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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: 1072532-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA) was given the wrong dosage of medication and that staff persons did not notice when the VA was having side effects. Allegation Two: There were concerns with staff persons interactions with the VA, including that they yelled at the VA. Date of Incident(s): Ongoing and prior to December 16, 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 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 January 18, 2023; from documentation at the facility and medical records; and through 11 interviews conducted with the VA, a facility client (C1), a supervisory staff person (P1), two facility staff persons (SP1 and SP2), the VA’s case manager (CM), the VA’s guardians (G1, G2, G3), and the VA’s day program staff persons (DP1 and DP2). This investigator requested law enforcement records but law enforcement did not have anything in their system involving the VA or the facility. The facility was a two-story home with a finished lower level. The upstairs had client bedrooms, a bathroom, living area, and kitchen. The lower level had a living area, staff office, the VA’s bedroom, and a bathroom. The VA enjoyed beading, going out to eat, and spending time with his/her family. The VA was diagnosed with autistic disorder. The VA’s Coordinated Service and Support Plan Addendum Summary last updated on December 16, 2020, said that staff persons were to assist the VA with medication administration and menu planning. It was important to the VA to get out into the community often. The VA’s strengths were that s/he was “kind,” had a good memory, and was a good self-advocate. The VA “loved” his/her large bedroom and did not want to move. The VA’s Individual Abuse Prevention Plan said that the VA may be unable to remove him/herself from abuse or be assertive enough to protect him/herself from abuse. Staff persons were to ensure the VA’s safety and remove the VA from a situation as needed. Staff persons were to report any suspected or known abuse. The VA’s Intensive Support Self-Management Assessment said that the VA could self-manage behaviors with staff assistance and redirection. Allegation One: It was reported that the VA was given the wrong dosage of medication and that staff persons did not notice when the VA was having side effects. DP2 said that at some point around December 14, 2022, the VA was not able to “put a sentence together” so DP2 thought that the VA was having a stroke or seizure. DP2 then notified G2 and DP1. DP2 later found out that facility staff persons had not followed directions regarding a medication that the VA had recently been prescribed. DP2 had concerns that the facility did not notify the VA’s day program that the VA started a new medication. The VA said that at some point, s/he got the “wrong medication” which caused the VA’s “brain to go out of whack” and the VA not feel like him/herself. G2 and G3 discovered that the VA was given the wrong medication and once it was fixed, the VA felt “great.” G1, G2, and an email that G1 sent to DP2 dated December 15, 2022, stated that the VA had “quite a week lately.” This included that on December 9, 2022, the VA saw his/her neurologist. The neurologist noticed symptoms of possible tardive dyskinesia and wrote a prescription for Topamax. The Topamax “instructions” included the “slow use of med to ease it into [the VA’s] system” but staff persons were giving the VA the medication three times a day at “full strength.” This caused the VA to be “out of it” and have an “overdose.” However, G1 said that s/he had to read the prescription a “couple of times to make it clear” “what was intended.” G1 thought that staff persons either “could not read the notes” or “looked at the numbers and did not understand [the] titration information.” The VA’s doctor “discontinued [the medication] immediately.” The facility had a nurse (RN) but G1 did not know if the RN was aware of these medication changes. The VA liked the facility, including the food, but was “having a difficult time feeling it was not safe to take meds out of order.” G3 said that in approximately December 2022, the VA’s neurologist changed the VA’s seizure medications. Staff persons did not “pay attention” to the instructions to “titrate” and instead gave the VA the “full dosage.” Staff persons also did not notice any concerns with the VA but the VA’s day program noticed “abnormal behavior.” This included concerns with the VA’s speech, and “trouble” following two to three step directions, which the VA normally had “no problems with.” Additionally, the VA normally had “very good verbal skills” but the VA was “not forming sentences.” The VA told G2 and G3 that s/he was not “feeling right” and that his/her “brain was not working right.” G3 also noticed this a “little” over the phone but said that s/he did not see the VA every day. The VA did not require hospitalization but the medication was discontinued. The VA was then “okay.” G3 had concerns that staff persons did not notice the “abnormal behavior.” DP1 and the 245D Progress Review dated December 9, 2022, said that on December 9, 2022, DP2 notified DP1 that the VA was not at his/her “usual baseline.” DP2 said that the VA was “struggling” to read words and form sentences and mentioned that something was “off with [him/her] neurologically.” The VA was normally good at words so DP2 was worried that the VA had a stroke. The VA said that G3 gave him/her an allergy medication but the VA did not provide additional information. DP1 then called P1 to see if G3 had given the VA a bottle of antihistamine and if the VA was “self-administering incorrectly.” P1 then checked the medication administration record (MAR) and saw that