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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: 806273-SUD (Substance Use Disorder) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a staff person (SP) called a vulnerable adult (VA) a “monkey,” which “infuriated” and made the VA’s “blood boil.” Date of Incident(s): February 3, 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): 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 for this investigation was obtained remotely, including documentation from the facility; and through interviews conducted with the VA, facility staff persons (the SP and P1), a facility supervisor staff person (P2), and a staff person (S) who worked at the VA’s current residence at the time of this investigation. According to the facility’s website, www.meridianprograms.com, “Cedar Ridge is a place that offers sober support and a feeling of [brother/sisterhood] … Here at Cedar Ridge, we utilize a full spectrum of evidence-based treatment methods, each designed to fit the individual needs of our patients and their individual needs and goals.” In January 2023, the VA moved into the facility seeking supports and services relating to his/her substance use disorder. The facility provided the VA with group therapy sessions, individual counseling sessions, medication management, and service coordination. The VA did not have a history of, or susceptibility to, abuse from others. It was anticipated the VA would complete the facility’s programming within one month. The VA provided the following information to this investigator: · On February 3, 2023, around 8:20 p.m., the VA grabbed two cookies from the facility’s communal snack area. The SP was watching and prompted the VA to only take one cookie. The VA responded, “My bad,” and began to return one of the cookies. The SP stopped the VA and said something, like, “You already put your monkey grabbers on them.” · The SP’s statement made the VA’s “blood boil … It infuriated me.” · The VA relayed his/her concerns to P2. However, shortly after, the VA saw P2 “skipping around” in a hallway, which appeared to the VA as though P2 did not take the VA’s concerns seriously. · On February 6, 2023, the VA submitted a Grievance Form to the facility, which stated the following: After accidently grabbing two cookies on Friday at 8:20 pm with a napkin. [The SP] told me after I look like i wanted to put one back ‘Never mind you already put your MONKEY GRABBERS [capitalization in original]’ on them which is not professional conduct. In the ‘Client Bill of Rights’ Procedure 6 i have the right to be free from being the object of unlawful discrimination while receiving Counseling Services… · On February 6, 2023, P2 responded to the VA’s Grievance Form with the following: [P2] spoke w/[the SP] and [s/he] reported not meaning disrespect but understands the importance of cultural sensitivity. [P2] had spoken with [the VA] in regards to incident. · The VA also told various staff persons, including P1, about the SP’s conduct. P1 told the VA that s/he was “overexaggerating.” Another staff told the VA that the SP “meant nothing” by what s/he said, and yet another staff person told the VA, “Focus on your recovery.” The VA felt that no one was taking his/her concerns of the SP’s conduct seriously. “I thought I was going crazy. I thought that I wasn't supposed to stand up for my rights, or that I was really being a distraction, or I thought I was really overexaggerating. I thought I was overanalyzing things because they kept drilling this in my head every time I went into the office, but I just I knew that they were, I knew they were wrong.” · According to the VA, the SP’s job duties included walking around the facility and ensuring all patients were present. The SP continued to work following the incident and walked through the areas the VA was in multiple times per day, which made the VA “uncomfortable.” The VA did not like seeing the SP and believed the facility should have taken additional corrective action toward the SP. “I didn’t want [the SP] checking on me to see if I’m okay. [The SP] knows I’m not okay. [S/he’s] the reason why I’m not okay.” · In late February 2023, the VA successfully completed the facility’s programming. Toward the end of the VA’s stay, s/he wanted to immediately leave and get away from the SP. The VA eventually called the police, who transported the VA to a mental health facility. The VA did not return to the facility. · The VA had written down prepared topics or reminders to talk to this investigator about during our interview. At various points, the VA read directly from his/her notes. During one such time, the VA said, “The errors of these individuals, or of this program has me feeling like, or I know what it has me feeling like, my mental health status will never. And, emphasis on ‘never.’ The errors of these individuals or of this program has me feeling like my mental health status will never be restored to its preexisting condition.” The VA added, “Just that sentence right there, like it says a lot that has to do with the whole mental health side of things. It’s powerful. I feel like that, as soon as, I don't think that my mental, my mental health will be restored. I don't know. I hope I can. I don't know if I can come back around to trusting people or trusting treatment centers or trusting people in authority right now. My trust is shot.” · “They put me through so much emotional anguish, by downplaying and minimizing my rights as a patient, a resident or citizen, to the point I didn’t, I didn’t even want to eat the food that they were providing me.” The S said that the VA told him/her about the SP’s statement about a month after it happened. The S described the VA’s demeanor while speaking of the incident as “physically and emotionally anxious, stressed out, pacing, angry, and