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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: 800078-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Deb Neubauer-Hoffman/Christine Henne 651-431-6567 Suspected Maltreatment Reported: It was reported that there were multiple concerns regarding a staff person’s (SP’s) interactions with three vulnerable adults (VA1, VA2, and VA3). In addition, it was reported that the SP gave VA1 the wrong medication which resulted in a seizure that the SP did not provide care to VA1, and that the SP gave VA1 pork knowing VA1 was allergic to pork. Date of Incident(s): Prior to December 17, 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 2, paragraph (c); 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. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. 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 December 21, 2022; from documentation at the facility; and through eleven interviews conducted with two staff persons (P1 and P2), two supervisory staff persons (P3 and P4), one community person (CP) who worked with VA1 outside of the facility, VA1, VA2, VA3, VA3’s case manager (CM), VA3’s social worker (SW), and the SP. According to the facility’s website, the facility operated in a trauma informed environment, which provides a holistic approach to substance abuse treatment. VA1 told this investigator that s/he liked to travel, read, go bowling, and enjoyed music artists like Lady Gaga and Britney Spears. The facility records for VA1 stated that the VA identified his/her strengths as sarcastic, hilarious, adventurous, relatable, and caring. VA1 reported that s/he was diagnosed with chronic post-traumatic stress disorder, schizoaffective disorder depressive type, and generalized anxiety disorder. VA1 reported symptoms of psychosis, lack of sleep, and moderate depression. VA1 was not subject to guardianship. VA2 told this investigator that s/he liked to paint, sing, and listen to music. The facility records stated VA2 was friendly, open-minded, and creative. VA2 was diagnosed with major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and an eating disorder. VA2 was not subject to guardianship. VA3 told this investigator that s/he liked to “hang out” with people s/he cared about. VA3 also enjoyed movies, loved any kind of music, and sometimes liked to read. The facility records stated VA3 was diagnosed with anxiety and depression. VA3 with not subject to guardianship. The facility had three floors. The first floor consisted of a kitchen, laundry room, offices, nursing station, library, bathrooms, dining room, living/group room, and television room. The second floor had an office, bedrooms, and bathrooms. The third floor had office space, a training room, and a supply closet. Facility documentation showed that all staff persons interviewed, including the SP, were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Regarding the SP’s interactions with VA1, VA2, and VA3: VA1 provided the following consistent information during his/her interview, in the facility Internal Review, and in a grievance to the facility: · VA1 found the SP to be “very weird” and had eyes like, “I’m [going to] follow you kind of eyes” that “gave” VA1 the “creeps.” · On an unidentified date in late November 2022, sometime in the middle of the day, while VA1 was “getting ready” for lunch, the SP entered VA1’s room without knocking and said VA1’s name. VA1 was “half naked” without “anything on top.” The SP said, “You look beautiful.” VA1 was “frozen” and “couldn’t speak,” and then the SP walked away. · On another unidentified date, four or five days after November 28, 2022, in the morning around 10:30 a.m., VA1 had “psychotic nightmares.” The SP entered VA1’s bedroom and said, “[VA1’s name], time to wake up.” The SP touched VA1’s upper right thigh and “strok[ed]” it to the inside of VA1’s leg. VA1 “immediately jumped out of bed” because it was “very triggering” to him/her. VA1 told the SP, “Get out.” VA1 was not fully clothed. At some point after the incident, another client (C2), who was VA1’s roommate, told VA1 that on this same date and time, before the SP touched VA1’s thigh, the SP “stared” at C2 while s/he was “half sleeping.” C2 did not see the SP touch VA1. · In early December 2022, (around the fourth or the fifth), on a weekend, before dinnertime, VA1 was in the shower (that was located in a separate room unattached from VA1’s bedroom) and the SP entered the bathroom without knocking and said, “[VA1’s name], it’s time to come out now you beautiful soul.” VA1 was “frozen” and told the SP to, “Get out.” · On an unidentified