the VA had not received any “antihistamines” or as needed medications. DP1 then called G3 who stated that s/he had only given the VA an over the counter “saline spray.” G3 told DP1 that on the evening of December 8, 2022, s/he also noticed that the VA was “struggling to talk.” G3 and DP1 “agreed” that the VA should be taken to the doctor and G2 then “immediately” took the VA to the doctor. It was discovered that the VA was taking a new medication not as prescribed. Medical records from the VA’s neurologist dated December 5, 2022, said that starting on December 5, 2022, the VA was to take 1 tablet Topamax (25 milligram) by mouth three times daily before meals. This order was sent to the VA’s pharmacy. According to the General Events Reports and the Internal Review, on December 7, 2022, the VA’s pharmacy delivered Topamax 25 milligrams with directions to be administered 3 times daily (which was reflected on the MAR and the VA received these doses on December 7 and 8, 2022, at 8 a.m., 2 p.m., and 8 p.m.). On December 9, 2022, G2 told the RN of possible side effects the VA was having, including lethargy and slurred speech. The RN then reviewed the medical referral and the pharmacy order which did not “match.” The order received from the pharmacy (that they received from the doctors office) and sent to the facility was Topamax 1 tablet by mouth three times daily. The RN then contacted the prescribing doctor and clarified the medication order. The correct order was 1 tablet by mouth 1 time daily for 7 days, then twice daily for 7 days, and then 3 times daily (which was updated on the MAR and began on December 10, 2022). The pharmacy was informed of the error and resent the correct dosage. On December 14, 2022, the medication was discontinued. Facility progress notes provided the following infomraion: · On December 3, 4, 5, 6, and 7, 2022, no health concerns were noted. On December 7, 2022, there was a nursing visit but the VA was “off site.” There were no health concerns noted on December 8, 2022. On December 9, 2022, there was a nursing visit but the VA was “off site.” However, the RN noted that staff persons stated that the VA was having a hard time waking up in the mornings and ran late to his/her day program. The RN told G2 who said that s/he would talk to the VA. Later, the RN documented that G2 was “concerned” about the VA’s dosage of Topamax and requested that the RN call and speak to the neurologist’s nurse. The RN called but was only able to leave a message for the neurologist’s office and was awaiting a return call. Later, the nurse called back and said that the VA should be given one tablet of Topamax by mouth once daily at dinner for seven days. Then, one tablet at lunch and dinner for seven days and then three tablets daily at meals. P1 was notified and was asked to remove the 8 a.m. and 2 p.m. dosage until needed and to notify evening staff persons of the change. There were no health concerns noted from December 10 to 12, 2022. · On December 13, 2022, the RN received a call from G2 stating that s/he had spoken with the VA’s neurologist concerning “side effects” of the Topamax and the neurologist discontinued the medication. The RN then left a message with the neurologist’s nurse with a request for an “order” to discontinue the Topamax. P1 said that at some point, the RN, who came to the facility “every day,” said there was an issue between the VA’s doctor and the pharmacy regarding one of the VA’s medications. The medication was discontinued but P1 did not know further details. The RN was “very good at checking in” on the clients. P1 did not see any issues because of the medication issue. SP1 did not typically administer medications and typically cooked meals. SP1 was not aware of any medication errors. SP2 said that the VA needed assistance with medications. SP2 followed the MAR and if there was something “fishy,” staff persons would “question it.” The RN also assisted with the medications. SP2 was not aware of the VA acting different than normal. The Policy and Procedure on Health Service Coordination said that the facility provided medication setup, assistance, and administration. Staff persons were to monitor the client’s health conditions. Changes in a person’s health was to be documented and the persons legal representative and case manager were to be notified. The Policy and Procedure on Safe Medication Assistance and Administration said that medication setup meant the arranging of medications according to instructions from the pharmacy or the prescriber. Staff persons were to document the date of medication set up, name of medication, quantity of dose, and times administered. Facility documentation showed that P1, SP1, and SP2 received training on the facility’s policies, including medication administration, person centered planning, client rights, and the Reporting of Maltreatment of Vulnerable Adults Act. P1, SP1, and SP2 each received training on the VA’s plans Conclusion for Allegation One: On December 7, 2022, the VA received a new medication (Topamax) and orders from the VA’s doctor showed that the VA was to take this three times a day before meals. Although there were concerns that staff persons were administering the wrong dosage, medical records showed that the wrong order was sent from the VA’s doctor to the pharmacy and that staff persons were following that order, which was three times the amount of medication than was intended. Progress notes showed that the facility nurse (RN) was frequently at the house and that staff persons documented any concerns they observed with the VA. On December 8, 2022, no health concerns were noted in the progress notes. However, on December 9, 2022, DP2 observed that the VA was not his/her normal “baseline” and was “struggling” to read, form sentences, and was lethargic. While DP1, DP2, G1, G2, and G3 had concerns that staff persons did not observe these changes, facility progress notes showed that the RN noted on December 9, 2022, that staff persons said that the VA had a hard time waking up. Medical attention was sought for the VA shortly after. Given that the VA had recently begun taking the Topamax two days prior, that staff persons, including the RN, documented concerns, that the VA’s doctor was contacted shortly after these concerns were noted, and that the VA did not require any medical attention, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services which were reasonable and necessary to maintain the VA’s physical health. 