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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: 1070661-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Sarah Schumacher Suspected Maltreatment Reported: Allegation one: It was alleged that two staff persons (SP1 and SP2) would not help a vulnerable adult (VA1) carry his/her walker up the stairs and told VA1 to “do it” him/herself. In addition, SP1 and SP2 were “mean” to and “harassed” VA1 and did not help VA1 when VA1 needed help. SP1 told VA1, “If you have fucking something to say, say it to my fucking face.” Allegation two: It was alleged that SP2 told a vulnerable adult (VA2) to “take your fucking medications now,” and when VA2 wanted to wait, SP2 said, “Fuck that, you take them now.” Date of Incident(s): Allegation one: Unknown dates Allegation two: Unknown date on or prior to April 18, 2022 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: Pertinent information was obtained during a site visit conducted on May 12, 2022; from documentation at the facility; and through four interviews conducted with VA2, two facility supervisors (P1 and P2), and a facility staff person (P3). Attempts made to request interviews with each SP1 and SP2 were unsuccessful. VA1 moved out of the facility during the investigation. An interview with VA1 was scheduled via phone but when this investigator called, VA1 did not answer. VA1 did not respond to an interview request sent via United States mail. However, VA1 provided information to staff persons so that information was included below. P1, P2, P3, SP1, and SP2 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act and on VA1’s and VA2’s plans. Allegation one: It was alleged that SP1 and SP2 would not help VA1 carry his/her walker up the stairs and told VA1 to “do it” him/herself. In addition, SP1 and SP2 were “mean” to and “harassed” VA1 and did not help VA1 when VA1 needed help. SP1 told VA1, ““If you have fucking something to say, say it to my fucking face.” VA1 diagnoses included a moderate developmental disability, schizophrenia, seizure disorder, arthritis, cardiomyopathy, and hypothyroidism. VA1 was not subject to guardianship. VA1 enjoyed fishing, watching movies, going out to eat, and spending time with family and friends. On March 9, 2021, VA1 was prescribed a front wheeled walker for ambulation. Staff persons were to assist VA1 with moving the walker to and from locations as needed. VA1 had a history of knee pain and arthritis. VA1 had a lock on his/her bedroom door. Staff persons were to knock and ask VA1 if they could open the door. VA1 and staff persons each had a key. P3 provided the following information: · P3 stated that SP2 was “mean” and “rude” to VA1. When VA1 was walking up the stairs and needed help carrying his/her walker, SP2 told VA1, “No, you can do it.” Other staff persons would tell SP2 that s/he needed to help VA1 with his/her walker and SP2 said, “Okay,” and helped VA1 but then later would not help. VA1 would hold a rail with one hand and his/her walker with the other hand while going up stairs. When P3 was working, s/he would see VA1 going up the stairs and would take the walker from VA1 and bring it up the stairs for VA1. P3 talked to SP2 about helping VA1 with his/her walker and SP2 told P3 that VA1 was capable so s/he was supposed to carry the walker him/herself. P3 initially stated that SP1 also would not help VA1 with his/her walker up the stairs but then P3 stated that s/he did not see SP1 not helping VA1 up the stairs with his/her walker. · SP1 did not remind VA1 to wake up at night to be changed so VA1 slept in urine and feces when s/he was incontinent at night. SP2 would let VA1 “sit in” urine. P3 did not recall specific incidents. · VA1 would get upset and go to his/her room where VA1 would be heard swearing. Initially P3 stated that one occasion, SP1 went to VA1’s bedroom door, unlocked the door and went in without knocking and told VA1, “If you have something to say to me say it to my fucking face.” Then, P3 stated it was SP2 who did this and not SP1. · SP2 told VA1 to “shut up.” SP1 would “yell” at VA1 and talk down to VA1. SP2 used a “loud” voice with VA1 and “intimidated” VA1. SP1 had the “same tone” as SP2. P3 stated that when supervisors were at the facility was the only time SP1 and SP2 were not “mean” to VA1. When SP1 and SP2 were “mean” to VA1, P3 would wait to see if they would “change their tone” but eventually P3 would tell SP1 or SP2 that VA1 was “sad” or “emotional” and tried to redirect the situation. P3 did not provide additional details. P2 stated that P3 provided P2 with the following information: · P3 “witnessed” SP1 and SP2 swear at VA1. P3 said on one occasion, VA1 was in his/her bedroom and SP1 was being “confrontational” and told VA1, “If you want to come out of your room and fucking say that to me.” · P3 said s/he witnessed SP2 swear using “the F word,” but did not specify if this was directed at VA1 or other residents. · P3 said that SP2 would not help VA1 bring his/her walker up the stairs and that SP2 told P3 to not help VA1 and that VA1 could “do it by [him/herself].” · P3 said that VA1 cried and told P3 that P3 was “the only [staff person] who was nice” to VA1. VA1 told P3 that s/he did not go out of his/her bedroom when SP2 was working. P3 told P2 that VA1 did not like SP2 because SP2 was “mean” to VA1. After P3 told P2 this information, P2 asked VA1 if s/he wanted to talk to P2 about anything and VA1 “pointed” at P3 and said P3 “can tell you.” P2 did not witness SP1 or SP2 do these things. P2 stated that VA1 needed help with his/her walker going up stairs. P1 stated that VA1 should not go up and down stairs without assistance. VA1 was to walk from room to room without assistance as able to strengthen his/her legs. P1 did not see SP1 or SP2 refuse to help VA1. P1 did not see SP1 go into VA1’s locked room. P1 heard SP1 and SP2 prompt VA1 to change his/her pants when incontinent in an appropriate manner. P1 did not witness SP1 or SP2 being “mean” to VA1. Conclusion for Allegation One: Regarding emotional abuse: P3 stated that SP1 and SP2 were “mean” to VA1 including yelling, telling VA1 to “shut up,” and using a “loud” tone of