Tuesday evening while VA1 got ready for bed, the SP walked into VA1’s bedroom when s/he was getting dressed. VA1 was only wearing undergarments. In the “most seductive way possible,” the SP said, “Oh my God you’re so beautiful. You have such a beautiful body. You’re so caring.” VA1 got dressed in “four minutes” while the SP stayed in the room. VA1 “walked away” to the bathroom and the SP did not follow him/her. C2 was not present during this incident. · On an unidentified date, VA1 first told the aforementioned incidents to VA3 and VA2 and “didn’t know” if s/he “should tell” a staff person because it was regarding a staff and VA1 “didn’t know” how the staff would “react.” VA1 then told C2 (roommate) who “acknowledged it” but told VA1 to tell staff. VA1 told a family member (FM) who also told VA1 to tell staff, and then call the police if “nothing happen[ed],” and to call the CP. VA1 left a voice message for the CP that same day. The next day, VA1 told P1 about his/her concerns with the SP and P1 told VA1 to go to “higher staff” to report the incidents. VA1 then told an unnamed “higher up” staff person. The same date, the CP told VA1 s/he wanted to talk to staff with VA1. VA1 told the “whole story” to the “higher staff” with the CP on the phone. VA2 provided the following consistent information during his/her interview and in the Internal Review: · On November 26, 2022, around 11:30 a.m., VA2 was getting changed and heard his/her door open without a knock or a verbal “call out.” The SP “peeked” his/her head inside VA2’s bedroom for about ten to fifteen seconds. VA2 was wearing shorts and was in the “midst” of changing his/her shirt. VA2 did not say anything to the SP. The SP “smile[d]” and “nod[ded]” and then left the bedroom. · VA2 said the aforementioned instance happened on more than one occasion (where the SP entered without knocking or announcing himself/herself). · VA2’s roommate, VA3, experienced his/her “own version” of “sexual harassment” from the SP. VA3 told VA2 that there were “times” while VA2 was asleep, that the SP entered their bedroom without knocking or announcing himself/herself and “[stood] over” VA3 and “watch[ed]” him/her sleep. VA3 also told VA2 that on “at least on one occasion,” the SP “pulled” a blanket back on VA3’s bed and “watch[ed]” VA3 sleep while VA3 was only wearing a “tank top” or an undergarment. · On a Wednesday evening, either December 7 or 14, 2022, during a group resident council meeting, VA2 and VA3 shared their concerns regarding the SP. After VA2 and VA3 shared their concerns, VA1 then “expressed” some “similar” concerns about the SP. VA1 said the SP entered VA1’s room while s/he had on pants and an undergarment and “looked [VA1] up and down” to “scan” his/her body and then make a “remark” about his/her body. However, VA2 was unsure how “valid” VA1’s “piece to the puzzle” was because VA2 “found out” that VA1 “lied” about two different diagnoses s/he had and that a “lot” of the “stories” VA1 told had been “lies,” and the following day, VA2 told P1 and two other staff persons (P7 and P8) this. VA3 provided the following consistent information during his/her interview and in the Internal Review: · In early November 2022, sometime in the early afternoon, the SP entered VA3’s bedroom without knocking. VA3 was changing after a shower and was only wearing undergarments. The SP stood in the bedroom for five minutes and “star[ed]” VA3 “up and down.” VA3 “yell[ed],” “Get out of my room. Get out of my room.” VA3’s roommate, VA2, was not in the bedroom when this happened. · On an unidentified date, sometime during the night, VA3 was changing into his/her pajamas and was only wearing undergarments when the SP “fully” entered his/her bedroom. The SP “star[ed]” at VA3 for two minutes. VA3 “yell[ed]”, “What the fuck is wrong with you? Get out of my room.” VA3 “slam[med]” the door on the SP. VA3’s roommate, VA2, was not in the bedroom when this happened and VA3 was not aware of anyone else hearing the conversation. · On unidentified date, around 1:30 a.m., the SP entered VA3’s bedroom while s/he was in bed, “look[ed] around” for about one minute to a minute and a half, and then took VA3’s blanket off of him/her. The SP “star[ed]” at VA3 for six to seven minutes. VA3 “kind of froze” and did not say anything to the SP because s/he was “scared” and knew the SP thought s/he was asleep. The SP did not touch VA3, but “tried” to by “leaning” towards VA3. VA3 saw the SP’s hand come close to VA3’s chest, so s/he moved, and the SP moved his/her hand and left the room. VA3 was wearing an undergarment and pants. VA2 was asleep during this incident. (Note: According to the staff schedule, the SP did not work any shifts in November 2022 or December, past 12:30 a.m.) · The SP had never knocked or announced himself/herself when entering VA3’s bedroom. · On an unidentified date and time, the SP told VA3 that s/he looked “beautiful” in a “weird” and “creepy” way. This happened when VA3 came out of his/her room and “ran into” the SP in a stairway. · After all of the aforementioned incidents, VA3 first told VA2 about what happened with the SP. VA2 told VA3 to tell staff persons so VA3 then told multiple staff persons including P1 and P2. P1 provided the following information: · On December 12, 2022, VA1 told P1 that s/he felt “uncomfortable” with the SP and that the SP came into his/her room “unannounced” while s/he was “half dressed.” The SP looked VA1 “up and down” and said, “You have a beautiful body,” and then left the room. VA1 told P1 that while s/he was showering, the SP walked into the bathroom and “requested” that s/he come out of the shower “immediately” (which VA1 did not do). After the SP lingered for one minute, the SP left the bathroom. VA1 also said that one day the SP rubbed VA1’s thigh to wake him/her up and VA1 felt “very uncomfortable” about that. The SP made a comment (on another unidentified date) to VA1 that s/he was a “beautiful soul.” VA1 said that s/he saw the SP “staring” at his/her roommate (C2) while s/he slept. VA1 was unable to provide dates to the aforementioned incidences. P1 directed VA1 to talk to P3 (a supervisory staff person) and walked with VA1 to the office so s/he could tell P3. · VA1 made false “reports” about other persons at the facility which made P1 “question” the incidents regarding the SP but said the allegations should not be “dismiss[ed].” P1 said “every time” VA1 “reported” an incident, it had been around two weeks or over a week before bringing it to staff’s attention and without specific dates or times. Since then, P1 said staff persons prompted VA1 to tell staff persons right away. · P1 said other clients “expressed” feeling “uncomfortable” around the SP, but P1 did not know “specific things” that happened. P1 heard from P4 that VA2 had an “experience” where s/he was “half dressed” and a staff person (not the SP) came in his/her room. P1 thought that was “very interesting” because it “mirror[ed]” VA1’s “experience” with the SP. · During shift rounds, staff persons are usually by themselves and are trained to knock on the bedroom door, announce themselves, knock again, and then slowly open the door while continuing to announce themselves. P1 said s/he stayed in the doorway, but was not specifically trained to stay in the doorway. P2 provided the following information during his/her interview and in the Internal Review: · On December 14, 2022, at 7 p.m., VA1 told P2 that the SP entered clients’ bedrooms without knocking or announcing himself/herself and lingered in the bedrooms longer than necessary. VA1 did not provide dates, but also told P2 the following multiple concerns s/he had with the SP: that the SP entered his/her bedroom without knocking or announcing himself/herself while s/he was changing, lingered for a couple minutes, and said s/he had a “beautiful body” and a “nice butt” (while VA1 wore an undergarment and pants); and that the SP entered the bathroom when VA1 was showering and asked VA1 to “get out” of the shower. · VA2 said the SP entered his/her bedroom without knocking or announcing himself/herself while VA2 was wearing undergarments and pants and that VA2 asked the SP to leave. · On an unidentified Wednesday evening around 7:30 p.m., after a resident council meeting, VA3 told P2 a “similar thing to [VA1]” that the SP entered his/her bedroom without knocking or announcing himself/herself while VA3 was wearing only undergarments. The SP stood in the bedroom and stared at VA3. VA3 had to ask the SP “several” times to “get out.” The SP told VA3 s/he had a “beautiful body.” VA3 slept only in undergarments and “awoke” a “couple” times to the SP “looking down” at him/her. · P2 was trained to do rounds by knocking on the bedroom door, announcing him/herself by saying his/her name, waiting a couple of seconds, and then slowly opening the door while announcing him/herself again and stating s/he was doing rounds. If P2 was unable to see inside the room from the doorway, P2 took a couple steps inside the room. VA1’s bedroom did not have a visibility issue from the doorway. P2 worked with the SP two days a week and observed the SP open bedroom doors without knocking or announcing himself/herself, and “look in.” P2 did not tell the SP that s/he was trained