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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: 1071080-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) was “mean” to a vulnerable adult (VA), pulled the VA’s hair, and spanked the VA’s buttocks. Allegation Two: It was reported that one time, the SP left the VA unsupervised in a parked car for approximately five minutes.
Date of Incident(s): Allegation One: Exact date unknown prior to February 24, 2023 Allegation Two: March 14, 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 (1); 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. 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 for this investigation was obtained during a site visit conducted on March 30, 2023; including documentation from the facility; and through interviews conducted with the VA, the VA’s guardian (G) who was also the VA’s family member, a facility staff person (SP), and a supervisory staff person (P). Attempts were made to contact a staff person (S1) who worked at the VA’s day services facility, but S1 did not respond by the completion of this investigation. In 2001, the VA moved into the facility seeking supports and services relating to his/diagnoses, which included developmental disability. The facility was a single-family home where the VA lived with three housemates. The facility employed at least one staff person 24 hours a day for care and supervision. Facility documentation stated that the SP received training on the VA’s support plan and support plan addendum; the facility policies and procedures; and the Reporting of Maltreatment of Vulnerable Adults Act. Allegation One: It was reported that the SP was “mean” to the VA, pulled the VA’s hair, and spanked the VA’s buttocks. The VA’s support plan and support plan addendum provided the following information: · The VA needed assistance to meet his/her daily needs and activities, including showering and other hygiene cares. · “[The VA] may not be able to defend [him/herself] from physical abuse … Staff will intervene, through verbal directives to assist [the VA] in avoiding or escaping dangerous situations and/or people.” On February 24, 2023, the VA told S1 that s/he was “scared” of a staff person at the VA’s home. The VA used a nickname to identify the staff person and described which shift (time of day) the staff person worked. [Note: The P confirmed that this was the SP’s nickname and the SP’s work shift.] S1 asked why the VA was “scared” of the SP, and the VA said that the SP was “mean” and spanked the VA’s buttocks and pulled the VA’s hair. [Note: There was no information that S1 observed injuries on the VA consistent with being spanked or having his/her hair pulled.] This investigator met the VA at his/her day services facility and a day services staff person (S2) joined the meeting to assist the VA with communication. S2, the FM, and the P provided information that the VA was easily distractable, very excitable, and sought physical contact with others which was consistent with observations during the interview. Throughout the interview, the VA made repeated attempts to shake hands and hug. The VA’s speech was difficult to understand, and s/he made unintelligible noises. When asked about his/her home, the VA made several unintelligible noises and fast movements with his/her body, and initially did not appear to understand. However, then the VA clearly stated, “[The SP’s nickname].” The VA followed this by making additional unintelligible noises while repeatedly trying to hug this investigator and S2. However, then the VA clearly stated, “[The SP’s nickname]. Mean to me. Pulled my hair,” and then the VA began pulling his/her own hair. The VA stated that this happened more than once. The VA did not make any statements about being “spanked.” The G provided the following information: · Over the past year, which was also the timeframe the SP worked at the facility, the VA became increasingly nervous and guarded, and was spending more time in his/her bedroom. According to the G, these changes indicated that the VA was “not comfortable” or that “something is not right.” · On or around February 24, 2023, the G was informed by a staff person at the VA’s day services program that the VA made a comment about the SP pulling the VA’s hair in the shower. The G wondered if the SP pulled the VA’s hair as a reaction to, or being “upset” by, the VA’s bowel movements. The VA’s bowel movements had a history of being “large and messy,” and requiring a shower to get cleaned up. The VA needed help from a staff person to shower. “All staff” were bothered by the VA’s bowel movements, and the G “suspected” they bothered the SP as well. The VA was “always apologizing” about his/her bowel movements. The G added, the VA should not be apologizing for going to the bathroom. · According to the G, the VA did not have a history of intentionally providing inaccurate information and/or trying to get staff in trouble. The P provided the following information: · The VA had a history of experiencing large and “messy” bowel movements, which “100% of the time” required staff assistance to clean up after. “Usually [the VA] needs a shower right after.” The VA always required help from a staff person to shower. · Regarding a concern that the SP might have pulled the VA’s hair or spanked the VA’s buttocks because the SP was “upset” about the VA’s hygiene needs; the P had no information this was the case. “[The SP] never said anything negative about” the VA’s bowel movements or hygiene needs. The P was not aware of any times when the VA needed a shower or help with hygiene, and the SP declined or did not do so adequately. · Staff recorded the VA’s bowel movements on a tracking form. According to the P, the SP consistently documented on the tracking form. The P was not aware of any indication in the SP’s documentation that s/he was “upset” about having to help the VA clean up. The SP also reminded other staff to document on the tracking form. · The P did not believe the VA would “complain” or “express [his/her] feelings” if s/he had concerns about a staff person. “[S/he] doesn’t express a whole lot.” · The VA did not have a history of intentionally providing inaccurate information and/or attempting to get staff in trouble. However, the VA did have a history of “misinterpreting information.” “I came in one day, and [s/he] said that [s/he] thought I didn’t like [him/her] because I was off for a few days.” The P had to reassure the VA that this was not the case. · The P did not have, and was not aware of others having, concerns with the SP’s conduct. The SP said that s/he “never” spanked the VA’s buttocks or pulled the VA’s hair. There was also “never” a time when the VA cried