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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: 1072478-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin/ Kyle Youker 651-431-6225 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) yelled at and berated a vulnerable adult (VA1). Allegation Two: It was also reported that the SP drank alcohol and then drove while working. Alleged Licensing Violations: There were also additional concerns that: · The SP left the vulnerable adults (VA1-VA4) alone at the facility for periods of time; and · The SP gave VA1-VA3 their medication after the administered time or left the medications sitting out on the kitchen table for VA1-VA3 to take independently. Date of Incident(s): Prior to and ongoing between February 28, 2022, and April 4, 2023. The Minnesota Department of Human Services received multiple reports regarding possible maltreatment during this time that were not assigned for investigation. On April 26, 2023, the report was assigned for possible maltreatment. 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 17, 2023; from documentation at the facility; and through 14 interviews conducted with four vulnerable adults (VA1-VA4), two supervisory staff persons (P1 and P2), three facility staff persons (P3, P4, and the SP), VA2’s guardian (G), VA1’s case manager (CM1), VA1’s and VA2’s mental health professionals (MHP1 and MHP2) respectively, and VA2’s guardian (G). VA1, VA3, and VA4 were not subject to guardianship. According to the facility’s Drug and Alcohol Prohibition policy, all staff persons were not allowed to be under the influence of a chemical that impaired their ability to provide services. The consumption of alcohol was prohibited while directly responsible for clients, on the facility property, or in facility vehicles. All staff persons interviewed, including the SP, were trained on VA1’s-VA4’s plans, the Drug and Alcohol Prohibition policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to this investigation. Allegation One: It was reported that the SP yelled at and berated VA1. VA1 was diagnosed with a mental health disorder. VA1’s Individual Abuse Prevention Plan (IAPP) did not identify that VA1 had risks related to emotional abuse. According to VA1’s Intensive Support Self-Management Assessment, VA1 scheduled his/her own medical appointments and wanted staff persons to attend “certain” medical appointments. VA1 lived at the facility for approximately six months prior to the investigation. VA1 stated on April 3, 2023, the SP drove VA1 and dropped him/her off at an appointment with MHP1. When VA1 checked in for the appointment, s/he was told his/her appointment was scheduled for May 3, 2023. VA1 called the SP to come pick him/her up and drive him/her back to the facility. While VA1 waited, s/he went back and spoke to MHP1 in his/her office. The SP went into the lobby and “complained” that VA1 called him/her but was not ready which “humiliated” VA1. When VA1 was at the front desk trying to schedule his/her next appointment, the SP “freaked out” on VA1 and everyone in the lobby heard. VA1 was not able to remember what the SP said during that time. MHP1 stated on April 3, 2023, VA1 came to his/her appointment on the wrong day. MHP1 met with VA1 in MHP1’s office and during that time, the SP returned to the office to drive VA1 back to the facility. The SP called and texted VA1 that s/he was in the lobby waiting. VA1 was already “very agitated,” and the text messages increased VA1’s frustrations. VA1 responded to the SP “in ways that may not have been appropriate” but included telling the SP that s/he was in a session. The SP continued to call and text VA1 saying s/he would leave the office without VA1 and VA1 showed the messages to MHP1. VA1 then left the session and when s/he was in the lobby, the SP “berated” VA1 and VA1 cried. Follow up phone calls to MHP1 for additional information were not returned. CM1 provided the following information: · Later on April 3, 2023, VA1 told CM1 that s/he showed up to his/her appointment with MHP1 on the wrong day so s/he called the SP for a ride. During that time, VA1 was called back into MHP1’s office. Once the SP arrived, s/he came in and out of the office door multiple times looking for VA1. VA1 went to the lobby and began to schedule a new appointment at the front desk. As s/he was doing so, the SP “yelled” at VA1 as they stood in the lobby. VA1 went back to the facility and called CM1 saying that s/he did not feel safe at facility. · On a later day, VA1 told CM1 that the SP “put [him/her] down” and made “inappropriate comments” about VA1’s mental health. VA1 did not provide any additional details to CM1. P1 stated s/he was aware of the incident and spoke to the SP about it. The SP told P1 that VA1’s appointment was scheduled for four hours so the SP planned to transport the other clients during that time. VA1 called the SP and told him/her that it was the wrong date, so the SP rearranged the other clients’ schedules and picked up VA1. The SP denied yelling at VA1. P1 said VA1 had a history of “exaggerating” incidents including interactions with the SP. When VA1 heard something s/he did not like, VA1’s perception of the incident was “more severe.” P1 stated that the SP was “more direct” with the clients then other staff persons. P1 was not aware of previous concerns with the SP’s interactions with the clients. The SP stated on the day of the incident, s/he dropped VA1 at the appointment. Once the SP returned to the facility, VA1 texted the SP asking for him/her to come pick up VA1. The SP drove back and waited for VA1 to