differently. · P2 believed VA3’s allegations (SP entering his/her room when changing) to be true because VA3 had a “trauma response” and felt “unsafe” and “vulnerable.” P2 also believed VA2’s allegations about the SP to be true but did not provide further information as to why. In regard to the SP entering VA1’s bedroom and some of the comments the SP made to VA1, P2 believed those to be true. However, the other claims VA1 made (such as the shower incident and the comment about VA1’s “butt”) seemed more “a little more farfetched.” · P2 did not work any overnights but said that the SP worked a “couple” overnight shifts but did not specify dates. The overnight “checks” were at 1, 3, and 6 a.m. and some staff just “look in” the bedrooms to see the clients and some other staff persons will go in the bedroom and” check over the clients.” · P2 said there was some interpersonal conflict between him/herself and the SP. However, when asked if s/he had any concerns regarding the SP’s interactions with clients, P2 said, “Nothing that’s like negligent or anything.” · During the Internal Review P2 stated s/he witnessed the SP enter rooms and it did not appear s/he announced him/herself but P2 “wasn’t sure.” P2 stated she had seen the SP enter rooms and just open doors but not in relation to the reports under investigation. P2 had other interpersonal concerns regarding the SP as well as how the SP interacted with clients and said that the SP was not behaving inappropriately but was not responding to clients in a way that s/he though s/he should. When clarification was requested of P2, P2 did not provided additional details. P3 provided the following information during his/her interview and in the Internal Review: · On December 15, 2022, around 9 a.m., VA1 told P3 that for the last three weeks, the SP entered VA1’s bedroom without knocking and on one occasion, the SP “stroked” VA1’s thigh. On another occasion, the SP entered the bathroom while VA1 was in the shower and asked him/her to “come out.” VA1 also told P3 that the SP stared at VA1’s roommate (from the doorway) while s/he was sleeping and said, “Wake up you beautiful soul.” P3 said that s/he heard the SP used the word “beautiful” when talking, but had not used it with P3. While in a hallway, walking to the kitchen, P3 heard the SP tell an unnamed client that s/he had a “beautiful” shirt on. The client said, “Thank you,” and did not seem “upset.” P3 did not see the SP interact with any clients in an inappropriate way. · VA1 talked to P2 the night before VA1 talked to P3. P3 did not know VA1 “super well,” but was informed VA1 “reports things” and “embellish[ed] the truth” and “goes beyond what has actually happened.” P3 said VA1 “tend[ed]” to “make things up for attention.” · P3 did not talk to VA2 or VA3, but “heard” that they were “involved too.” · P3 did not work any overnight shifts but was trained to do daytime rounds to first knock on the bedroom door and announce that it was staff, knock again if no response, announce again, then open the door. At nighttime, P3 was trained to “softly” knock on the door, open the door while staying in the doorway (not entering the bedroom), and use a flashlight to ensure clients were safe and in their bedrooms. If a client was in “danger” or asking for help, P3 then entered the bedroom. · P3 said the SP had a “big personality” but always wanted to “help” and was the first to “volunteer” for things. The SP was “always willing” to do the “work” that was needed. · During the Internal Review P3 said s/he witnessed the SP tell a client that s/he had a beautiful shirt, but that was the only thing s/he had witnessed. P4 provided the following information: · P4 heard about the allegations from P3 on December 15, 2022. P4 said the allegations were brought up in a resident council meeting on December 14, 2022, from 6:30 p.m. to 7:30 p.m., and P4 believed VA1 was the first person to bring up concerns regarding the SP; however, P4 was not present at the meeting. The resident council meeting consisted of all clients receiving services at the facility as well as one to two staff persons. On the December 14, 2022, meeting VA1, VA2, VA3, and P2 were present. · P4 said staff persons were trained to do rounds to ensure “eyes on” for clients, and ensure they are “okay.” When staff did rounds, they were instructed to knock on the door, announce that they are staff, knock again if needed, and open the door slowly while announcing themselves again. Typically, staff would not enter a room unless there was another staff present and a room search was needed. During overnight rounds, staff persons would knock “lightly” on the door, stay in the doorway, and check to see clients are in their beds and breathing. · There were some “concerns” about VA1’s ability to accurately report information and that there was some “conflict” with some of his/her peers. There were also some “concerns” about VA3’s ability to “consistently report” information based off of previous “differing stories” VA3 told. VA2 was “more likely” to accurately report information. · When asked if P4 had heard of any other clients or staff persons bringing up concerns with the SP not knocking and entering bedrooms, P4 said s/he had not heard of any concerns prior to the resident council meeting. The CP said VA1 had a history of “telling lies,” “making things up”, “exaggerating” and “embellishing” information. The CP said there was a “kernel of truth,” but then it was “just built up from there.” Around mid-December 2022, VA1 called the CP from the facility with a “whole list of complaints” about the SP and that the SP did “something” that “trigger[ed]” VA1. The CP told VA1 to get a “trusted” staff person and to call back to discuss VA1’s concern. VA1 said to the CP that s/he told P1 three different times about the concerns s/he had with the SP and was not aware of any “action” taken. VA1 did not identify when these incidents happened and told the CP the following information: · The SP walked into VA1’s bedroom without knocking when VA1was not wearing a shirt or undergarments and the SP stood there and looked VA1 “up and down.” VA1 told the SP to knock next time.
· The SP entered the bathroom while VA1 was showering. · The SP came into VA1’s bedroom while VA1 was in bed and the SP touched VA1’s thigh. The CM said VA3 had some “paranoia symptoms” related to his/her diagnoses. VA3 was “hypervigilant” and had a history of thinking community persons of the opposite gender were “following” him/her and “gets creeped out really easily.” However, the CM was not aware of VA3 reporting false allegations and said that VA3 would be able to identify how a situation made him/her feel. On March 24, 2023, VA3 reported being “sexually touched” by a cab driver on his/her way to an appointment. After reviewing video footage, it was found that the no one touched VA3, and it was considered a “trauma response.” The SW did not have any information whether VA3 was able to provide accurate information and was not aware of VA3 reporting any concerns with staff persons. The SP provided the following consistent information in his/her interview and in the Internal Review: · The SP was trained to do rounds by knocking on the bedroom door, announcing himself/herself, and if the client responded, the SP would stand at the door and look inside the room to see the client. If the client did not respond after the first knock, the SP knocked again and if no one answered, the SP stood at the door and made sure the client was safe. The SP had a flashlight for nighttime rounds to ensure clients were in their rooms and breathing. The SP said s/he “always” knocked. If the SP had to go inside a bedroom, s/he would have another staff person with him/her and kept the door open. · When this investigator asked the SP why multiple clients would say that s/he did not knock on doors or announce him/herself, the SP said, they were all “best friends.” VA3 was friends with VA1 and VA1 would do “anything” VA3 told VA1 to do. · The SP denied all the allegations including lifting a blanket off of a client while they were in their bed, touching a client’s thigh, entering the bathroom and telling a client to get out of the shower, The SP said s/he had never seen a client not fully dressed. The SP denied telling a client s/he had a beautiful body. The facility completed an Internal Review that provided the following information: · VA2 and VA3 “shared” that they do not believe the allegations reported by VA1. · VA2 said that there were no witnesses to his/her claims, but they occurred during the day on weekends. Staff persons at the facility did not notice any other reactions, discomfort, tension or changes in VA2’s behavior the weeks preceding his/her report. · VA3 said that the concerns about the SP had been going on for a while but s/he had not told anyone and felt unable to go to staff persons. The incidents happened during the overnight shift and also during the day on weekends and that there were no witnesses. Outside of a panic attack on December 14, 2022, and signs of anxiety on the morning of December 15, 2022, staff persons did not notice any other reactions, discomfort, tension, or changes in behavior in VA3 the weeks preceding the report. P7 provided examples