|
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: 1104819-HCBS (Home and Community-Based Services) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP1) screamed at, was mean to, and threatened a vulnerable adult (VA) because the VA did not pick up his/her dirty clothes. In addition, SP1 sometimes smelled like alcohol when s/he worked at the facility. It was also reported that a second staff person (SP2) frequently smelled like marijuana, and on January 13, 2023, SP2 “reeked” of marijuana and laughed at the VA when s/he took the VA to an appointment in the community. Date of Incident(s): Prior to February 2, 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); 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: 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. 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: The apartment where the VA lived was an unlicensed residential setting where the VA was provided services twenty-four hours a day, seven days a week that were administered under the parent company’s home and community-based services license. The VA was to have two awake staff persons during the day and one awake staff person at night. There were alarms on the apartment’s main door and on its windows that sounded to alert staff persons when the door or windows were opened. The VA’s apartment will be referred to in this report as “the facility.” Pertinent information was obtained during a site visit conducted on March 2, 2023; from documentation at the facility; and through five interviews conducted with facility staff persons (the P, SP1, and SP2), the VA’s case manager (CM), and the VA’s guardian (G). This investigator met the VA and talked with him/her, but s/he did not provide information regarding the allegations in this report. Facility documentation showed that the VA was diagnosed with a developmental disability, and s/he had a history of providing inaccurate information according to the Individual Abuse Prevention Plan. There were no rights restrictions in place for the VA and no protocol that permitted staff persons to search him/her or his/her bedroom. The VA was vulnerable to maltreatment and would not likely recognize dangerous situations. Staff persons were to always have eyes on the VA in the community and closely supervise him/her in the facility. The VA’s needs were discussed with him/her, and staff persons were to assist the VA to make appropriate word choices and intervene if s/he became verbally or physically inappropriate with others. The VA had a history of sniffing/smelling unsafe scents or fumes, using vape devices, or spraying aerosol chemicals onto his/her body without regard to his/her personal safety when his/her access to these items was unsupervised. If the VA obtained an item that s/he should not have, the VA might ingest or use the item quickly and when s/he was told “no” or “stop,” the VA might become physically or verbally aggressive. The VA had no mobility issues and sometimes used his/her quickness to get away from staff persons or leave the facility without supervision to find items that s/he should not have which s/he hid in his/her clothing to access them later in his/her bedroom or bathroom. The VA had no unsupervised time at the facility or in the community and was subject to guardianship. Using technology and computers was enjoyable to the VA but s/he was to be closely supervised by staff persons when s/he browsed the internet or handled electronic items. Interviews with this investigator and information from the facility provided the following: The G said that the VA told him/her that on dates the VA could not recall, SP1 “screamed” at the VA because s/he did not pick up his/her dirty clothes, was “mean” to the VA, and threatened him/her not to bring up SP1’s name to others or talk about him/her, all of which caused the VA to go to bed early to avoid SP1. At team meetings, SP1 raised his/her voice to the VA, told the VA not to “talk about” him/her, and advised the VA that s/he would “confront” him/her if s/he became aware that the VA had talked about him/her. The G thought that SP1 retaliated against the VA by yelling at him/her more when the VA expressed his/her concerns. In addition, SP1 often smelled like alcohol when s/he worked at the facility and SP2 smelled like marijuana and laughed at the VA at an appointment in the community, which upset the VA and caused him/her to engage in aggressive behaviors. SP2 carried a vaping device in his/her pocket and brought a lighter at the facility. The VA obtained the vape device and used it in his/her bedroom during an overnight shift and a staff person took the device from the VA the next morning when s/he became aware that the VA had it. The G was concerned that staff persons might not be able to adequately supervise the VA if they were “impaired” and thought that the “atmosphere” at the facility was “toxic” for the VA. SP1 said that it was difficult to provide services to the VA because the VA did not agree with his/her plans or the facility’s policies and procedures. The VA often did not follow redirections from staff persons and complained about the rules