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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: 1067819-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) pushed a vulnerable adult (VA) when the VA did not want the SP to work at the facility and that the VA fell against a cabinet and sustained bruising. Date of Incident(s): April 30, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 8, 2023; from documentation at the facility; from the VA’s medical records; and through six interviews conducted with the VA, the VA’s guardian (G), the SP, a facility management staff person (P1), and two facility staff persons (P2 and P3). The facility’s front door, which had a window, opened inward to a small foyer. Inside the foyer was a built-in cabinet that was about six feet from the door. The VA’s Self-Management Assessment showed that the VA ambulated independently, but “needs prompts to slow down.” The VA’s Coordinated Services and Support Plan stated that the VA’s goals were to maintain good physical hygiene and develop and maintain healthy relationships with his/her peers. An interview with P2 and a General Event Report, written by P2, provided the following information: · When the SP arrived at the facility on April 30, 2023, the front door was locked so P2, who was already at the facility, unlocked the door. As P2 did that, the VA was “yelling you’re fired,” and “You can’t come in,” to the SP. Initially, the VA was behind the door and “trying to push it closed” so the SP could not enter, but the VA stopped doing that and moved away from the door as the SP opened the door. · As the SP entered through the door, the SP told the VA, “You’re stupid, move away.” The SP then used both of his/her hands and “immediately” pushed the VA on his/her chest causing the VA to fall against the cabinet before falling to the floor on his/her back. P2 told the SP, “Don’t do that.” After the SP pushed the VA and the VA fell, the SP said, “I’m sorry.” · P2 then sought assistance from P3, who was downstairs. P2 and P3 assessed the VA and assisted him/her to stand up. After that, the VA went to his/her bedroom and P2 followed the VA. P2 noticed a “bruise” and a “little cut” that was about a half inch on the VA’s elbow, but P2 did not remember which elbow. After the incident, the VA did not complain of head pain and appeared to have a good night. Later that night, P2 noted that the VA had a bruise on the VA’s right hip. No first aid was needed. After the incident, P2 called P1. · When P2 arrived at the facility for his/her shift the following day, a supervisor told P2 that just prior to P2’s arrival, the VA had requested to go to an emergency room (ER) because his/her head began hurting. P2 took the VA to the ER and after tests were completed, the results showed, “CT scan of head and abdomen checked out as normal. Xray of elbow back as normal as well.” P3 said that when the incident happened, P3 was in the basement and did not hear or see anything. When P2 asked for assistance, P3 went upstairs and the VA told P3 that the SP “pushed” the VA and that the VA landed on the floor. P2 and P3 assisted the VA to stand up. P1 said that the VA called P1 after the incident and said that s/he was “upset” that the SP came to work and when the VA told the SP, “You’re fired, get out of here,” the SP “pushed” the VA on his/her chest and the VA fell to the floor. Later, P1 learned that the VA had some bruising near his/her hip and right elbow and the following day, the VA told P1 that his/her head “hurt.” As a result of that, the VA was taken to the ER and it was determined that “everything is fine” with the VA. The VA said that on the day of the incident, the staff person (the VA did not know the name of the SP), came to work shortly after 2 p.m. while the VA stood by the front door. The SP said, “Get out of the way,” and then used both of his/her hands and “pushed me up against the cabinet” and my head “hit the door to the cabinet” and “hit my side on the side of the cabinet.” The VA then fell on the floor on his/her right side. The VA said that another staff person said, “You’re out of here, get out, your gone,” to the SP. The G stated that the VA called the G after the incident and was “very upset.” The VA told the G that the SP “pushed me,” that the VA “fell down” and “hit” the cabinet. The VA also told the G that s/he had bruises from the incident and that the VA told the SP that s/he was “not supposed to be here.” The VA’s medical records, dated May 1, 2023, stated, “Probable small subcutaneous contusion on the right flank. Irregularities of bilateral ribs, some of which are clearly chronic. Correlate for focal tenderness. No acute displaced fracture. Otherwise no acute process in the abdomen or pelvic,” and “contusion of