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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: 1104285-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: Allegation one: It was reported that two staff persons (SP1 and SP2) picked on a vulnerable adult (VA) and called the VA names, such as “bitch” and “retard (R word).” In addition, a staff person told the VA that no one loved the VA. Allegation two: It was reported that SP1 hit the VA. Date of Incident(s): Prior to March 23, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clauses (1) and (2): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · The use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility, from law enforcement records, from the VA’s medical records, and through six interviews conducted with the VA, the VA’s guardian (G), the VA’s case manager (CM), the VA’s medical doctor (MD), SP1, and a facility management staff person (P1). Although this investigator contacted SP2 and a facility staff person (P2), they did not respond to requests to be interviewed. Although this investigator talked to P3, P3 chose to not provide information in an interview. The facility had a stairwell that led from the main floor to the upper level. The upstairs had three bedrooms and two bathrooms (one of which was in one of the bedrooms). The staircase had seven steps and the width of the staircase was 36 inches wide. The VA’s Support Plan showed that s/he enjoyed shopping, attending church, and working on crafts. The VA’s Individual Abuse Prevention Plan showed that s/he had 12 hours of unsupervised time in the community. The plan further showed that the VA had a history of engaging in verbal and physical aggression toward others. When that happened, staff persons were trained to “attempt to recognize potential triggers” and “work through coping skills with [the VA] before [s/he] escalates.” The facility’s training records showed that all staff persons interviewed for this investigation, including SP2, P1 and P3, were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to March 15, 2023. Allegation one: It was reported that SP1 and SP2 picked on the VA and called the VA names, such as “bitch” and “[R word].” In addition, a staff person told the VA that no one loved the VA. The VA provided the following information to this investigator: · On various occasions, SP1 and SP2 told the VA that s/he was “[R word],” and that they “pick on me.” The VA gave an example in which s/he asked for help, and the staff person “ignores me,” but the VA did not give specific examples or provide names. Staff persons also told the VA that s/he was not loved by others and spent time on their phones, but the VA did not remember specific information or who said that. · Even though the VA had unsupervised time in the community, there were times that the VA asked staff persons to take the VA into the community, but staff persons refused. The VA was not able to specifically give examples of who did this. SP1 denied calling the VA names or saying that no one loved the VA. SP1 also stated that it was the VA that called staff persons names that were racially motivated. SP1 further stated that s/he had not heard a staff person use derogatory language toward the VA. SP2 did not respond to requests to be interviewed. P1 provided information that was consistent with the information provided by SP1. P1 also stated that there were occasions in which the VA was asked to go out on a community outing, the VA declined the offer because s/he preferred to go with another staff person. The G stated that there were occasions in which the VA told the G that staff persons told the VA that no one loved the VA, but the VA did not provide specific information. The G also stated that there were occasions the VA told the G about regarding staff persons using derogatory terms to the VA, but the G did not remember specific examples. This investigator requested documentation, dated January 1 through March 19, 2023, from the facility regarding the VA’s community outings with staff persons. Documentation showed that on five occasions, staff persons accompanied the VA on community outings. The CM stated that the VA had mentioned that staff persons called him/her names, but the VA did not provide detailed information to the CM. When the CM followed up with P1, P1 told the CM that it was the VA that was the person calling others names. When the CM was asked about the VA’s ability to provide information, the CM stated that the VA had the ability to “fabricate” information. Conclusion for allegation one: The VA told this investigator that SP1 and SP2 told the VA that s/he was “[R word]” and that they “pick on me,” and that an unnamed staff person told the VA that no one loved him/her. The VA told the G and the CM that staff persons called the VA names. However, SP1 and P1 stated that it was the VA who talked in a negative manner toward staff persons and call staff persons names. SP1 and P1 provided consistent information that they had not heard anyone use derogatory language toward the VA. SP2 did not provide information for the investigation. Given that SP1 denied the allegations, that the VA provided limited information without details, and that there was no further information to confirm or refute the allegations, there was not a preponderance of the evidence whether SP1 or SP2 engaged in non-therapeutic conduct that could be reasonable expected to cause emotional distress to the VA. It was not determined whether emotional abuse occurred (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). Allegation two: It was reported that SP1 hit the VA. The VA stated that although s/he did not remember the date, s/he was on the upper level of the facility and was about to begin walking down the stairs when SP1 began walking up the stairs. Shortly after SP1 and the VA passed on the stairs, SP1 hit the VA on his/her lower back, which caused “pain.” SP1 did not say anything to the VA. As a result, the VA told P2 and later called the MD and law enforcement and told them about the incident. The law enforcement report, dated April 4, 2023, stated that as SP1 and the VA passed each other on the stairs, SP1 “touched” the VA, but later the VA stated that SP1 “hit” the VA on his/her back. The VA’s medical records, dated April 6, 2023, and an interview with the MD showed that when the VA and the MD talked on the phone, the VA stated that s/he “got attacked by my staff [person]” and that the VA was “push[ed] on the stairs and hit in back.” The records also showed that the VA requested having X-rays taken. The MD stated that the VA’s ability to provide accurate information was “questionable” and that the X-rays did not show “anything acute.” SP1 provided the following information to this investigator: · At about 6:45 a.m. on the day of the incident, SP1 began walking up the stairs to use the bathroom on the upper level. As SP1 neared the top of the stairs, the VA came out of his/her bedroom and “told me to move.” As SP1 continued going up, the VA came down in a “rush.” While SP1 and the VA passed one another on the staircase, they brushed up against one another. As that happened, SP1 almost lost his/her balance and fell, but did not. · When SP1 finished using the bathroom and went back to the main floor, s/he overheard the VA “screaming” to P2 and P3 that SP1 “touched” the VA. Later, SP1 heard the VA on the phone saying that SP1 “hit” the VA. SP1 denied hitting the VA. P2 and P3 did not respond to requests to be interviewed. Conclusion for allegation two: Although the VA told this investigator and law enforcement that SP1 hit the VA as the VA and SP1 passed one another on the stairwell, SP1 denied hitting the VA and stated that the SP and the VA brushed up against each other when the VA rushed past the SP. SP1 heard the VA telling P2 and P3 that SP1 “touched” the VA on the stairs. When the VA talked to the MD, the VA stated that s/he was “attacked by my staff [person],” but later said that SP1 pushed and hit the VA. When the VA sought medical care, his/her medical records did not provide information that the VA had a back injury that could be attributed to the alleged incident. Given that SP1 denied hitting the VA and stated that they made incidental contact on the stairs, that the VA had no injury, that information was unable to be obtained from P2 and P3 who were present the day of the incident, and that the VA provided conflicting information, there was not a preponderance whether SP1’s actions were accidental or could be reasonably expected to cause physical pain. It was not determined whether physical abuse occurred (Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility completed an Internal Review and determined 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 action taken.
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