of instances where VA3 felt threatened/stressed and paranoid outside of the facility and that VA3 showed signs of being impacted immediately. P7 was confused that VA3 did not have these same symptoms related to the experiences VA3 reported with the SP. P7 shared that another staff person (P9) Reminded P7 that there was a credible note about VA3 making previous accusations against other staff at programs outside of the facility s/he currently was at. Regarding the SP administering the wrong medication to VA1 which resulted in a seizure that the SP did not provide care to VA1: VA1’s facility file provided information that the VA reported having a history of epilepsy and that his/her last seizure was in 2014. VA1 provided the following information: · On an unidentified date, in late November 2022, on a weekend, between 12:30 p.m. and 1:00 p.m., the SP gave VA1 the wrong medication (a “diabetic pill”) that was supposed to go to another client (C1) with a similar name as VA1. (Note: C1 told VA1 s/he took orange diabetic pills). VA1 asked the SP if the two “orange” pills were his/hers because s/he was not aware of any “orange” pills s/he took, and the SP said that they were. VA1 took the medication and it “immediately took effect” giving VA1 a headache. About twenty minutes later, VA1 felt like his/her “brain was shutting down” and like s/he was going to have a seizure. VA1 lay down on a couch and had a “grand mal” seizure that lasted twenty-five minutes. VA1 was “foaming at the mouth” and VA3, who was present, gave VA1 chest compressions. The SP did not help VA1 because s/he was “doing group,” but was still in the same room. VA1 “died for a minute,” and 9-1-1 was not called. At the same medication passing time, the SP also did not give the “full dosage” of VA1’s epilepsy medication (there were usually two pills according to VA1). VA1 did not “feel” like “arguing” with the SP about it. · VA1 filed a grievance on November 23, 2022, and said s/he felt “disrespected,” and “unsafe” around the SP due to the SP watching “cat videos” while s/he had a twenty-minute seizure. VA1 also said that the SP and another staff person (P6) gave him/her another client’s medication and “forced” him/her to take it. VA1 did not feel “safe” around the SP or P6. A progress note dated November 23, 2022, stated VA1 reported multiple seizures. VA1 “expressed” that s/he was “dealing” with a lot of “mistrust” with “specific” staff. VA2 stated that on the weekend of December 16, 2022, sometime after dinner, VA2 saw VA1 have “something of a seizure.” When this investigator asked if VA2 had ever seen VA1 have a seizure, VA2 asked, “A real or a fake one?” because VA2 “found out” VA1 actually did not have epilepsy. VA1 was supposedly “triggered” by the smell of marijuana on another client which caused a “seizure.” During this incident, VA3 was “holding” VA1 and VA2 got a blanket for VA1. VA2 then went and told an unnamed staff person about the situation. VA1 also “claim[ed]” that the SP “switched up” a medication (that was for a different client with a similar name) that also “triggered” a seizure. VA2 did not witness that seizure and said it happened before the aforementioned incident. VA3 said that VA1 had two or three seizures while VA3 was at the facility. VA3 saw “full body shaking” and one time, in the main living room, VA3 saw “foam” coming out of VA1’s mouth. VA3 “helped [VA1] through it” by “grounding” him/her and told VA1, “Everything was going to be fine.” VA3 did a “sternum rub” a “couple times” to see if VA1 “responded to pain.” VA3 was unsure of the cause of the seizure. The SP was “watching” the seizure and VA3 told the SP to get other staff persons, but the SP did “nothing about it.” P1 stated that on an unknown date, VA1 told P1 that the SP gave VA1 the wrong medication “bin,” which “didn’t really make sense” to P1 because staff persons did not give the medication “bins” to the clients. VA1 said s/he was instructed to take his/her own medications because the computer was not “loading.” P1 did not know if VA1 took the incorrect medications. P1 told P4 about this incident. Later, P1 heard from another unnamed staff person that VA1 had a seizure due to the incorrect medication given. P2 stated that on December 14, 2022, at 7 p.m., VA1 told P2 that the SP “overdosed” VA1 on another client’s diabetic medication that was not prescribed to VA1 which caused VA1 to have a seizure and that on an unidentified Sunday, the SP failed to do anything when VA1 had a seizure. In a clinical review meeting, on a Tuesday, staff persons at the facility talked about VA1’s seizure that happened the previous