|
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: 1071882-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kyle Youker/Anna Parkin Kyle.youker@state.mn.us Suspected Maltreatment Reported: Allegation One: It was alleged that a staff person (SP1) provided alcohol a vulnerable adult (the VA) and smoked marijuana with the VA. Allegation Two: It was alleged that a staff person (SP2) helped the VA purchase marijuana and smoked marijuana with the VA. Allegation Three: It was alleged that another staff person (SP3) smoked marijuana with the VA. Date of Incident(s): Unknown dates prior to February 6, 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 17, paragraph (a): 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 8, 2023; from documentation at the facility; and through seven interviews conducted with the VA, SP1, SP2, the VA’s guardian (G), a supervisory staff person (P1), another staff person (P2), and a client (C). Attempts were made via telephone and mail to contact and interview SP3. However, the attempts were unsuccessful. The facility had a main floor and a basement. The VA’s bedroom was on the main floor with a kitchen, living room, and sliding glass door leading to a deck. The staff office was in the basement along with the C’s bedroom. The VA was very social and enjoyed cooking and making crafts. The VA was diagnosed with dementia and had a history of substance abuse. The VA was of legal drinking age. P2 provided the following information: · P2 previously worked at the facility and maintained a friendship with the VA after his/her employment ended in November 2021. P2 stated the facility was aware of the friendship and “approved of it.” The VA and P2 routinely sent each other text messages. · On unknown dates, the VA texted P2 that on unknown dates between the spring 2022 through January 2023, s/he smoked marijuana with SP3. P2 responded to the VA that s/he should not be smoking marijuana. The VA also texted that on unknown dates, s/he went out with SP3 into his/her personal vehicle and smoked marijuana. On unknown dates, the VA texted P2 that SP1 and SP2 were “cool”, and they smoked marijuana. P2 did not tell staff persons from the facility about the text messages with the VA because s/he did not want to “break up our friendship.” · P2 stated the VA told him/her on an unknown date, an unknown “friend” of the VA delivered marijuana to the facility. The VA also told P2 on an unknown date that SP2 provided him/her with an “inhaler” for marijuana. On an unknown date, the VA asked P2 for money so SP2 could purchase marijuana for the VA but P2 did not give the VA any money. · On an unknown date in late January 2023, the VA texted P2 a picture of a clear container that had a specific shape that was filled with a white liquid. The VA told P2 this white liquid was “caramel liquor,” and the VA was going to put it in his/her coffee. That same date, P2 told a supervisory staff person, who immediately told P1. Text messages between the VA and P2 provided the following information: · On an unknown date the VA texted three pictures of container that was a specific shape that appeared to have white liquid inside. On the same date the VA texted it was a “caramel and cream liquor shot” that s/he was putting in his/her coffee and that SP1 gave him/her the container. · Other unknown dates showed that the VA texted P2 that s/he wanted to “get high” and that SP1 gave him/her marijuana “here and there.” · On an unknown date the VA texted P2 stating that SP2 had an “inhaler” to smoke marijuana with. · On an unknown date the VA texted P2 asking for $20 so SP2 could purchase an “inhaler” for the VA. The G stated the VA had a history of drug use. The G stated the VA was not an accurate reporter and might “lie” to avoid getting someone in trouble. P1 stated the VA had a history of substance abuse prior to moving to the facility. The VA could be manipulative and had attention seeking behavior. P1 stated the VA was not always an accurate reporter because when the VA would get upset with staff persons, s/he “lied” to get them in trouble. The Drug and Alcohol Policy prohibited staff persons from possessing or using alcohol, drugs, or other controlled substances at the facility. The Code of Conduct Policy stated that professional boundaries between staff persons and clients must be maintained. Allegation One: It was alleged that SP1 provided alcohol to the VA and smoked marijuana with the VA. The VA provided the following information: · The VA had a good relationship with SP1 and denied that s/he smoked marijuana with SP1. The VA stated the text messages s/he sent to P2 about smoking marijuana with SP1 were a “joke.” · The VA stated on an unknown date s/he saw a clear container that had a specific shape in SP1’s personal bag. The container was empty so the VA asked SP1 if s/he could have it for sand art and SP1 gave the empty container to the VA. · Later that day, the VA took coffee creamer from the facility refrigerator and filled the container with coffee cream and sent a picture of it to P2 and told P2 it was alcohol as a “joke.” This investigator observed the container in the VA’s bedroom, and it was filled with sand. P1 stated that after s/he was informed of the allegations on January 29, 2023, the following day s/he reviewed the Drug and Alcohol Policy with SP1 and told him/her about the allegations. P1 stated SP1 did not “defend” him/herself of the allegations. P1 stated SP1 did not seem “surprised” by the allegations and his/her response to P1 was, “Okay, got it.” The C stated s/he never saw SP1 smoking marijuana with the VA. SP1 provided the following information: · On an unknown date in January or February 2023, the VA noticed a container in SP1’s bag and wanted to do sand art with it, so SP1 gave it to him/her. SP1 did not know what liquid was originally in the container but believed it may have been alcohol. · Later, the VA filled the container with coffee cream and told SP1 s/he sent a picture of it to P2 as a “joke.” SP1 stated s/he was unsure exactly what was said but believed it to be a joke about alcohol. SP1 stated the VA would commonly make “inappropriate jokes.” SP1 denied providing the VA with alcohol. · SP1 stated that on an unknown date P1 spoke to him/her about the Drug and Alcohol Policy. SP1 did not state why P1 spoke to him/her about the Drug and Alcohol Policy. SP1 denied smoking marijuana with the VA. SP2 stated s/he was not aware of SP1 smoking marijuana with the VA. Facility documentation showed SP1 was trained on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility policies, and on the VA’s plans.