agitated.” The SP said that at the time of the incident, s/he intended to say to the VA, “You already put your pudgy grabbers on” the sandwiches. [Note: The VA said that s/he grabbed two “cookies” and the SP said that they were “sandwiches.”] The SP explained that s/he was trying to be “cute or funny” with the VA, but the SP’s statement accidentally came out as “monkey grabbers.” The VA did not immediately react in any way and left the area without incident. The SP did not think anything more of it. However, shortly after, the VA confronted the SP and the SP “immediately apologized.” Later that same evening, the SP checked-on the VA. They fist-bumped and the incident appeared to be resolved. The two went on with their evenings without further incident. However, a few days later, the VA relayed his/her concerns to P2. A meeting was held with the VA, the SP, and P2 to talk about what happened. In this meeting, the SP again apologized to the VA. According to the SP, the VA stared at the ceiling and repeatedly asked to leave, disregarding the SP’s apology. “I tried to make amends. It was an accident. But, [the VA] was not receptive to any of it.” P1 and P2 never had concerns with the SP’s conduct. P1 said that the facility admitted clients from “all walks of life” and of different cultural backgrounds. P1 was not aware of any concerns with the SP’s conduct toward any specific group of people. P1 added that when the VA was initially admitted to the facility, s/he appeared focused on finding what was “wrong” with the facility. The VA would focus on one topic and then become focused on another topic, and so on. When the incident with the SP happened, the VA focused on that. Additional information unrelated to the incident: The VA shared the following additional concerns regarding the facility’s operation: · The VA believed that the facility was withholding his/her mail. The VA had expected to receive an electronic benefits card in the mail, which never arrived while s/he was living at the facility. The VA had applied for the benefits card around January 25 or 28, 2023. The VA moved out of the facility on February 15, 2023; and as of this investigator’s interview with the VA on March 3, 2023, the card had not yet arrived in the mail. The VA also expected to receive a letter in the mail from a lawyer. The VA did not have a specific lawyer s/he was waiting to hear from; rather, the VA said, “I was expecting a letter from a lawyer because I was calling lawyers back-to-back.” [Note: At the completion of this report, this investigator attempted to contact the VA to check the status of his/her mail. The VA’s whereabouts were unknown and so receipt of the benefits card or letters were not verified and/or delays in delivery were not determined. The residence where the VA had most recently been living told this investigator that they received mail addressed to the VA but were unable to locate him/her for a forwarding address. A violation was not determined.] · P2 had a history of “screaming” at the patients. The VA provided an example that P2 would scream something, like, “Go to group.” “[S/he’s] screaming in my ear. Like, my ear was ringing.” The VA confronted P2 about his/her screaming; and P2 responded something, like, “Thank you for telling me that … I’ll take it into consideration.” [Note: Given that the example provided by the VA did not include treatment that violated the VA’s right to be treated with courtesy and respect, a violation was not determined.] · The facility did not review their grievance policy with the VA when s/he initially moved in. [Note: The facility provided documentation that the VA was oriented, given information, reviewed, and had the opportunity to ask questions about various policies, including the Patient Grievance Policy. A violation was not determined.] · The facility removed access to the patient phones during group times. “The phones will get put back after group.” [Note: P2 provided information that the patient phones were removed between 9 a.m. and 4 p.m. on weekdays to encourage group attendance. However, professional calls to lawyers, probation officers, etc., remained available with staff assistance. This removal of telephones was consistent with the facility’s policies and procedures, and licensing guidelines. A violation was not determined.] Facility documentation stated that the staff persons interviewed for this investigation received training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The VA and the SP provided consistent information that on February 3, 2023, the SP stopped the VA from returning a cookie or sandwich that s/he touched to the facility’s communal snack area. The SP said something, like, “You already put your monkey grabbers on them.” The VA said that the SP’s statement made his/her “blood boil … It infuriated me.” The SP said that s/he misspoke while trying to be “cute or funny” with the VA. The SP did not think anything more of it; however, “immediately apologized” when the VA expressed concern. P1 and P2 never had concerns with the SP’s conduct. Given that the SP described his/her statement as an accident; that the SP “immediately apologized” and later apologized again in the presence of P2; that there was no information the SP’s statements were repeated or with malicious intent; and that there was no information the SP treated the VA in a manner which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening, there was not a preponderance of the evidence whether the SP’s single statement could reasonably 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 completed an internal review and determined that policies and procedures were adequate and followed. The facility provided additional training to the SP. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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