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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: 1070450-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP), on multiple occasions, accused a vulnerable Adult (VA) of doing things the VA had not done, yelled at the VA, cursed at the VA, and called the VA names. Date of Incident(s): March 14, 2023, and other unknown dates 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 27, 2023; from documentation at the facility; and through five interviews conducted with the VA, a facility supervisor (P), the VA’s housemate (HM), the VA’s case manager (CM), and the SP. The VA received daily Independent Living Skills (ILS) services through the facility, as well as 24-hour emergency services. The ILS services provided to the VA included things such as, but not limited to grocery shopping, meal planning/cooking, cleaning, laundry, hygiene, medication administration, community safety and boundaries. The VA had 1:1 staffing when receiving services, and shared an apartment with the HM. The VA valued his/her independence, and it was important for him/her to have space for belongings. The VA’s “challenging day” would include being stressed out and having anxiety attacks. The VA did not like when s/he was told “no,” or had items taken away so the VA may engage in negative behavior in those situations. The VA enjoyed music and drawing/art projects and was routine oriented. The VA enjoyed going shopping, and enjoyed the Mall of America and State Fair. The VA was diagnosed with development disabilities and was diabetic. The VA’s client specific programming showed the VA was at risk of self-neglect, as well as abuse, neglect, and exploitation by others. The VA was able to communicate very well verbally, but may not always understand what was being asked or discussed. The VA may start talking about a topic of interest to him/her rather than the topic being discussed. The VA provided the following information: · The VA said s/he did not get along with the SP, and did not trust the SP. The SP “shouts,” and “yells” at the VA when the VA did “something wrong.” The VA said s/he got emotionally sensitive when the SP used a “tone” of voice with him/her, and there were interactions with the SP which made the VA emotional and upset. · The VA said the SP did not direct any swear words, name calling, or degrading statements towards the VA, but the SP would raise his/her voice “every so often” towards the VA. The HM heard the SP interact that way around the VA. The VA was unsure how long the SP “yelled” at him/her, but said it could last for 10 minutes, or an hour. The VA said the SP had never yelled at him/her for multiple hours. · The VA said there was an incident (unknown date) that while in a grocery store parking lot the SP “yelled” at the VA. · The VA said s/he called 9-1-1 on March 14, 2023, because s/he was “emotional and depressed.” The VA did not remember what was discussed with emergency responders. · The VA said the SP would deny yelling at him/her and “acts” like s/he was “always right.” The VA felt like the SP was a “control freak,” and controlled what the VA did. The VA said the SP would ask why his/her chores were not completed and the SP would say the VA was lying. The HM provided the following information: · The HM had observed the SP “raise” his/her voice, and on/or around March 14, 2023, the SP “yelled” at the VA for three straight hours. Thereafter law enforcement (LE) became involved, and the VA was taken to the hospital after LE came to the facility. The HM said the incident happened “so fast,” that s/he was unable to record the interaction between the SP and VA. During the incident the VA was in his/her bedroom and the SP was in the living room. The SP was “shouting,” about the VA not answering his/her phone. The HM said there was three or four incidents in which the SP had interacted with the VA in that manner. · The HM said during one incident s/he “was around,” and the SP yelled at the VA while they were in a vehicle. However, later the HM said s/he had heard the SP yelling at the VA while they were in the parking lot of the apartment complex. · The HM said the P was aware of the interactions, but “doesn’t do anything” to intervene. The P “defends” the SP, and would say the SP was a “wonderful staff [person].” The HM said the P does not interact with the SP as often at the VA or HM. · The SP previously provided services to the HM; however, the HM ended the services. The P provided the following information: · The P spoke with the VA approximately twice a week and was not aware of any incidents of the SP yelling, but the VA did bring up concerns related to the HM, and the HM’s messiness within the apartment. · The P was not aware of any incident in March which involved 9-1-1, and if the VA contacted 9-1-1 independently the facility may not have been aware. · The SP was the VA’s primary staff and the VA had made good progress with his/her programing while working with the SP. The P did not have any concerns with the SP’s interactions with the VA. The P said the SP did talk loudly, but did not consider it to be aggressive or any form of emotional/verbal abuse. · The P said the SP’s and the HM’s interactions were like “oil and water.” The SP provided the following information: · The SP denied yelling, name calling, or making any derogatory comments at the VA. · The SP believed s/he worked well with the VA, but said admitted s/he did speak louder than other people. The SP added that s/he tried to work with the VA and picked his/her “battles” as the VA would lie to the SP and the SP would try to address the situation. The SP said an example of that was when the SP was talking to the VA after a doctor’s appointment in which the VA did not appear to be paying attention to the doctor. The SP and VA went to a grocery store after the medical appointment, but the VA refused to talk with the SP after the SP attempted to address the concern of the VA using his/her cell phone in the appointment instead of listening to the doctor. The SP would also ask if the information the VA provided was true, because the VA would tell “big stories,” but the SP only challenged the VA if his/her safety was in jeopardy. · The SP “heard” the VA was suicidal and s/he called 9-1-1, but the SP was not with the VA during that time. The SP spoke with the VA after s/he went to hospital, but the VA did not share a lot of information with the SP. The P and the SP completed training on the Reporting of Maltreatment of Vulnerable Adults, the facility’s policy and procedures, and were trained on the VA’s client specific programming. Conclusion: It was reported that on multiple unknown dates the SP yelled, swore, called the VA names, and accused the VA of doing things s/he had not done. The VA said the SP would “shout” and “yell” at the VA, and accused the VA of lying. The VA said those interactions made the VA emotional and upset, but denied the SP called him/her any names. The VA, the HM, and the SP provided conflicting information about an incident that occurred in a parking lot. On or around March 14, 2023, 9-1-1 was contacted, however the VA was not being provided services at the time of the incident. The VA said s/he called 9-1-1 because s/he was “emotional and depressed.” However, the VA did not state the SP interactions were the reason for 9-1-1’s involvement. The HM said s/he observed the interactions between the VA and the SP and said the SP yelled at the VA, however there were inconsistencies within the information the HM provided which was inconsistent with the information the VA provided. The SP denied ever yelling, or calling the VA any names. The SP admitted to talking louder than most people. The SP stated that s/he tried to work with the VA to address the situation when the information the VA provided seemed inaccurate which the VA did not like. The P observed the SP and did not have any concerns with the SP’s interactions with the VA. The P said the VA had not shared any concerns with him/her about the interactions with the SP. Although the VA said that the SP “shouts” and “yells” at the VA when the VA did “something wrong,” and the interactions with the SP made the VA emotional and upset, the SP denied yelling at the VA and stated that the SP tried to address situations with the VA which the VA did not like. Given this and that the VA stated that the SP did not direct any swear words, name calling, or degrading statements toward the VA; that during an incident when the HM stated the SP yelled at the VA, the HM and the VA provided conflicting information and the SP might not have been working during the incident; and that the P did not have concerns with the SP’s interactions with the VA, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or could be reasonable 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 completed an internal review and determined that the policies and procedures were adequate, and followed. The facility did not complete any additional staff training, and no corrective action was taken. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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