and how things were “set up” at the facility. The VA felt that s/he did not have the freedom to come and go as s/he pleased, and because of his/her supervision needs, two staff persons were required to take the VA on outings in the community, which caused the VA to be frustrated when there were not two staff persons per shift. The VA preferred to have a set routine that did not change. In addition, the VA might tell a staff person that he did not receive an item from a previous staff person to obtain the item from the staff person on the next shift. On a shift a few weeks ago, SP1 smelled a “strong substance” in the bathroom and told the P (who was a supervisory staff person) about it. SP1 and the P later learned that the VA had a vape device in his/her bedroom that s/he found in the community and had been using the device in the bedroom and in the bathroom. The VA gave the device to staff persons and after that incident, staff persons began observing the VA more closely during and after community outings for items s/he should not have. SP1 said that the G had threatened to sue him/her and the parent company when the G was upset with the care that the VA received and “went ballistic” because s/he thought that staff persons were preventing the VA from participating in a sports event selected by the G. SP1 explained to the G that the VA was not being held back from the event, but had decided that s/he did not want to take part in it. There were sometimes issues with communication between staff persons, the facility, the VA, and the G, which was often a cause of stress for all involved when the VA’s team was not “on the same page.” SP1 said that s/he followed the VA’s plans, was direct with him/her, and did not go along with the VA when s/he spoke negatively about other staff persons to SP1. The VA might consider these actions threatening or confrontational. When SP1 worked overnight shifts, s/he used a mouthwash before s/he went to sleep at the facility and in the morning when s/he woke and supposed that it was possible that the VA confused the smell of mouthwash with the smell of alcohol. However, SP1 denied that s/he screamed at the VA, was mean to him/her, threatened the VA, or used alcohol at the facility. SP2 stated that s/he had previously discussed allegations in this report with the P and acknowledged that s/he used a vape device but did not use it at the facility The VA liked to have things go his/her way and when they did not, the VA called staff persons names and tried to talk about them to other staff persons. Staff persons were to ignore the VA’s statements or redirect the VA by telling him/her that his/her statements were not nice and that they did not appreciate the VA calling them names. The VA was manipulative, had a history of providing inaccurate information, and tried to obtain desired answers from newer staff persons if seasoned staff persons declined his/her requests for preferred items. SP2 heard from the P that the VA found a vape device in the facility parking lot and used it in the bathroom during shifts when various staff persons worked. SP2 worked his/her shifts at the facility without becoming involved in the gossip that occurred there and had no concerns about staff persons working under the influence of alcohol or using raised voices at the facility. The SP denied that s/he laughed at the VA, denied that s/he smoked or used a vape device at the facility, and said that the VA found the vape device s/he used at the facility in the community, but the device did not belong to SP2. The P said that s/he learned of the concerns regarding the SPs in late January or early February and took them seriously, interviewed staff persons, and the VA. There were concerns about the VA because s/he often left the facility when staff persons who were working single staffed went to the bathroom and was very difficult to supervise. The VA might attempt to disable the alarm on the facility door and had many needs. SP1 had worked with the VA since s/he moved into the facility and was very “by-the-book” which was upsetting to the VA and caused the VA to have “issues” with SP1. Other staff persons let the VA “get away with things” and let him/her have extra food items that s/he should not have but SP1 did not let the VA have extra food items and followed the VA’s plans. P had no concerns regarding SP1’s work and thought that SP1 did not “shout” at the VA. When the P asked the VA about SP2 smoking marijuana at the facility, the VA initially said that SP2 was smoking cigarettes in the facility then later said that SP2 smoked marijuana. The P interviewed staff persons and SP2 and information was consistent that no one smelled smoke or observed SP2 smoking anything at the facility. The VA obtained a vape device that s/he likely found in the community, used the device in the bathroom/bedroom at the facility, and later gave the device to a staff person. It was possible that the VA found the vape device when s/he was on a visit with the G. The P had no concerns regarding SP2’s work at the facility but thought that the facility and its staff persons were no longer able to provide