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: There were concerns with staff persons interactions with the VA, including that they yelled at the VA. DP2 provided the following information: · The VA told DP2 multiple concerns. This included that a staff person “pounded” on the VA’s door and left a “hole.” Additionally, a staff person took away the VA’s juice and grabbed the VA’s shirt. A staff person also pushed the VA against a wall. DP2 was not aware of any reason why the VA would say these things if they were not true. The VA was “very smart” and a “very good reporter when it comes to feeling safe or unsafe.” However, the VA may “stretch some things to benefit” him/herself. DP2 provided an example that the VA may not have food options that s/he liked and would say that s/he was “starving to death” when there were other food options. · DP2 also had concerns that the facility did not take the VA on outings and that the only time the VA did outings was when G1, G2, or G3 took the VA. · Additionally, the VA “loved” fruits and vegetables including salads. However, the VA said that the facility did not let him/her bring salads as they were for other “meals.” · DP2 did not see anything concerning with staff persons interactions but said that s/he did not typically see staff persons’ interactions with the VA. · The VA called G1, G2, and G3 daily to “express [his/her] concerns.” DP2 felt “bad” as G1 and G2 were “making excuses” for staff persons behaviors, including that staff persons were “overworked.” However, that did not give “anyone the right” to treat the VA the way s/he said s/he was being treated. The VA provided the following information: · At some point (the VA did not recall the date), the VA was drinking apple juice that s/he got from G2. SP2 then “chased” the VA around the facility and grabbed the VA’s shirt to get the juice away from the VA. The VA did not know why SP2 took his/her juice. SP2 then set the juice on the counter and was trying to “let it spoil.” There was no damage to the VA’s shirt. · Staff persons also did not take the VA on outings to his/her favorite places, including the library, thrift stores, or the dollar store. The facility was “pretty understaffed.” · Staff persons did not “compromise” with the VA regarding food the VA wanted to eat. Staff persons, including SP2, did not like to be “social” and did not like to hear about the VA’s day, including what the VA did at his/her day program. The VA wanted to “move” but his/her team said there were no other homes with a large bedroom and closet, such as what the VA had at the facility. · A staff person (P2) treated the VA “okay.” However, at some point one evening when the VA was using the bathroom, P2 was having a “big tantrum” and pounding on the bathroom door. The VA was “afraid” P2 was going to “bust” the door down and “invade” the VA’s privacy, which the VA “did not like.” P2 left a “discoloration” on the door (Note: This investigator viewed the bathroom door and did not observe any damage to the door). Later, the VA said that it was SP1 that did these things, including “pounding vigorously” on the VA’s bathroom door. SP1 also “yelled” at the VA, including when the VA asked what was for dinner. SP1 also “ignored” the VA, including when s/he asked for a snack. · Additionally, a former staff person (P5) had a “verbal fight” with the VA and the VA and P5 argued and yelled at one another. The VA also did not like a staff person (P6) and “some of the answers [P6] gave [the VA].” This included that P6 would not let the VA do what s/he “wanted to do.” This made the VA “upset and uncomfortable.” Another staff person (P7) would not let the VA wake up early and was “rude” and “overly strict.” When the VA walked upstairs, P7 made the VA go downstairs. Another staff person (P8) did this too. · When another client (C2) “goes off,” staff persons “ignored that” which the VA “did not like.” · The VA made his/her own lunch. · The VA stayed in his/her room “all the time” due to these concerns. · Although the VA had some concerns about staff persons, the VA liked P1 and said that s/he could talk to P1 if s/he had concerns. The VA also did not have concerns with other staff persons, including (P3 and P4). No staff person called the VA any names or swore at the VA. No staff person hung up the phone on the VA. G1, G2, and emails that G1 sent to DP2 provided the following information: · When the VA had concerns, s/he told G1, G2, and/or G3 “immediately” by notifying them via phone which “infuriates the staff.” This included that on the evening of December 14, 2022, the VA called G1 to “complain” and “vent” about staff persons, including a staff person “screaming and yelling” at him/her and using “bad language.” During this call, a staff person began “screaming” and “pounding” on the door and G1 could hear it in the “background” while on the phone. G1 did not know who the staff person was. The VA said that the staff person “pounded on [the VA’s] bedroom door and made a hole in it.” The VA said there was a “crack,” “mark,” or “line” in the door. However, G1 and G2 did not “check” the