come out of building. After approximately 35 minutes, the SP went inside the lobby and asked the front desk where VA1 was and was informed s/he was back talking to MHP1. The SP stated that during that time, two other clients needed rides to and from locations, so the SP texted VA1 that s/he was there to pick him/her up and that the SP had to “get going.” Eventually, VA1 came out and scheduled a follow up appointment and the SP asked VA1 not to text him/her until VA1 was ready for pick up. The SP stated s/he used a “regular voice” and denied yelling. VA1 was “really upset” and “embarrassed” that s/he showed up on the wrong day and that the SP asked VA1 not to text him/her until VA1 was ready. P4 worked overlapping shifts with the SP and did not have concerns with the SP’s interactions with VA1-VA4. P4 stated there were times when VA1 was accurate with providing information but other times VA1 said things that “[were] not true” including about staff persons. VA2 stated that the SP spoke to VA2 “stern[ly]” before but VA2 denied that the SP yelled at him/her or VA1. Conclusion for Allegation One: VA1 provided consistent information during his/her interview and to CM1 that on April 3, 2023, while waiting for VA1 at a medical appointment, the SP was in the lobby and “complained” that VA1 called him/her but was not ready which “humiliated” VA1. When VA1 was at the front desk trying to schedule his/her next appointment, the SP “freaked out,” was “very agitated,” and “yelled” at VA1 and everyone in the lobby heard. VA1 was not able to provide details regarding what the SP said. The SP denied yelling at VA1. MHP1 provided information that the SP continued to call and text VA1 saying s/he would leave the office without VA1 during the appointment, and that when VA1 went into the lobby, the SP “berated” VA1 and VA1 cried. However, MHP1 did not respond to requests for follow up information. Although information was consistent that there was some verbal interaction between the SP and VA1, given that there were no details from VA1 or MHP1 regarding what the SP said, that P1 and P4 did not have concerns regarding the SP’s previous interactions with VA1-VA4, and that P1 and P4 each stated that VA1 was not always able to provide accurate information about events including “exaggerating” incidents so they appeared “more severe,” there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or whether the SP interacted with VA1 in a manner that could reasonably be 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). Allegation Two: It was also reported that the SP drank alcohol and then drove while working. VA2 was diagnosed with schizoaffective disorder. VA2 moved out of the facility on March 7, 2022. VA3 was diagnosed with a mood disorder and traumatic brain injury. VA4 was diagnosed with a mental health disorder. VA4 moved out of the facility on May 9, 2022. VA2-VA4 provided the following information: · On a previous occasion, while the SP worked, VA2 found a small empty bottle of alcohol on the sofa in the living room. The SP then got in the facility vehicle alone and drove away. VA2-VA4 called P4 and P4 came over to the facility. The SP was gone approximately one to two hours and when s/he returned, P4 spoke to the SP. · On another previous occasion, the SP “got right up in” VA2’s face and the SP’s breath smelled like alcohol. The SP acted “really strange” and slurring his/her words. VA3 also previously smelled alcohol on the SP’s breath and said the SP slurred his/her words. VA4 described the SP being intoxicated as a “pattern of behavior.” When asked if there was a time when the SP drove a client after consuming alcohol, VA3 and VA4 each responded that they did not think so. VA1 stated on multiple previous occasions, the SP came to work intoxicated. Approximately three to four months prior to the investigation, the SP walked in the kitchen and fell twice. The SP said s/he slipped on water but VA1 smelled alcohol on the SP’s breath. CM1 said that after the incident on April 3, 2023, at some point VA1 told CM1 that the SP showed up to the facility intoxicated and “high” which “trigger[ed]” VA1’s mental health. P3 and P4 provided the following information: · On a previous occasion, P3 called P4 and said that VA2 called P3 and said s/he smelled alcohol on the SP’s breath and that s/he was “concerned.” P3 was at the facility with VA1-VA4 when the SP returned and said the SP was “agitated” when talking to P3 but did not come close enough to P3 for him/her to smell the SP’s breath. P3 told the SP that s/he could go home and P3 stayed at the facility with VA1-VA4. · P4 stated on a previous occasion, s/he drove the SP to his/her personal vehicle in the facility vehicle. When the SP got out of the facility vehicle, P4 looked over and saw alcohol bottles inside the SP’s personal bag that was on the floor. The SP had not transported VA1-VA4 in the facility vehicle. P4 took pictures of the alcohol with his/her personal cell phone. P4 stated s/he never saw the SP where s/he thought s/he was under the influence of alcohol and P3 and P4 each stated they never smelled alcohol on the SP. P1 provided the following information: · Over a year prior to the investigation, s/he was made aware of the allegations but the SP had not driven clients after s/he drank alcohol. A few days later, P1 spoke to the SP who denied the allegations. After the incident, the SP was randomly breathalyzed while working and there was no indication s/he had been drinking alcohol so eventually P1 stopped requiring the SP to test. · A few months prior to this investigation, VA1 told P1 about concerns