the level of care and supervision that the VA required. The VA’s team had met many times to discuss the VA’s care and the program recommended that the VA receive services through another program after April of 2023. The CM said that the VA was frustrated and might have physical or verbal outbursts but could generally communicate his/her wishes to staff persons and others. Facility administrative staff persons were sometimes slow to respond when the CM asked them for information, but s/he had no concerns regarding the VA’s care. A law enforcement agency was aware of the information in this report but did not investigate it. Personnel files, including training information, were reviewed. The SPs were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s plans of care prior to January of 2023. Conclusion: Regarding SP1: The G said that SP1 sometimes “screamed” at the VA, was “mean” to him/her, threatened the VA, and smelled like alcohol when s/he worked at the facility, which caused the VA to be upset and go to bed early when SP1 was on shift. This investigator met the VA, but s/he did not provide information regarding the allegations in this report. SP1 stated that generally the VA did not agree with his/her plans, staff persons, or the facility’s policies and procedures, which made it difficult to provide care to him/her. There were communication issues between the VA, the G, facility staff persons, and the VA’s team, which caused stress and made it hard for everyone have the same understanding of the VA’s needs. According to SP1, the G threatened to sue SP1 and others when s/he thought they prevented the VA from participating in an event the G wanted the VA to take part in, but it was the VA who declined to participate in the event. SP1 said that s/he followed the VA’s plans but denied that s/he screamed at the VA, was mean to him/her, or threatened him/her, and denied that s/he used alcohol at the facility. The P said that s/he had no concerns regarding SP1’s work but took the above issues seriously and investigated them. The VA was upset by SP1 and had issues with him/her because SP1 was “by-the-book” and strictly followed the VA’s plans. Although there were concerns regarding SP1’s interactions with the VA, given that the VA had a history of providing inaccurate information, that there were no corroborating witnesses to the information provided regarding the allegations, that the P had no concerns about SP1’s work, and that SP1 denied that s/he screamed at the VA, was mean to him/her, or threatened him/her, and said that s/he did not use alcohol at the facility, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or maintain the VA’s health or safety or whether all of SP1’s conduct was therapeutic and could be expected to cause the VA emotional distress. It was not determined whether neglect or emotional abuse 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 or 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). Regarding SP2: The G said that on January 13, 2023, SP2 smelled of marijuana and laughed at the VA at an appointment in the community which upset the VA, and often smelled like marijuana when s/he worked at the facility. SP2 said that s/he worked his/her shifts and then left, without becoming involved in gossip at the facility. SP2 used a vape device but denied that s/he used the device or marijuana at the facility and denied that s/he laughed at the VA. According to SP2, the VA found a vape device in the parking lot and used it in the bathroom when various staff persons worked. The P said that s/he had no concerns regarding the SP2’s work and thought that the VA obtained a vape device in the community that s/he used at the facility. The VA had no rights restrictions and staff persons were not permitted to search him/her or his/her bedroom. The P thought that the facility could not provide the level of care that the VA needed, and it was recommended that s/he no longer receive care or services from the facility. Although there were concerns that SP2 often smelled like marijuana at the facility and laughed at the VA at a community appointment on January 13, 2023, given that the VA had a history of providing inaccurate information, that there were no corroborating witnesses to the information provided regarding the allegations, that the P had no concerns about SP2’s work, that information was consistent from staff persons that the VA obtained a vape device in the community on an unknown date and used it the bathroom/bedroom, and that SP2 denied that s/he used marijuana or vaped at the facility and said that s/he did not laugh at the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or 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: The facility completed an Internal Review which determined that its policies and procedures were adequate and were followed. The facility thought it could no longer provide the level of care and supervision that the VA required and recommended that the VA no longer receive services from the facility after April of 2023. Action taken by Department of Human Services, Office of Inspector General: No further action taken
|