door to see if it was damaged. G1 said that the VA and other clients should not “live in fear” of the staff persons. G1 “felt bad” for C1 whose bedroom was above the VA’s as s/he was “most likely kept awake during all that.” The “verbal things” took a “toll” on the VA and G1 and G2. On the morning of December 15, 2022, G1 spoke to the VA and the VA “seemed to be fine.” · G2 said that the incident occurred when the VA was in the bathroom (and not his/her bedroom). The bathroom was “semi-private” to the VA but other people could use it. The VA was in the bathroom but G2 did not know if the VA was showering or using the bathroom. During this, another client needed to use the bathroom and G2 did not know if the staff person “explained” to the VA why they needed to use the bathroom. · Additionally, around December 2022, the VA said that s/he was “surrounded” by staff persons yelling at him/her because the VA used a “bad word” after repeating a word from a song. Staff persons were “angry” that the VA used that word, even though the VA had “no idea what it meant.” G1 did not recall the word and said that G1’s family member had to “explain” it to G1 and that it was a “bit inappropriate.” · Around December 2022, G1 also had a “recording” of a staff person “yelling and cursing.” However, G1 did not know how to get the recording off his/her phone and would need to “activate” it. G1 did not know who the staff person was but said it was a staff person who no longer worked at the facility. That staff person was normally very nice. G1 said that s/he had an “issue” with his/her ear after that recording due to “ringing or humming” in his/her ears. · G1 also had concerns that C2 was really “rude” and got the VA “going.” G1 had concerns that staff persons did not “intervene” with C2 but would instead “ignore it and hope it goes away.” When this occurred, the VA sometimes went to his/her room which was “okay” as the VA liked his/her room and would stay there until things “calm down.” · English was a second language for some staff persons so how they “interpret things” may be “different” than what the VA was “used to.” The VA also had a “problem” understanding people who did not speak English. G1 said that a “lot” of the staff person yelled. However, staff persons were “stressed” and short staffed. When staff persons raised their voice, it made the VA talk “louder.” It helped when staff persons stayed calm. Staff persons should also explain things to the VA. G1 said that due to staff turnover, more training and retraining was needed. G1 did not know if staff persons were trained on the VA’s plans. · Recent supervisory staff persons seemed to be “responsive” to the concerns. However, the good and “reliable” staff persons got promoted and then did not work at the facility with the VA. · G1 also had concerns that the facility spoke about all the outings they were going to do but G1 could “hardly count” the number of times the VA had been on outings. · The VA’s communication skills were “pretty good.” The VA was “usually fairly accurate.” · The VA “loved” the facility including his/her “big bedroom” and having a bathroom close by. G1 said that although the VA had concerns with staff persons at the facility, the VA “did not complain” about any staff persons at the day program. G3 provided the following information: · G3 said that G2 was at the facility approximately two times per week and G3 was there “at least once a week.” · The VA “complained” about staff persons and clients “periodically” but it was typically “nothing very serious.” The VA had the “most problems” with SP1. At some point, G3 heard SP1 “accuse” the VA of lying over the phone and SP1 told the VA to “stop lying.” This occurred when the VA was “reporting” things that staff persons were “doing wrong,” like staff persons being on their cell phones or not helping the VA. G3 said that at least half the time when s/he picked the VA up, staff persons were on their phones or not “actively” interacting with any clients. · G3 was not aware of staff persons pushing the VA but said that they took things out of the VA’s hand. This included SP1 who tried to get the phone out of the VA’s hands, as G3 “heard” the VA “backing up” and stating, “Don’t touch me.” The VA said that s/he then called 9-1-1 as a result. · The VA resided downstairs and had his/her own bathroom. The VA was the only person who used that bathroom. At some point, SP1 had pounded on the VA’s bathroom door for the VA to get out. The VA said that there was a “dent” on his/her bathroom door as a result but G3 did not see that but said that s/he typically did not go downstairs. G3 also heard SP1 yelling when the VA spoke to him/her on the phone. · G3 did not know if the staff persons were not trained on the VA’s plans or if they did not “understand” the VA. C1 also told G3 that staff persons did not know how to work with the VA and his/her “autism.” The VA did not like to be “yelled at.” Staff persons did not know how to interact with someone such as the VA, who was “easily affected by sensory overload.” DP1 and the 245D Progress Review dated December 9, 2022, provided the following information: · The VA did not tell DP1 any concerns. However, DP1 heard about the concerns from emails from G1 and from DP2. This included that SP1 and SP2 made the VA feel “unsafe.” At some point when the VA felt unsafe, s/he called 9-1-1 and a staff person (who was not identified), hung up the phone. Additionally, a staff person (who was not identified), held the VA against a wall and took something from him/her.
