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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: 1100381-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) verbally threatened a vulnerable adult (VA), picked up the VA by one of his/her arms and legs and then let go of the VA, causing the VA to fall onto the floor. Date of Incident(s): January 5, 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 was obtained during a site visit conducted on February 23, 2023; from documentation at the facility and a school that the VA attended daily; and through seven interviews conducted with facility staff persons (the SP, P1, and P2), two education professionals (EP1 and EP2), the VA, and the VA’s guardian (G). This investigator also contacted five additional education professionals (EP3, EP4, EP5, EP6, and EP7), by phone who might have witnessed the incident, but they did not respond. The VA attended school daily in the community at a school that provided education services to young people with disabilities. The school had small highly structured classes and a calm learning environment. Its employees had skills which assisted students to self-regulate. Social workers who provided mental health supports were employed at the school and teachers were to treat the students with respect, dignity, and compassion. Facility documentation showed that the VA was diagnosed with autism, an intellectual disability, and anxiety. The VA had no unsupervised time in the community and attended the school five days a week. If there were unexpected changes to the VA’s schedule, s/he needed extra time to adjust to the changes. The VA might become upset, try to leave the school without supervision, leave the facility, or lock staff persons out of the facility and think about or talk about what happened for hours or days. An Action Plan showed that the VA might make verbally aggressive statements of harm toward others, destroy property, throw items, hit doors/walls, or slam doors, bite, hit, pinch, grab, kick, punch, scratch, or posture to hit others. If the VA engaged in verbal or physical aggression toward anyone, staff persons were to remain calm, use a soft tone of voice, remain out of arm’s reach of the VA when talking with him/her, use empathic statements to validate the VA’s feelings, and redirect the VA to preferred topics. Staff persons were not to argue or engage in power struggles with the VA but should physically intervene if the VA targeted staff persons, a housemate, or others, and could not be redirected. The VA might not recognize dangerous situations/persons or react appropriately. The VA expressed his/her concerns but not immediately or clearly and had a high pain tolerance. Computers/technology interested the VA, but s/he got very upset quickly if devices did not function properly or like the VA thought it should. Facility documentation and information provided by the VA, P1, P2, the SP, EP1, EP2, and the SP, and information from the Internal Review, provided the following: EP1 said that at 8:15 a.m. on January 5, 2023, the VA banged a table in his/her classroom, made verbal threats, and asked EPs to fix his/her laptop computer, which was not working with audio/headphones. The EPs called the G to notify him/her about the VA’s behavior and fixed the VA’s laptop, but the VA was still upset and made additional verbal threats, so the VA was given an as needed medication at 8:30 a.m., to calm him/her. The VA calmed and took a nap in the classroom from 8:30 to 9:55 a.m., but when s/he woke, s/he hit an unspecified EP “in the face” and then tried to follow him/her out of the classroom. Other EPs blocked the VA from leaving by standing between the VA and the door, and the VA began hitting, grabbing, trying to bite the EPs, and kicking the classroom door. The VA was taken to a safe quiet room at the school to take a break and the EPs attempted to verbally de-escalate the VA. However, the VA continued to hit and scratch the EPs. At 10:20 a.m., the VA calmed and returned to the classroom. From 10:20 to 11:07 a.m., the VA intermittently punched tables, grabbed and pushed EPs, and engaged in “minimal to medium” property destruction. At 11:09 a.m., the EPs began taking the VA to the quiet room for a break but when they neared the room, the VA hit, kicked, and grabbed the EPs. The EPs placed the VA in the room, exited the room themselves, then closed and locked the door, leaving the VA inside. The VA made verbal threats and kicked/hit the door. EPs attempted to unlock the door to let the VA out at 11:18, 11:23, 11:28, and 11:33 a.m., when the VA moved away from the door. Each time the door was opened, the VA moved toward the EPs and exhibited physically aggressive behavior, which caused the EPs to close and lock the door with the VA inside, while they remained outside the door to monitor the VA and verbally de-escalate him/her. EPs contacted the G and the SP, who each suggested that leaving school might “break” the VA’s fixation on the issue that upset him/her, and the SP came to the school at 12:15 p.m. to take the VA back to the facility. However, the VA declined to leave with the SP and attempted to return to his/her classroom while physically aggressing toward the EPs. At 12:20 p.m., the SP and the EPs brought the VA back to the quiet room, but the VA was physically aggressive, and at 12:30 p.m., the SP gave the VA an as needed medication to calm him/her. At 12:45 p.m., the SP asked the VA to walk to the facility van with him/her, but the VA had “high magnitude aggression” toward the EPs including wrapping his/her legs around the legs of unspecified EPs and declining to walk with the EPs, who attempted to verbally de-escalate the VA. Soon, the VA entered the facility van and the SP attempted to take the VA back to the facility, but the VA physically aggressed toward the SP in the van, and it became unsafe. The SP and the VA then re-entered the school and the VA sat on a bench in the school’s entrance for about 35 minutes with the SP redirecting the VA to calm. At 1:25 p.m. the VA left the school safely and entered the van with the SP. EP1 said that the SP made threatening statements to the VA including asking the VA whether s/he wanted the SP to beat him/her up or beat his/her ass, asking the VA what was wrong with him/her, and telling the VA to shut up. After several minutes of the VA and the SP exchanging verbally aggressive statements, the SP picked up the VA by his/her arm/leg then released the VA, which caused the VA to fall