Sunday. P2 said there was now a protocol in place to clear the area of other persons, ensure VA1 was monitored and safe, and call 9-1-1 if the seizure lasted more than five minutes. The SP had a “lot of difficulty” with medications and usually had to have another staff member help him/her give medications. P3 did not see the SP administer medications any time s/he worked with him/her. The CP stated that VA1 told him/her that the SP gave VA1 another person’s diabetic medication. The SP denied giving VA1 incorrect medication and denied ever seeing VA1 have a seizure. Emails dated November 26 to December 29, 2022, from a supervisory staff person (P5) to P3, P4, and a facility health professional (HP) provided information about VA1’s concern that s/he received the wrong medication on the evening of November 19, 2022. P5 said s/he spoke with the SP and P6 individually and they provided consistent information that on November 19, 2022, P6 assisted the SP when the medications were passed, and they documented it electronically which meant the laptop was not down. Both the SP and P6 confirmed the correct medications were passed, and documentation aligned with that. P5 stated that C1 was not on site that evening and did not have evening medications. The HP stated that s/he talked to VA1 and VA1 told him/her s/he thought s/he was given C1’s medications, specifically vitamin D. Regarding the SP giving VA1 pork knowing VA1 was allergic to pork: On November 9, 2022, VA1 provided information to the facility, that was documented in a progress note, that s/he had multiple allergies including allergies to pork. VA1 stated that sometime in early December 2022, on a weekend, in the kitchen during lunchtime, the SP told VA1 that the food was a “beef patty.” VA1 said, “The next thing I knew, it was pork.” VA1 was allergic to pork and reacted with hives on his/her hands and wrist area. VA1 “puk[ed] non-stop” for about two hours. VA1 ate half of the patty because s/he thought it was maybe beef with pork seasoning, but then realized it was pork and went to the bathroom and “puked [his/her] guts out.” VA1 had to lay down afterwards and was “not [himself/herself].” A progress note dated November 23, 2022, stated that VA1 reported that s/he had an allergic reaction to pork. The facility menus provided the following information: · On November 23, 2022, Italian seasoned chicken was served for lunch and mushroom ravioli with alfredo sauce was served for dinner. There was no pork served on this day. · December 4, 2022, French toast bake, sausage, and breakfast potatoes were served for lunch and barbeque meatballs were served for dinner. (There was no information regarding what meat the sausage or meatballs were made from.) · December 11, 2022, spaghetti with meat sauce was served for dinner. (There was no information regarding what meat the meat sauce was made from.) P3 stated that VA1 told him/her, s/he was allergic to pork, but that it was not documented in his/her records. The CP stated that VA1 told him/her, that the SP fed VA1 pork knowing s/he was allergic. On another unknown prior date, VA1 told the CP that s/he was fed pork at the facility and had an allergic reaction. VA1’s said his/her face was red and a “little puffy” and developed hives, but did not require medical attention.) The SP denied feeding VA1 pork. P1 did not recall if VA1 had any food allergies. Conclusion: A. Maltreatment: Regarding the SP’s interactions with VA1, VA2, and VA3: Regarding sexual abuse: Although VA1 said the SP touched his/her upper thigh when s/he was in bed and VA3 said the SP came close to touching his/her chest when s/he was in bed, given that the SP denied these allegations, that multiple persons questioned VA1’s credibility, that a CM said that VA3 did not always provide accurate information, and given there were no witnesses to the aforementioned incidents, there was not a preponderance of the evidence whether the SP had sexual contact with VA1 and VA3. It was not determined whether sexual abuse occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast). Regarding emotional abuse: All staff persons interviewed, including the SP, provided information that when completing rounds at the facility, staff persons were to knock on the bedroom door and announce themselves prior to checking on a client.