· DP1 also had concerns that on December 16, 2022, the VA only brought chips to his/her day program for lunch. The VA was a “picky eater” but liked salads so the VA was asked why s/he did not bring a salad. The VA stated that s/he was told by the facility that s/he could not have salads as they were for dinners. The VA did not like sandwiches but DP2 told the VA that s/he could bring lunch meat. The VA said that s/he was “not allowed.” DP2 then provided food to the VA to ensure s/he had a “nutritious meal.” · The VA was a “pretty accurate reporter” and “pretty objective.” The VA was not a “false reporter” and had no reason to say things that were not true. However, the VA may “downplay” something if s/he was “over it” or felt that s/he might get in trouble. DP1 did not know how long the VA may remember something. Facility progress notes provided the following infomraion: · On December 1, 2022, the VA was “screaming and shouting” and calling staff persons, including (P9), names including “lazy.” The VA then left for his/her day program as his/her ride had arrived. Later, a staff person noted that the VA had a “wonderful evening.” · On December 3, 2022, P9 noted that during the morning shift, the VA was yelling at another client and staff persons were trying to get the situation “under control.” G2 then came to the facility and the VA left with G2. · On December 15, 2022, SP2 noted that after dinner, another client was taken downstairs to use the bathroom and the VA was in the bathroom making calls and using his/her tablet. SP2 asked the VA if s/he could use the phone outside the bathroom so that the other client could use the bathroom. The bathroom upstairs was also in use. The VA refused and around 7:50 p.m., the VA called 9-1-1 stating that staff persons were knocking on his/her door. During this, the client that needed to use the bathroom had urinary incontinence. The VA then notified G1 and G2. Law enforcement called the facility and staff persons told law enforcement what happened. SP2 also notified P1. · On December 16, 2022, a staff person (P10) noted that the VA was screaming and crying asking why G2 and G3 were not picking up the phone when s/he called them. P10 assisted the VA to calm and reminded the VA that it was “late” and to go to bed and that G2 and G3 would be available the next day. C1 never heard a staff person yell or scream at a client but said that s/he had heard clients yell at one another. This included the VA and other clients. C1 was “absolutely” happy with living at the facility. C1 would tell staff persons if s/he had concerns. SP1 was “wonderful” and C1 did not have any concerns with him/her. SP2 was “feisty” and “energetic.” The VA did not have any concerns with SP2’s interactions with the clients. Staff persons might yell down to the VA to tell the VA that his/her day program ride was at the facility but otherwise, the facility was “pretty placid.” P1 provided the following information: · Two to three staff persons typically worked at the facility at one time. Staff persons gave the VA verbal reminders, including that his/her day program ride was ready. The VA talked to staff persons throughout the day, including telling staff persons how his/her day was going. Staff persons were not to be on their phones while working and should be interacting with the clients. P1 was not aware of staff persons being on their phones while working. · P1 liked to be independent with making his/her own lunch so staff persons gave the VA “space to grab what [s/he] wants.” Clients could bring what they wanted for lunch, including salads. P1 sometimes assisted the VA with making his/her lunch but later, the VA may “change” what s/he brought. P1 was not aware of the VA not being able to take salad. · The VA did not go on many outings recently due to the facility being short staffed and the needs of the other clients. However, P1 was trying to “implement” more activities. · When this investigator asked P1 if the VA had expressed any concerns with staff persons or the facility, P1 said that the VA wanted certain meals, including steak. The facility “tried” to make steak or something similar. The VA told P1 that s/he liked P1, P3, and P8. However, the VA did not like SP1 or SP2 and said that SP1 and SP2 did not “understand” him/her. The VA also told P1 that SP1 and SP2 yelled at him/her. However, P1 did not see them yelling or doing “anything they were not supposed to be doing.” SP1 and SP2 spoke in a “loud” voice which P1 thought was due to their “culture.” The VA may have also misunderstood them and at some point, the VA asked P1 if s/he “heard them wrong.” At times when there were concerns, P1 asked the VA and staff persons to talk to make sure everyone was on the “same page.” · The VA told P1 that at some point around December 2022 (the VA told P1 that s/he did not remember the date), the VA was using the downstairs bathroom and was on his/her tablet. SP1 then knocked on the bathroom door and began yelling, which the VA did not like. The VA also described it as “pounding.” SP1 did this because another client needed to use the bathroom and the bathroom upstairs was occupied. P1 asked the VA if SP1 let him/her know that s/he needed to use the bathroom for another client and the VA said that SP1 did not. The VA then said that s/he did not “like” SP1 and SP2 and that they were “mean” to him/her. · At some point, P1 spoke to SP1 and SP2 who said that the incident did not happen as the VA described. SP1 and SP2 said that the VA was in the bathroom but was not “using” the bathroom and was “sitting behind the door” on his/her tablet. SP1 and SP2 each said that they asked the VA to “please come out [which the VA said was a “lie”.] P1 then told SP1 and SP2 to document similar incidents going forward, especially when P1 was not at the facility as P1 was pulled in “two” directions. P1 could not “pinpoint” what was “true or false.” P1 did not see damage to the door but said that the door was “old” so might have a “ding” on it. At times, other clients would need to