard the VA talking to his/her family member and telling them that the VA was getting ready to leave on a community outing with staff persons and that staff persons would not put a coat on the VA. However, the VA was wearing a coat at the time s/he was talking to his/her family member. P2 also stated that once s/he tightened the VA’s glasses and they worked for the VA so they did not need to be tightened by a doctor. P4 denied refusing to assist the VA with putting on his/her glasses and denied saying that the VA was “only looking at four walls.” Regarding the concern that P3 told the VA that s/he was tired of the VA’s “bullshit:” P2 stated that the VA told him/her that P3, who was new to the facility at the time, stated something to the effect that s/he was sick of the VA’s bullshit and that the VA was upset by the comment. When P2 learned about it, P2 told P3 that type of comment was unacceptable. Since that time, P2 had not heard from the VA or other staff persons that similar comments had been made to the VA. In addition, P2 stated that often times, the VA seemed to be more verbally aggressive with new staff persons and that the facility provided coaching to all staff persons, particularly new staff persons, to walk away or ask another staff person to assist the VA if they were getting upset related to the VA’s requests. The VA did not remember anything related to this concern. P3-P5 all stated that they did not know anything about this concern and P6 did not respond to requests to be interviewed. P3 stated that s/he did not remember making the comment to the VA, but stated that s/he might have used the word “bullshit” when s/he was frustrated, but that it was more of a general comment that s/he was sick “of the bullshit,” but that it was not directed at the VA. Regarding the concern that staff persons did not plan sufficient activities for the VA: The VA stated that although s/he was supposed to go out and access the community at least two times monthly, the VA “never” got to go out, with the exception of medical appointments. P2-P5 stated that although the goal was to ensure that the VA went out at least twice monthly, there were times that staffing and weather conditions prevented the VA from accessing the community. P2 stated that sometimes the VA refused to go on community outings because s/he did not like the location that staff persons were planning to go to. A review of the VA’s Leisure/Family/Community Access Record for December 20, 2022, through February 24, 2023, showed that the VA accessed the community with staff persons on five occasions and refused to go one time. In addition to community activities, the VA assisted with preparing meals and baking with staff persons on a number of occasions. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to March 7, 2023. Conclusion: Regarding neglect: Several concerns were reported regarding the VA’s care at the facility. The VA’s family had concerns that staff persons took naked pictures of the VA, however, information from the investigation showed that the pictures of the VA were not naked but of the VA after s/he showered in a towel with the VA’s neck and shoulders bare. The photos were taken to show the VA’s family members that adequate care had been provided to the VA and that the VA was receiving showers. The VA stated that on two occasions, when P2 and P3 were transferring the VA using the Hoyer lift, the VA “got hit” with it, but the VA did not provide specific information. Later, the VA told P2 that when P3 used the Hoyer lift, the VA’s cheek was bruised. P2 saw a dime sized yellow bruise. P3, P4, and P5 each stated that they did not see a bruise and there was no documentation regarding a bruise on the VA’s cheek. Additional concerns were brought forward regarding the care that was provided to the VA which included the VA not being assisted in a timely manner, the VA’s adult undergarments not being changed, the VA’s glasses not being fixed or given to him/her, the VA’s hair not being washed, and the lack of activities being provided. Information from the investigation showed that staff persons assisted the VA with cares, his/her glasses, and activities as needed but there were times that the VA needed to wait for staff persons to finish assisting other clients and times that the VA refused and would often times become verbally aggressive to staff persons. Although there were concerns about the VA’s care at the facility, given that information showed staff persons assisted the VA as needed, and that there was no further information to confirm or refute the information provided, there was not a preponderance of the evidence whether there was a failure 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 emotional abuse: It was reported that P3 told the VA that s/he was sick of his/her “bullshit.” P3 stated that s/he might have made the comment, but that it was a general comment that s/he was sick “of the bullshit” and not directed to the VA. The VA told P2 about the comment so P2 told P3 that was not an appropriate comment. When asked by this investigator, the VA did not remember anything related to this allegation. Although it was likely P3 used the phrase “sick of the bullshit,” in the presence of the VA, given that P3 stated s/he did not remember making the comment but if s/he did, it was not directed toward the VA; that the VA did not recall the incident; and that there was no information that P3 used this phrase again, there was not a preponderance of the evidence whether P3’s comment could be expected to produce emotional distress. It was not determined whether 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: 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’s Report Form for Internal Investigation showed that policies and procedures were adequate, followed, and that no additional training was needed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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