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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: 1104516-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) put his/her hands around a vulnerable adults (VA) neck after the VA broke a staff person’s necklace. Date of Incident(s): May 18, 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 25, 2023, from documentation at the facility, and through six interviews conducted with the VA, the SP, a facility staff person (P), the VA’s family member (FM), the VA’s guardian (G) and a community person (CP) at the VA’s school. The VA was the only client that lived at the facility. The VA’s Intensive Services Assessment showed that s/he enjoyed accessing the community and interacting with staff persons. The plan showed that some of the VA’s diagnoses included fetal alcohol syndrome, autism, and that the VA had a moderate developmental disability. Due to behavioral reasons, the VA had two staff persons with him/her during all awake hours. The VA’s Individual Abuse Prevention Plan showed that the VA engaged in physical aggression, verbal aggression, property destruction, and self-injurious behavior. When that happened, staff persons were trained to provide verbal redirection to the VA. The CP provided the following information: · On May 17, 2023, the VA, who provided limited information, told the CP that s/he broke the P’s necklace and that the SP said, “No touching,” and “No attacking [the P].” The SP then put his/her hands on the VA’s neck. (Investigator’s note: information from the SP, the P, and facility documentation showed that the incident likely occurred on May 18, 2023). · The CP saw three “dime” size bruises, two on one side of the VA’s neck and one on the other side that were “yellow greenish.” The CP did not take pictures of the bruising on the VA’s neck. Although this investigator talked to the VA, the VA did not provide information for the investigation. The G stated that s/he did not talk to the VA about the incident and did not know whether the VA had the ability to provide information for the investigation due to his/her diagnoses. The FM stated that s/he talked to the VA on the afternoon of the incident, but the VA only stated that s/he had bruises on his/her neck and the VA did not provide information as to how the bruises happened. The SP provided the following information: · On May 18, 2023, the P, the SP, and the VA were in a facility vehicle when the VA began to “get agitated.” When that happened, the SP provided verbal redirection to the VA, but the VA began “kicking” and hitting the P. As a result, the SP pulled the vehicle over to the side of the road, got out of the vehicle, and opened the door by the VA and told the VA to “stop,” but the VA grabbed and broke the P’s necklace. Then, the SP, the P and the VA returned to the facility. · The SP denied putting his/her hands on the VA’s neck and the SP did not have knowledge that the VA had any bruising on his/her neck. The P provided the following information: · The P did not remember the date but stated that one morning the P and the SP were transporting the VA to school. While the SP drove, the P and the VA were in the backseat. The VA was “really good” that morning. · About two to three minutes after leaving the facility, the VA began talking about “poop” which was an antecedent to the VA engaging in behavioral incidents. When that happened, the P began to redirect the VA verbally, but the VA grabbed the P’s necklace and shirt and broke the necklace. The P and the SP both asked the VA to “stop” and the VA complied. After the incident happened, the VA was brought back to the facility instead of to school. · The P denied seeing the SP have any type of physical contact toward the VA and did not see bruising on subsequent days. The VA’s case notes, dated May 18, 2023, and written by the SP, stated that the VA “got behavior and broke staff [person]’s necklace and was returned back home.” A review of case notes in the days following May 18, 2023, did not indicate that the VA had neck bruising. The facility’s training records showed that the SP and the P were trained on the Reporting of Vulnerable Adults Act and the VA’s care plans. The facility’s Internal Review of an Alleged Maltreatment Report provided information that was mostly consistent with the information provided in this report. Conclusion: The CP stated that when s/he talked to the VA on May 17, 2023, the VA said that after s/he broke the P’s necklace, the SP put his/her hands on the VA’s neck and the CP stated that s/he saw three bruises that were “yellow greenish.” The P and the SP provided consistent information that an incident occurred when the VA was being transported to school by the SP and the P. The VA became aggressive and broke the P’s necklace. The SP stopped the vehicle and told the VA to “stop.” The VA complied and they returned to the facility and did not go to school. The SP denied touching the VA, the P stated that the SP did not touch the VA’s neck, and the SP and the P each stated that they did not see bruising on the VA. Conflicting information was provided in regard to the date of the incident, but the VA told the CP the incident happened when s/he broke the P’s necklace which according to facility documentation and information from the P and the SP was during an incident on May 18, 2023. Although the CP saw brises on the VA’s neck and the VA told the CP that the SP put his/her hands on the VA’s neck, given that the SP denied doing so and that the P who witnessed the incident stated the SP did not touch the VA’s neck, there was not a preponderance of the evidence whether the SP engaged in non-therapeutic conduct that could reasonable be expected to cause the VA 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). Action Taken by Facility: The facility’s Internal Review of an Alleged Maltreatment Report showed that policies and procedures were adequate, followed, and that additional training was provided to the SP. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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