use the downstairs bathroom. · The VA also told P1 that SP2 chased him/her and pulled his/her shirt. The VA said that s/he did not know why SP2 did that. P1 spoke to SP2 who denied doing so. · P1 was not aware of staff persons telling the VA to go to his/her room and said that would not be appropriate to do. P1 was not aware of any staff persons telling the VA that s/he could not wake early and said that staff persons could not “control” when someone wakes. P1 was not aware of a staff person with P6’s name and said that P5 worked at the facility “years ago.” · The VA and C2 did not get along as sometimes the VA would go in C2’s “bubble” and C2 wanted to be “left alone.” They would “sometimes exchange words.” When that occurred, staff persons should “break it up” and talk to them. · P1 was not aware of staff persons yelling, including on a voicemail message for G1. P1 was not aware of staff persons surrounding the VA when s/he said a bad word and could not see staff persons doing so. P1 was not aware of a staff person holding the VA against a wall and taking something from the VA. P1 said that SP1 “rarely talks” and P1 was not aware of SP1 yelling or calling the VA a liar, including while G3 was on the phone. SP1 was “quiet” and did his/her “job.” SP1 and SP2 “did not strike [P1] as people that scream and yell.” P1 did not hear that they did so from other staff or clients. P1 described SP1 and SP2 as “very sweet.” P1 was not aware of the VA calling 9-1-1 because s/he did not feel safe and staff persons hanging up on the VA. · Staff persons were trained to be “patient and calm” when working with the VA and they should listen to the VA. The VA could be loud sometimes and staff persons may think the VA was yelling. The VA “struggles” with “verbal words” and may get “frustrated” because of that. Staff persons should sit with the VA and do activities and listen to him/her. · The VA provided accurate information about 50% of the time. P1 said this because when the VA said something concerning, P1 then spoke to staff persons and realized it may have been a “misunderstanding.” However, P1 was not aware of the VA saying something about staff persons that were not true. If there was something the VA did not like, the VA had a “pretty good memory of it.” · C1 would tell staff persons if there were concerns and was a “great person” to say what was “going on or not going on.” C1 did not have a history of providing inaccurate information and “communicates really well.” SP1 provided the following information: · At some point in approximately December 2022, SP1 “knocked” on the VA’s bathroom door but did not “pound” on the door. At that time, C3 needed to use the bathroom and would “scream” to indicate s/he needed to do so. Another client was using the bathroom on the main floor so SP1 took C3 to the downstairs bathroom. The VA was in the bathroom on the phone talking to G3 and brushing his/her teeth and was not “using” the bathroom. SP1 knocked on the door and said to the VA to “please” let C3 in the bathroom as C3 was “screaming and crying.” SP1 knocked on the bathroom three times and said “please.” C3 then “tapped” SP1 to show SP1 that s/he had urinary incontinence so SP1 took C3 to get changed. As SP1 was washing C3’s clothing, the VA came up to SP1 and said that s/he was “calling the police.” The VA then handed SP1 the phone and said that law enforcement wanted to talk to him/her. SP1 then spoke to law enforcement and they asked if the VA was “okay.” SP1 said that s/he “thinks [the VA] is okay.” Law enforcement then called back about 10 minutes later and asked if they still needed “help” and SP1 said, “No” and that they were “okay.” The VA also said that s/he was “okay.” The next day, the VA was “so worried” that s/he had called the police and told SP1 that s/he was “so sorry” that s/he called the police. No staff person hung up the phone on law enforcement. There was no damage to the door. SP2 was also present at the facility but was taking care of another client in his/her room. · The VA sometimes needed help with preparing his/her lunches for his/her day program. The VA prepared his/her lunch the night prior but if the VA needed help s/he would let staff persons know. Staff persons could not “refuse” giving clients salad. · SP1 did not have any concerns with staff persons interactions, including with SP2. SP1 described his/her and SP2’s interactions with the clients as “good.” However, the VA did not like “any staff” except for new staff persons such as P3. At some point, the VA wrote a note telling SP1 to “quit” and that s/he did not like him/her. Staff persons did not respond when the VA did this. SP1 had not yelled at the VA and had not heard a staff person yell at the VA and said that would not be appropriate to do. However, the VA yelled at staff persons. The “problems” staff persons had with the VA was typically regarding food, including that the VA did not like the “cooking.” SP1 liked working with the clients, including the VA, and taking care of them. · Staff persons were not trained to take phones from the clients and SP1 was not aware of any staff persons doing so. · Staff persons only used their personal phones on break or during emergencies. SP1 had not seen staff persons using their phones when working. · SP1 had not heard a staff person tell a client to go to their room. However, staff persons may say it was time to go to bed although the VA typically went to bed on his/her on “anytime [s/he] liked.” SP1 was not aware of staff persons calling the VA a liar or yelling at him/her. SP1 had not seen a staff person getting upset regarding a song. · The VA’s family typically took the VA on outings but sometimes in the summer, staff persons took the VA outside to ride his/her bicycle. The VA did activities at home but did