during a shower or pulled away from the SP’s reach. The SP did not believe the VA would make a statement, like what was alleged, unless someone asked him/her specifically about it; and even then, the VA had a history of saying “yes or no to anything” without knowing what was being asked. An additional concern was raised that one time, the SP gave ice cream to the housemates, except the VA. The P said that the VA did not have a written plan regarding his/her diet, but that the VA would “eat sweets all day long” if s/he was able. The P and the SP each said that staff encouraged the VA to eat healthy, including to finish his/her dinner before receiving desserts, like ice cream. Regarding this specific incident, it was not recalled how it concluded and/or if the VA eventually ate his/her dinner and/or the ice cream. Although the concept of withholding food was inconsistent with licensing guidelines, it was unknown if the ice cream was completely withheld and if so, for how long; and to what degree the SP was encouraging the VA to finish dinner before eating ice cream. A licensing violation was not determined. Conclusion for Allegation One: The VA told S1 that the SP was “mean” and spanked the VA’s buttocks and pulled the VA’s hair. The VA also told this investigator that the SP was “mean” and pulled the VA’s hair. The SP denied the allegations. The G did not believe the VA had a history of providing inaccurate information. However, the P said that the VA had a history of misinterpreting information; and the SP said that the VA had a history of saying “yes or no to anything,” and would not typically make a comment like what was alleged unless s/he was specifically asked about it. The P also did not believe the VA would “complain” or “express [his/her] feelings” if s/he had concerns about a staff person. “[S/he] doesn’t express a whole lot.” The P was not aware of previous concerns with the SP’s conduct and added, “[The SP] never said anything negative about” the VA’s cares or gave any indication of such in his/her documentation. S1 did not provide information for this investigation so the circumstances surrounding the VA’s initial disclosure were unknown. Given that additional information from S1 was not available, that the SP and the VA provided conflicting information, that there was no information provided that the VA sustained injuries, and that there were no other concerns regarding the SP’s interactions, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or whether the SP’s actions included conduct which produced or could reasonably be expected to produce 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). Allegation Two: It was reported that one time, the SP left the VA unsupervised in a parked car for approximately five minutes. The VA’s support plan and support plan addendum provided the following information: · “[The VA] is unable to remain alone in any environment. Staff accompany [the VA] to all community activities. [The VA] is to remain within visual range and within an arms-length of staff at all times. Staff will intervene, through verbal directives to assist [the VA] in avoiding or escaping dangerous situations and/or people.” · “[The VA] can be easily led by others and may talk, hug, kiss, or hold a stranger’s hand … [The VA] may not be able to communicate where [s/he] lives, identify safe persons to talk to, and could easily become disoriented and scared in the community.” · “[The VA] does not monitor traffic or activity in parking lots and/or in streets. [The VA] is unable to take public transportation and benefits from supervised transportation to all community activities. [The VA] is unable to be in the community alone. [S/he] tends to elope if not being supervised.” The SP said that on March 14, 2023, s/he parked his/her car “pretty close” to a grocery store and then went inside to grab an additional item for dinner, leaving the VA unsupervised in the car for about five minutes. The car doors were locked, and the VA was listening to music. The VA remained in the car, unharmed, until the SP returned. According to the SP, s/he had previously asked the P if it was okay to leave the VA in a car for the purpose of running into a store to grab something quick, and according to the SP, the P said that this was okay to do. In hindsight, the SP believed that the P might have misunderstood and/or was not familiar with the VA’s supervision requirements at the time, and so the SP should have asked someone else this question. The G said that the VA had “no alone time” in the community. Staff should be “standing right next to” the VA when in the community. “You can’t leave [him/her] alone for a second.” The P said that following this incident, s/he reminded the SP about the VA’s supervision requirements. The P was not aware of previous concerns with the SP’s provision of the VA’s supervision. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), states the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071. Conclusion for Allegation Two: On March 14, 2023, the SP left the VA unsupervised in a car for five minutes; the VA remained in the car and was unharmed. The SP believed that s/he had received approval to leave the VA in such situations; however, later realized that s/he should have asked for more clarification. The conduct of leaving the VA unsupervised in the community was inconsistent with the VA’s support plans, and a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a). However, given that the VA was left alone for a short period of time and was not harmed, there was not a preponderance of the evidence whether the SP’s conduct included a failure which was reasonable and necessary to maintain the VA’s health or safety. 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). Action Taken by Facility: Allegation One: The facility completed an internal review and determined that that policies and procedures were adequate and followed. The SP denied pulling the VA’s hair, spanking the VA’s buttocks, and withholding food from the VA. The facility provided additional training to the SP on the VA’s support plans and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was no longer working with the VA. Allegation Two: The facility completed an internal review, and determined that policies and procedures were adequate, but not followed. The facility provided additional training to the SP on the VA’s support plans and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was no longer working with the VA. Action Taken by Department of Human Services, Office of Inspector General: On May 17, 2023, the facility was issued a Correction Order for the violation outlined in this report.
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