about six inches to the floor, but EP1 was unsure whether the VA landed on his/her side, back, or face down. EP1 told the SP that grabbing the VA then dropping him/her to the floor was not a physical procedure used at the school and the SP said that s/he understood. EP2 provided a similar account of the statements the SP made to the VA during the incident but added that the SP did not drop the VA; it was more like the VA pulled away from the SP and then fell. Information was consistent that the VA had no visible physical injuries after the incident. The SP stated that s/he went to the VA’s school to help with the VA because the VA had a “serious behavior” At the school, the SP gave the gave the VA an as needed medication which s/he brought with him/her but the VA continued to be upset. The issue with the computer was resolved, the VA said that s/he was okay, and wanted to return to class, but the EPs thought that the VA might aggress toward his/her classmates and said that the VA could not stay at the school. The SP asked the VA to go to the facility, but the VA declined, began hitting the EPs, and spitting on the SP’s face but s/he continued redirecting the VA toward the facility van and the VA got into the front passenger seat. When the SP sat in the driver’s seat, the VA spat on the SP, hit and kicked him/her, and kicked the windshield of the van. The SP attempted to hold the VA’s hands and legs to prevent the VA from having further physical aggression but realized that s/he could not take the VA to the facility while the VA was extremely upset. The VA freed him/herself from the SP’s grasp, exited the van, and ran toward the school. The SP ran after the VA grabbing the VA’s clothing to prevent him/her from entering the school and physically aggressing toward others. The SP and the EPs discussed the best course of action to take with the VA, redirected the VA to return to the facility, and the SP offered to buy the VA food from one of his/her favorite restaurants. The VA quickly agreed to having food from the restaurant, calmed, and walked willingly with the SP to the facility van. The SP said that s/he did not pick the VA up by his/her arm/leg, drop him/her, or threaten to hit or beat the VA during the incident. The VA did not fall during the incident and sustained no injuries during his/her interactions with the SP. The SP and VA went to the restaurant and the rest of the day passed without incident. P1 said that the facility was made aware of the concerns regarding the SP and began an investigation. According to P1, the VA told him/her that the SP did not threaten to “beat” his/her “ass,” pick him/her up by his/her arms/legs, tell him/her to shut up, slap him/her, or hit him/her. P2, the SP’s supervisory staff person, said that the actions attributed to the SP were “very shocking” and surprised him/her. According to P2, the SP knew the VA very well and had a strong history of being able to de-escalate the VA when s/he was upset. The SP worked well with the VA because s/he did not “get scared” of the VA and was able to handle difficult situations. The SP might raise his/her voice when the VA or his/her housemates behaved aggressively but P2 thought that the SP’s voice was firm, and s/he did not have concerns regarding the SP’s work. The VA did not complete an interview with this investigator and said that s/he did not want to discuss the incident. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was trained on Crisis Response and De-escalation on April 16, 2022, and retrained on January 13, 2023, and attended the facility’s annual policy and procedure training on June 24, 2022. Relevant Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection-related rights include being treated with courtesy and respect. Conclusion: Information was consistent that on January 5, 2023, the VA was upset and had physically and verbally aggressive behaviors at the school. The EPs called the SP for assistance and the SP attempted to redirect and calm the VA, but his/her behavior remained escalated, so it was decided that the SP should take the VA to his/her residential facility. There were concerns that the SP made repeated threats of physical violence to the VA and that s/he picked up and dropped the VA during the incident at the school. EP1 and EP2 each stated that the SP asked the VA several times if the VA wanted to the SP to “beat” his/her “ass,” said that s/he would beat the VA’s ass and told the VA to shut up. EP1 said that the SP picked up the VA and dropped him/her but EP2 stated that it was more like the VA fell when pulling away from the SP. The VA sustained no physical injuries during the incident. The VA did not complete an interview with this investigator and the SP denied that s/he said s/he would beat the VA’s ass, asked the VA if s/he wanted the SP to beat his/her ass, told the VA to shut up, or dropped the VA. Regarding physical abuse: Although EP1 said that the SP picked the VA up by an arm and a leg then dropped him/her, given that EP2 stated that the VA pulled away from the SP, that the SP denied that s/he picked up or dropped the VA, and that the VA did not sustain a physical injury, there was not a preponderance of the evidence whether the SP picked up and dropped the VA or whether all of the SP’s actions were non accidental and could be reasonable expected to cause the VA physical pain or injury. 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). Regarding emotional abuse: The SP denied that s/he threatened to beat the VA’s ass, asked the VA whether s/he wanted the SP to beat his/her ass, or told the VA to shut up, but EP1 and EP2 provided consistent information that the SP made the aforementioned statements to the VA, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Although it was likely that the SP used these phrases toward the VA, given that there was no information that the SP had done so on other occasions, there was not a preponderance of the evidence whether this incident was repeated or would be considered by a reasonable person to be humiliating or threatening. 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). Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but could not determine whether the policies and procedures were followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The facility took immediate action and the SP no longer worked at the facility so a correction order for the violation outlined in this report was not issued.
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