not always need help from staff persons. · The VA and C2 also did not get along. This included that the VA would say that C2 was looking at him/her and then the VA and C2 began shouting at each other. Staff persons would then ask the VA to “calm.” · SP1 had “never seen” a staff person hold the VA against a wall. The only time SP1 touched the VA was to give him/her a high five. SP1 was not aware of any staff persons chasing the VA around to get juice or grabbing his/her shirt. SP2 provided the following information: · There were typically between two to three staff persons working at the facility at all times. The facility was sometimes short staffed so it was “impossible” to take the clients on outings. · If the VA requested assistance with his/her lunch, staff persons would do so. · SP2 described the VA as “sweet.” SP2 said that “sometimes” the VA got along with him/her and sometimes the VA did not, but typically, the VA was “okay” with SP2. At times, the VA would “scream” at SP2 said “not even want to see [SP2].” The VA also did so with SP1. The VA would ask staff persons when they were going to “quit.” When this occurred, staff persons told the VA that they were there to help the VA and that they should “work together.” The VA was “outspoken” and told staff persons how s/he felt, including if s/he was having a “bad day.” If the VA was having a bad day, staff persons could give the VA things s/he liked including beading or coloring and then sit with the VA when s/he did those activities. The VA also liked to have “conversation” with staff persons.
· SP2 did not have any concerns with staff persons interactions with the clients, including with SP1. SP1 was “good with the clients” and the VA typically got along with SP1 “good.” SP2 had never heard a staff person yell or scream at a client but said that SP1 was “loud.” SP2 denied yelling at a client and said it would not be appropriate to do.
· At some point around December 13, 2022, SP1 and SP2 were working at the facility. Around 8 p.m., C3 needed to use the bathroom. Another client was using the upstairs bathroom so SP2 told the VA that s/he needed to use the bathroom downstairs. SP2 remained upstairs so did not know what happened. However, C3 and the VA were “screaming.” SP1 then came upstairs and said that C3 was “wet.” SP1 said that prior, s/he knocked on the VA’s door to ask if s/he was using the bathroom or on his/her tablet and realized that the VA was talking to someone on the phone. SP1 said that s/he knocked and “requested” that the VA use another room. SP2 was not aware of anyone banging on the door and was not aware of damage to the door. The VA also called 9-1-1 and 9-1-1 called the facility twice. SP1 answered the phone and law enforcement told SP1 to notify the supervisor so SP2 notified P1. · Staff persons could bring their own food or drink to the facility and wrote their initials on it and stored it in the fridge. At some point, the VA told SP2 that s/he wanted apple juice. SP2 told the VA that they did not have apple juice but had other juice or milk. The VA said, “No” and that s/he wanted apple juice. Later, SP2 heard “hearsay” that SP1 gave the VA a little bit of apple juice but it was a staff persons or C1’s juice and that C1 would be “mad.” The following day, another staff person told the VA that s/he drank someone else’s juice and the VA said it was his/her juice. SP2 then told the VA to put the juice on the table and then returned the juice to the fridge. SP2 did not see any staff person chasing the VA and could not see a staff person doing so. SP2 did not see anyone grabbing the VA by the clothing. · SP2 had not seen a staff person telling the VA to go to his/her room and said that it was the client’s house and they had a “right to stay anywhere.” · SP2 never saw a staff person holding the VA against a wall. SP2 had not heard a staff person call a client a liar. SP2 had not seen a staff person getting upset for the VA singing. · The VA and C2 did not get along and would start “bickering” and screaming at one another. When that occurred, staff persons would ask them to separate. The General Events Reports and the Internal Review provided the following information: · A supervisory staff person (P11) said that the VA told him/her that s/he did not feel “safe” at the facility due to the way that staff persons treated him/her. This included that staff persons were “verbally aggressive” and did not answer the VA’s questions. Staff persons were also “rude and disrespectful.” This included specifically with SP2. The VA said that SP2 chased him/her when s/he had a drink and then grabbed the back of the VA’s shirt and would not let the VA drink his/her own apple juice. SP1 also pounded on the VA’s bathroom door and was yelling at the VA to come out of the bathroom. The VA locked the door so that SP1 could not come in and said, “stop.” The VA described his/her relationship with SP1 and SP2 as “not good” and “very bad.” The VA told G2 and G3 about these concerns but it “did not seem to help.” The VA had two housemates s/he did not like and did not like the facility. The VA liked two prior staff who were no longer at the facility. · SP1 said that s/he felt “confident and competent” working with the VA. At some point, C3 needed to use the bathroom but the main floor bathroom was occupied. SP1 then went downstairs to the bathroom that was mainly used by the VA. The VA was brushing his/her teeth so SP1 believed that the VA could leave the bathroom to allow the C3 to use the bathroom so that C3 did not have an accident. The VA “refused and locked the door.” SP1 “tried to work” with the VA but the VA was “upset” and C3 ended up having an “accident” on him/herself. Later, the VA came upstairs and handed SP1 the phone and said that s/he called the police. SP1 and law