Conclusion for Allegation One: Although the VA sent text messages to P2 that SP1 gave the VA marijuana and alcohol, the VA denied that SP1 did so, and stated that both were done as a “joke.” Given that the VA provided conflicting information and that SP1 denied providing alcohol to the VA and smoking marijuana with the VA, there was not a preponderance of the evidence whether SP1 gave the VA alcohol or marijuana. 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). Allegation Two: It was alleged that SP2 smoked marijuana with the VA and helped the VA purchase marijuana. The VA denied smoking or purchasing marijuana with SP2 and stated that the text messages s/he sent to P2 were a “joke.” The C stated on an unknown date in November 2022, the s/he observed the VA and SP2 smoking marijuana on the back deck of the facility. The VA and SP2 were passing a “pipe” around. P1 stated s/he was “shocked” by the allegations involving SP2 and never had any concerns about SP2. SP2 stated on an unknown date s/he came to the facility wearing a jacket that belonged to his/her sibling that smelled like marijuana. SP2 stated s/he knew that the jacket smelled like marijuana, so s/he left it in his/her vehicle. SP2 denied smoking marijuana with the VA or purchasing marijuana for the VA. SP2 did not know why someone would say s/he did so. SP2 also stated that s/he did not work at the facility for the entire month of November 2022, due to an injury. Facility documentation showed that in November 2022, SP2 worked November 1 to November 4, 2022. SP1 stated s/he was not aware of SP2 smoking marijuana with the VA. Facility documentation showed SP2 was trained on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility policies, and on the VA’s plans. Conclusion for Allegation Two: Although the C stated s/he saw the VA and SP2 smoking marijuana on the back deck of the facility in November 2022, given that there was no additional information to support or refute the C’s information, that the VA provided conflicting information to P2 and this investigator regarding whether s/he smoked marijuana with SP2 and whether s/he purchased marijuana from SP2, and that SP2 denied smoking marijuana with the VA and purchasing marijuana for the VA, there was not a preponderance of the evidence whether SP2 and the VA smoked marijuana together. 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.) Allegation Three: It was alleged that another staff person (SP3) smoked marijuana with the VA. The VA stated other residents and staff persons made comments about the odor of marijuana from SP3. On an unknown date in December 2022, the VA smelled marijuana on SP3, so s/he asked SP3 about the smell. SP3 pulled marijuana and a pipe out of his/her coat pocket, and they smoked marijuana together on the deck of the facility. The VA stated it made him/her feel “high.” The VA denied smoking marijuana with SP3 on any other occasions. The C stated that on multiple unknown dates, s/he saw SP3 smoking marijuana in the staff office and his/her vehicle and SP3 consistently smelled like marijuana. On multiple occasions, the C saw SP3 and the VA inside SP3’s vehicle in the driveway smoking marijuana. On unknown date in December 2022, the C observed the VA and SP3 smoking marijuana on the deck of the facility. P1 stated s/he had not spoken to SP3 since s/he ended his/her employment at the facility (January 1, 2023). SP1 provided the following information: · SP3 smelled of marijuana that “lingered” on him/her. SP1 never asked SP3 about the odor of marijuana because s/he kept to himself/herself. · On an unknown date in December 2022, when SP1, SP2, and SP3 were working at the facility, SP1 smelled marijuana on the jacket that belonged to SP3. SP1 stated s/he had SP3 put his/her jacket outside and then told P1 at an unknown time after. · On an unknown date in January 2023, the VA told SP1 that s/he smoked marijuana with SP3. The VA did not provide any specifics to SP1 about smoking marijuana with SP3. SP1 stated s/he informed P1 immediately and P1 stated s/he would talk to another supervisory staff person but did not know what P1 did with the information. SP2 worked with SP3 and on multiple dates suspected SP3 of smoking marijuana while s/he was working at the facility. SP3 went to his/her personal vehicle in the driveway of the facility for 10 to 15 minutes and then came back inside the facility smelling strongly of marijuana. SP2 never saw SP3 smoking marijuana. SP3 also smelled like marijuana when s/he came to work at the facility. Facility documentation showed SP3 was trained on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility policies, and on the VA’s plans. Conclusion for Allegation Three: A. Maltreatment: SP3 did not provide information for this report and the VA did not accurately report information regarding SP1 and SP2. However, the VA acknowledged “joking” about his/her interactions with SP1 and SP2 and provided consistent information to this investigator and SP1 that s/he smoked marijuana with SP3 on one occasion, and the C said s/he saw SP3 and the VA smoking marijuana. Therefore, it was more likely that the VA’s and the C’s accounts of SP3 smoking marijuana with the VA was accurate. Given that smoking marijuana with the VA encouraged the VA to participate in illegal activity, there was a preponderance of the evidence that SP3 failed to supply the VA with care or services which were reasonable and necessary to maintain the VA’s health and safety. It was determined that 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.) B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Facility documentation showed SP3 was trained on the facility’s Drug and Alcohol Policy, the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. SP3 was responsible for the maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which SP3 was responsible did not meet statutory criteria to be determined as recurring or serious. Although the C stated that s/he saw the VA and SP3 smoking marijuana on two occasions, the VA stated that it occurred one time. In addition, the VA did not sustain a serious injury that required treatment by a physician.
Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies and procedures were adequate, but not followed by staff persons. All staff persons were retrained on the Drug and Alcohol Policy and maintaining professional boundaries. Action Taken by Department of Human Services, Office of Inspector General: SP3 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP3 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP3. The determination that SP3 was responsible for maltreatment is subject to appeal.
|