abdominal wall, initial encounter. Abrasion of right elbow, initial encounter.” There was no information that treatment was needed. Photographs taken by the facility, on May 1, 2023, showed that the VA had a scabbed area, about the size of a dime, on his/her elbow, and a red bruised area on his/her hip. The facility’s Internal Review provided the following information: · When the VA was interviewed on May 1, 2023, the VA said that the SP “pushed” him/her with “two hand[s].” · When the G was interviewed on May 1, 2023, s/he said the VA called the G and said that the SP “pushed” the VA and that the VA “fell into the cabinet and that it was bruised and they will be watching it.” · When P2 was interviewed on May 1, 2023, P2 said that the SP “pushed” the VA and the SP said, “Why are you pushing, these people are stupid.” P2 also stated that the VA remained on the floor for ten minutes. · When the SP was interviewed on May 1, 2023, s/he stated that the VA “was by the door, trying to push the door and fell on [his/her] butt.” Later, the SP stated that the VA was “behind” the door when the SP pushed the door open. The SP also stated that the VA was on the floor for one minute. · When P3 was interviewed on May 2, 2023, P3 stated that s/he did not witness the incident, but that the VA was on the floor for five minutes and that the VA told P3 that the SP “pushed me.” · The Internal Review stated that the SP “pushed the door open as [the VA] was blocking it, which caused [the VA] to fall backwards and sustain minor injuries.” The SP provided the following information: · When the SP arrived at the facility the day of the incident, the front door was locked, but P2 unlocked the door and opened it partially, but the SP did not remember how far the door was opened. · The VA was behind the door “screaming and saying I should not enter” and I “guess my hand touched [him/her] and the door touched [him/her] as well and [s/he] fell,” but the SP denied pushing the VA. · The incident was “unintentional,” and “I didn’t mean to do it.” · The SP denied telling the VA that s/he was stupid. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to April 30, 2023. Conclusion: A. Maltreatment: When the SP arrived at the facility the day of the incident, the VA yelled at the SP because the VA did not want the SP to enter. P2 said that s/he unlocked the door and when the SP entered the facility, the SP told the VA, “You’re stupid, move away,” which the SP denied saying. P2 said that the VA moved from behind the door and then the SP put his/her hands on the VA’s chest and pushed the VA, which caused the VA to fall against the cabinet before falling to the floor on his/her back. The SP stated that the SP’s hand “touched” the VA as well as the door causing the VA to fall. The SP denied pushing the VA. P3 was downstairs at the time of the incident but after the VA fell, P2 asked P3 for assistance to help the VA stand. P3 stated that P2 and P3 helped the VA to stand from the floor and then the VA told P3 that the SP pushed the VA. The VA had a bruise and a “little cut” on his/her elbow and a bruise on his/her hip area. P2 and P3 assessed the VA and the VA did not need medical attention. However, the next day, the VA said his/her head hurt so the VA was seen at the ER. The VA’s head CT and x-rays were “normal” and there were no other injuries. After the incident, the VA called the G and told him/her that the SP pushed the VA, the VA told P1 that the SP pushed him/her on his/her chest, and the VA told the internal reviewer that the SP pushed him/her with “two hands.” Although the SP denied pushing the VA and said that the SP’s hand and the door unintentionally caused the VA to fall, given that P2 witnessed the incident and stated the SP put two hands on the VA’s chest and pushed causing the VA to fall; that the VA provided consistent information to P1, P3, the G, and for the facility’s Internal Review that the SP pushed the VA; and that the SP had reason to minimize his/her actions for fear of the repercussions, there was a preponderance of the evidence that the SP’s conduct was not an accident and caused the VA physical pain and injury. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained in the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for physical abuse of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated physical abuse for which the SP was responsible was not recurring maltreatment because it was a single incident but was serious maltreatment because the VA sustained bruising and a cut. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate, followed, and that all staff persons received additional training. The SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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