with the SP drinking alcohol the previous day. That day, P1 spoke to the SP who denied drinking alcohol so P1 required the SP to use the breathalyzer again and the SP did not have alcohol in his/her system. P2 provided the following information: · On a previous occasion, P4 found an empty bottle of vodka inside a bag that belonged to the SP. Later on, P2 spoke to the SP about it and the SP said the bottle of vodka was inside his/her personal bag that was already empty prior to the SP coming to the facility and the SP forgot it was inside. P2 reminded the SP not to do it again and the SP agreed. · On February 24, 2022, VA2 saw the SP drink a water bottle full of vodka. After the SP’s shift was over, the SP left the water bottle at the facility and after being notified, P2 “examined” the water bottle and only found water inside. The SP also did not drive the clients during that shift. · P2 was not aware of hidden bottles of alcohol found around the facility. On March 17, 2022, a staff person (P2 did not provide information as to which staff person) assisted VA4 with cleaning out his/her bedroom closet and found an empty bottle of whiskey. VA4 declined to provide information on the whiskey. The SP denied bringing alcohol or consuming alcohol while at the facility, including while driving clients. MHP2 stated that VA2 felt “unsafe” when the SP worked. The G stated that VA2 had been “recently” accurate when providing information and the G did not have concerns with the facility. Conclusion for Allegation Two: Consistent information was provided that on multiple previous occasions, the SP drank alcohol while working at the facility. Although the SP denied drinking alcohol, the SP had reasons to minimize his/her actions for fear of repercussions, so it was more than likely the SP drank alcohol. The SP drinking alcohol while working was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. However, given that there was no information provided that VA1-VA4 were in a vehicle when the SP drove after drinking alcohol, and there was no information provided that VA1-VA4 were harmed, there was not a preponderance of the evidence whether the SP failed to provide VA1-VA4 with reasonable and necessary care. 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). Alleged Licensing Violations: Regarding the SP leaving the vulnerable adults alone at the facility for periods of time. According to VA1’s-VA4’s annual plans, VA1-VA4 were each allowed between two and four hours unsupervised time at the facility. VA1 and VA2 each provided information that the SP left the facility for up to two hours at a time. P1, P2, and P4 each stated that VA1-VA4 had alone time at the facility and none of them expressed concerns when the SP left the facility or that they were unsafe. P2 stated occasionally clients are at the facility alone based on the needs of the other clients but they all have access to the facility phone and VA1 had a personal cell phone in case of emergencies. On a few previous occasions, the SP picked up shifts for other staff persons after his/her scheduled shifts. The SP left the facility in the evening to go take care of personal concerns, such as letting his/her dog outside for a short time, but then returned to the facility. The SP stated there were on occasion, times when s/he worked a double shift and was gone for approximately 30 minutes from the facility. Given that VA1-VA4 each had unsupervised time at the facility, no licensing violation was determined. Regarding the SP giving VA1-VA4 their medication after the administered time or leaving the medications sitting out on the kitchen table for VA1-VA3 to take independently. According to VA1’s Self-Management Assessment, VA1 took his/her own medications and required staff persons “visual support.” According to VA1’s Intensive Support Self-Management Assessment, VA1 fell asleep prior to his/her medications “at times” and staff persons had “difficulty” waking VA1. There was no information provided about who administered VA1’s medications. According to VA2-VA4’s Coordinated Services and Support Plan (CSSP) Addendum, staff persons administered VA2-VA4’s medication. P4 stated that VA1 and VA3 told him/her that on occasions, the SP prepared VA1’s-VA4’s medications and placed them on the dining room table for when they come out of their bedrooms. P4 had not seen the SP administer medications that way. VA2 stated at medication administration time, the SP prepared VA2’s medications and set them on the dining room table. Some of the times, VA2 was there and took the medications. Other times, VA2 was in his/her bedroom so the SP knocked on VA2’s bedroom door and asked him/her to come out and take medications. VA1 stated on previous occasions, staff persons knocked on VA1’s bedroom door and told VA1 that his/her medications were ready. VA1 walked out to the kitchen and took his/her medications. VA1 stated this was a “problem” so VA1 spoke to each staff person and it improved. The SP stated there were occasions when the clients were in their bedrooms, that after preparing each of the clients’ medications, s/he went to the bedroom doors and knocked and asked the clients to come take their medications. The SP denied leaving the medications unattended on the table. Given the above information, a licensing violation was not determined. Action Taken by Facility: The facility completed internal reviews and determined that policies and procedures were adequate and followed and no additional action was necessary. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
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