voice to “intimidate” VA1. P3 stated that the “only time” SP1 and SP2 were not “mean” to VA1 was when supervisors were at the facility. P3 stated that one occasion, either SP1 or SP2 (P3 initially said SP1 but later said it was SP2 and not SP1) unlocked VA1’s bedroom door when VA1 was upset and swearing, and told VA1, “If you have something to say to me say it to my fucking face.” Although P3 had concerns about SP1’s and SP2’s treatment of VA1, given that P1 and P2 did not witness SP1 or SP2 being “mean” to VA1, that P3 did not have specific details, and that there was no further information to support or refute the information, there was not a preponderance or the evidence whether SP1 and or SP2 engaged in conduct or treatment of VA1 that could be reasonable 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). Regarding neglect: VA1 was prescribed a front wheeled walker for ambulation. Staff persons were to assist VA1 with moving the walker to and from locations as needed. VA1 had a history of knee pain and arthritis. VA1 was supposed to walk without assistance as much as s/he could to build strength. P3 stated that SP2 would not help VA1 carry his/her walker up the stairs. Initially P3 stated SP1 also did not help VA1 but later, P3 stated s/he did not see SP1 not assist VA1. SP2 told VA1 and told P3 that VA1 was capable and could do this by him/herself. When P3 worked and VA1 was going up the stairs, VA1 would hold the rail with one hand and hold the walker with the other hand. P3 would take the walker from VA1 and carry it the rest of the way up the stairs. Although VA1 needed assistance moving his/her walker to and from locations as needed, VA1 was also supposed to walk from area to area without assistance to build up strength. Given that VA1 would independently go upstairs when s/he wanted to, that there was no information that VA1 was injured while walking up the stairs with his/her walker, and that there were no details regarding specific details or occurrence, there was not a preponderance of the evidence whether there was a failure to provide VA1 with reasonable and necessary care and services. 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). Allegation two: It was alleged that SP2 told VA2 to “take your fucking medications now,” and when VA2 wanted to wait, SP2 said, “Fuck that, you take them now.” VA2’s diagnoses included pervasive developmental disorder, oppositional defiant disorder, anxiety disorder, mild intellectual disability, and attention deficit hyperactivity disorder. The VA had a history of physical and verbal aggression. The VA was “often angry and resentful” and “often spiteful or vindictive, blaming other for his/her mistakes or behavior. Staff persons were to offer verbal redirect and suggest coping strategies. VA2 enjoyed riding bike, playing basketball, playing cards, and being outdoors. P1 and P2 each stated that on April 18, 2022, they had a conversation with VA2 and another facility resident about respect and that they had the right to not be yelled at or swore at and they should tell P1 and P2 if that was happening. VA2 then told P1 and P2 that the night before, SP2 told VA2 to “take your fucking medication.” VA2 told SP2 that s/he did not want to take medications “now” and would take them “later.” SP2 told VA2, “No you have to take them fucking now.” Later that day, VA2 told P1 that s/he “just can’t get along with” SP2 and “wanted [SP2] to get fired.” VA2 provided similar information to a facility manager when interviewed for the facility’s Internal Review. VA2 also told the facility manager that s/he “was going to get [SP2] fired.” VA2 told this investigator that SP2 swore at VA2 “several times.” One occasion (VA2 did not recall when) SP2 told VA2 that SP2 was “not [VA2’s] fucking slave” and that VA2 needed to “do your fucking dishes.” SP2 told VA2, “I’m in charge here listen to me fucker.” VA2 told SP2 that s/he was a staff person and did not need to be swearing at him/her and that SP2 thought s/he could swear because “no one was around.” One occasion (VA2 did not recall the date), SP2 told VA2 to take his/her medications “now” and VA2 told SP2 that s/he was “on [his/her] own time so leave me the fuck alone or I’ll call the cops.” VA2 told SP2 that s/he would “turn your ass in” and SP2 would be fired. SP2 replied, “I don’t give two fucks.” SP2 “pissed off” VA2 “so bad that day.” P1 stated that s/he did not have concerns about SP2’s verbal interactions with VA2. P1 stated that VA2 “tends to exaggerate a bit.” P2 did not see SP2 interact with VA2 very often so did not have information to provide. On April 16, 2022, SP2 documented in VA2’s progress notes but did not document concerns with VA2 taking his/her medications and stated that VA2 did take his/her medications. On April 17, 2022, there was no information in VA2’s progress notes regarding VA2 not taking medications. Conclusion for allegation two: VA2 told P1 and P2 that SP2 told VA2 to “take your fucking medication.” VA2 told SP2 that s/he did not want to and would take them later. SP2 told VA2, “No you have to take them fucking now.” When interviewed by this investigator, VA2 stated that the SP told VA2 to take his/her medications, “now,” so VA2 told SP2 that s/he was “on my own time so leave me the fuck alone or I’ll call the cops.” VA2 told SP2 that s/he would “turn your ass in,” so SP2 said, “I don’t give two fucks.” Although VA2 said SP2 swore at him/her about taking medications, given that VA2 provided inconsistent information regarding what SP2 said, that VA2 told P1 and a facility manager that s/he was going to “get [SP2] fired,” that P1 stated that VA2 “tends to exaggerate,” and did not have concerns with SP2’s verbal interactions with VA2, and that there was no other information to support or refute the incident, there was not a preponderance of the evidence whether SP2 engaged in conduct that would be reasonable expected to cause 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 but not followed. All staff persons were retrained on “proper workplace communication” with facility residents. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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