enforcement then spoke on the phone about the situation. SP1 had not witnessed “any form of abuse” by staff persons but if s/he did, s/he would notify supervisory staff persons. · SP2 felt “competent” when working with the VA but said it was “difficult to support [the VA] when [the VA] was lying.” SP2 was not involved in the bathroom incident and had “never” pounded on the bathroom door. During the incident, SP2 was upstairs with the other clients. Later, the VA came upstairs and told SP1 that s/he called the police and then SP1 spoke to police. SP2 had not witnessed “any form of abuse” by staff persons but if s/he did, s/he would notify supervisory staff persons. · A facility maintenance person “examined” the bathroom door and “found no evidence of damages.” · Staff persons were trained on the VA’s plans upon hire, annually, and as the VA’s needs changed. It was not requested to train staff on Autism so that was not done. However, if it was requested, the facility would talk to the VA’s team. The CM said that G1 and G2 had been “concerned” “on and off” with things regarding the facility. The CM also spoke to staff persons about some of the concerns. However, there was a lot of “turnover” so it was “hard to keep track of who is in charge.” When the CM was at the facility, there were typically two to three staff persons working and “everything seemed okay.” The CM did not know if the VA was an accurate reporter but said that if the things that the VA said were happening were true, the VA needed “people looking out for [him/her].” The VA could “certainly tell you a lot of info.” The CM was not aware of any reason why the VA would say these things happened if they were not true. G1, G2, and G3 were often at the facility and would be “good people” to talk to. Conclusion for Allegation Two: The VA told DP2, G1, G2, G3, and this investigator that SP1 pounded on his/her door, causing a hole, “dent,” or “discoloration.” The VA also told investigator that P2 did this. However, this investigator and a maintenance person from the facility observed the door and did not see any damage. The VA also said that SP1 yelled at him/her. G1 and G3 also said that they heard a staff person yelling in the background during a call and G3 said that it was SP1. SP1 denied yelling but said that during the bathroom incident, C3 was yelling as s/he needed to use the bathroom. G1 also had a voicemail recording of a staff person yelling but did not know who it was. Although G1 said that the VA said that staff persons used “bad language,” the VA told this investigator that no staff persons swore at him/her. P1 did not hear SP1 or SP2 yell but said that they spoke in a loud voice. P1 said that C1 would be able to say if there were any concerns. C1 said that s/he never heard any staff person yell at a client, including the VA. C1 did not have any concerns with staff persons interactions with the clients, including with SP1 and SP2. SP1 denied yelling at the VA and had not heard any other staff persons doing so. SP2 was not aware of any staff person yelling and denied doing so. However, P1 and SP2 described SP1 as “loud.” P1 also described SP2 as loud. Although DP1 said that the VA tried to call 9-1-1 and a staff person hung up the phone on the VA, the VA told this investigator that no staff persons hung up the phone on him/her. The VA also said that SP2 took away his/her juice and chased him/her around and grabbed his/her shirt. SP2 denied doing so but said that the VA had someone else’s juice so s/he asked the VA to return the juice and then put it back in the fridge. There were other concerns regarding that the VA did not pack enough to eat, including salads, and that the VA did not go on outings. The facility said that they did not typically take the VA on outings due to staffing but P1 said that s/he was trying to work on that. Information was consistent that the VA often packed his/her own lunch but that salads or other foods were available to the VA. The VA was described as “very smart” and a “good reporter” but may “stretch some things” to benefit him/herself. DP1 said that the VA was not a “false reporter” and had no reason to say things that were not true. While it was possible that staff persons including SP1 and SP2 engaged in language and actions that were not therapeutic conduct, which was inconsistent with the role or a professional caregiver in a facility licensed by the Minnesota Department of Human Services, given the conflicting information regarding the details of the interactions between SP1, SP2, and the VA, that P1 and C1 did not witness SP1’s and SP2’s conduct in a manner consistent with the VA’s statements, and that SP1 and SP2 denied the allegations, there was not a preponderance of the evidence whether all of SP1’s and SP2’s conduct was therapeutic or whether SP1’s and SP2’s conduct produced or could reasonably be expected to produce emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language or treatment which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 completed an internal review and determined that policies and procedures were adequate and followed. The VA had a housemate s/he did not get along with which could upset the VA and lead to escalated behaviors. Staff persons were to intervene and deescalate the situation. Staff persons were to work with the VA on self-managing behaviors. The VA could get “easily upset” when asked to do things s/he did not want or if s/he could not get something s/he wanted, such as going into the community. Staff persons were to support the VA if something s/he desired and could not have in the “moment.” The facility provided no additional training. There were no similar concerns. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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