However, information from VA1, VA2, and VA3 was consistent that on multiple occasions, the SP entered their rooms without knocking or announcing him/herself, and at times they were unclothed. According to VA1, the SP entered his/her bedroom unannounced multiple times while s/he was not fully clothed and made comments such as, “You look beautiful.” According to VA2, the SP entered his/her bedroom unannounced on more than one occasion and there was one instance when s/he was not fully clothed. According to VA3, the SP entered his/her room without knocking or announcing him/herself and on three occasions, VA3 was not fully clothed. On one of those occasions, the SP “star[ed]” VA3 “up and down.” The SP denied the aforementioned allegations. Although VA1 and VA3 had a history of providing inaccurate information, given that VA1’s- VA3’s information was similar in nature, that VA1 provided consistent information to multiple persons, and that the SP had reason to minimize his/her actions for fear of repercussions, there was a preponderance of the evidence that the engaged in the actions as described by VA1, VA2, and VA3. Entering the bedrooms of without knocking and engaging in the conduct as described by VA1, VA2, and VA3 and who are persons with diagnoses such as that include, chronic post-traumatic stress disorder, generalized anxiety disorder, and anxiety and/or depression, could reasonably be expected to produce emotional distress. It was determined that 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 the SP administering the wrong medication to VA1 which resulted in a seizure that the SP did not provide care to VA1: Information obtained showed that VA1 had a history of seizures and that upon arrival to the facility VA1 reported that s/he had not had a seizure since 2014. Although all staff persons interviewed provided information that they did not see VA1 have any seizures at the facility, VA1, VA2, and VA3 each stated that VA1 had between one and three seizures while at the facility. VA1 stated that one of the seizures was the result of the SP administering him/her the wrong medication but provided inconsistent information regarding what medication, either a diabetic medication or vitamin D. However, there was no information provided to support that the SP administered VA1 any other persons medications. VA1 and VA3 each stated that the SP observed a seizure of VA1’s but failed to provide assistance. However, their information regarding what the SP was doing was different. VA1 stated that in late November 2022, on a weekend, between 12:30 and 1 p.m., the SP was doing group during VA1’s seizure but in VA1’s grievance dated November 23, 2022, VA1 said that the SP was watching “cat videos” while VA1 had a seizure. VA3 did not provided a date but on one occasion, the SP watched VA1 have a seizure and VA3 told the SP to get other staff persons, but the SP did “nothing about it.” Given that there was no information provided to support that the SP administered VA1 any other person’s medications, that VA1 and VA3 provided different accounts of the SP’s actions during one seizure, and that the SP denied ever observing VA1 have a seizure, there was not a preponderance of the evidence whether the SP administered VA1 another person’s medications or failed to take action when VA1 had a seizure. 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.) Regarding the SP giving VA1 pork knowing VA1 was allergic to pork: Information showed that VA1 had an allergy to pork. The progress note said that on November 23, 2022, VA1 had an allergic reaction to pork. However, the menu showed that no pork was served that day. VA1 also said that the SP gave him/her pork on an unknown date in early December 2022, on a weekend. There were possibly three meals: two on December 4, 2022, and one on December 11, 2022, that may have contained pork. But given that the menu did not identify what type of meat was used it was not determined whether VA1 ate pork. Although VA1 may have been served pork on either December 4 or 11, 2022, there was no information that VA1 sustained any lasting injury. Given the information provided, there was not a preponderance of the evidence whether VA1 obtained the pork by any means other than accidental. 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. 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 on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of VA1, VA2, and VA3. 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 emotional abuse for which the SP was responsible was “recurring” because the SP’s interactions occurred with three vulnerable adults. However, it did not meet the statutory criteria to be determined serious. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and stated that their policies and procedures were adequate and followed. 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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