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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: 802845-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that there were multiple concerns with a staff person’s (SP) interactions with clients. This included that the SP screamed at a vulnerable adult (VA1) and slammed a door in VA1’s face; and that the SP yelled and swore at other vulnerable adult’s, including (VA2 and VA3). Date of Incident(s): Ongoing prior to December 30, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on January 31, 2023; from documentation at the facility; and through eight interviews conducted with VA2, VA3, two facility supervisory staff persons (P1 and the SP), and four staff persons (P2, P3, P4, and P5). Attempts were made via phone, email, and U.S. mail to contact and interview VA1 but the attempts were not successful. However, during the attempts, VA1 left this investigator a voicemail message stating that since the incident, his/her life had been in “complete shambles” and s/he would be difficult to contact. Attempts were also made to contact and interview two additional clients (C1 and C2) but the attempts were not successful. The facility was a residential treatment facility that was split by gender into two buildings. The building VA1, VA2, and VA3 were in had three floors and clients typically did urinalysis (UAs) in a bathroom on the main floor. VA1’s Admission Application said that VA1 was diagnosed with stimulant dependence and moderate nicotine use disorder. VA1’s “drug of choice” included alcohol and methamphetamine. VA1 also had a history of anxiety disorder and depression. VA1’s Individual Abuse Prevention Plan did not identify any risks to VA1. VA1 enjoyed playing frisbee golf and drawing. The Pathway House Discharge Status said that on December 31, 2022, VA1 was discharged “against staff approval.” VA1 said that s/he was leaving because a client was “trying to set [VA1] up by selling [VA1] pee and ratting [VA1] out.” VA1 struggled with impulse control and “anger” while at the facility. VA2’s plans showed that VA2 was admitted to the facility on April 13, 2022. VA2 was diagnosed with alcohol dependence. VA2’s Individual Abuse Prevention Plan did not identify any risks to VA2. An email from P1 to VA2’s probation officer dated April 25, 2022, said that the prior weekend, a staff person (who was not named) said that VA2 was yelling at him/her and “getting in [his/her] face.” P1 said that staff persons were “trying to work with” VA2. On May 4, 2022, P1 emailed VA2’s probation officer and said that it was “best” that VA2 was no longer a client at the facility as P1 overheard VA2 stating that s/he was going to “beat someone’s ass.” Additionally, two staff persons told P1 that VA2 said that s/he was going to “punch one of the staff in the face and beat another staff’s ass.” P1 said that s/he could not have staff persons feeling “unsafe.” VA3 was admitted to the facility on August 31, 2022. VA3 was diagnosed with stimulant dependence. VA3’s Individual Abuse Prevention Plan did not identify any risks to VA3. Initial information regarding the allegations provided the following: · VA1 was admitted to the facility on December 22, 2022. VA1 was “dropped off and given no direction or explanation.” It took VA1 a “long time to figure out what was going on” because “no one told [VA1] anything.” This included that staff persons never explained the program or when to eat. VA1 never received a handbook or any type of orientation (Note: Documentation from the facility showed that the SP “reviewed” facility policies and procedures with VA1 on December 25, 2022. This included house expectations and the facility “services and schedule.”) · VA1 often had difficulty providing a UA as s/he had “problems urinating in front of others.” On those occasions, it took VA1 three to four attempts before s/he was able to complete a UA. · At some point on December 30, 2022, VA1 was in the SP’s office waiting to take a UA. VA1 said that s/he had already taken a UA earlier in the day and “admitted that day to a use.” At 3:00 p.m., a staff person (who VA1 did not name) told VA1 that s/he did not have to take a UA so VA1 went to the bathroom. · Around 6 p.m., an unknown staff person “changed their mind” and wanted VA1 to take another UA. Around 8:30 p.m., VA1 was waiting to take a UA and was talking to the SP about another treatment facility. The SP then began “screaming” in VA1’s “face” and stated, “I don’t care what happened to you at the other place.” The SP was “nose to nose” with VA1. VA1 said that s/he raised his/her voice a “bit” but only because s/he was trying to get the SP to “listen” to him/her. VA1 then told the SP that s/he could not “pee in a cup” when the SP was “screaming” at him/her. The SP told VA1 to “just go into the bathroom” by him/herself to “take the test” and then the SP “slammed” the door in VA1’s “face.” The door was so close to VA1’s face that it almost hit VA1’s face. VA1 said that “everyone” at the facility could “hear and feel” the incident because the “whole house shook.” It took VA1 a while to provide the UA because VA1 was “afraid” to leave the bathroom. VA1 provided the SP the UA and then VA1 left the facility. As a result, VA1 became homeless and “relapsed.” · VA1 spoke to an unknown staff person and two clients (C1 and C2) about the incident prior to VA1 leaving as they asked VA1 what happened. VA2 said that s/he was a client at the facility in approximately April 2022. VA2 did not recall the SP by name but described the SP. VA2 said that the SP “almost got into a fight” with VA2 including that the SP got into VA2’s “face” and called VA2 “all types of names,” including “bitches” and “mother fucker.” The SP told VA2 that s/he could “leave” the facility but VA2 was “court ordered” and could not leave or s/he would go to jail. When this investigator asked VA2 how often the SP interacted with him/her in this manner, VA2 said that it was “every time” that VA2 tried to talk to the SP. The SP “did not want to listen” which caused VA2 to get “mad.” VA2 described the SP as “real wild” and “crazy.” The SP also yelled at VA2 “in front of everyone” at the facility. The SP’s interactions made VA2 feel “bad” because s/he was not able to leave and had a “big ego” so had to “swallow that.” At some point, VA2 told his/her probation officer about the concerns who found VA2 another similar program that VA2 moved to. VA3 said that around the “beginning” of 2023, the SP “blew up on [VA3] and “yelled” at VA3 because of a “TV stand.” The SP called VA3 “all kinds of names” including “stupid,” a “fucking moron,” and “asshole.” The SP “belittled” VA3 and was “very unprofessional.” The SP then “kicked [VA3] out on the street” during the winter for “no apparent reason.” As a result of this, VA3’s “mental health was not in a good state” and VA3 had a “difficult time” and was “hurt.” VA3 was close to graduating from the facility and had a job, but because of the SP’s interactions, VA3 no longer had a job. VA3 had been to prison and other treatment facilities and had “never seen a staff behave like that.” VA3 said that P1 and P4 had seen the SP’s interactions including with the TV stand and were not “cool with how [the SP] was behaving. However, VA3 was “worried” that they may not say anything due to losing their job. Additionally, the SP had a familial relationship with the license holder and was the “honcho” of the facility. P3 provided the following information: · P3 said that s/he had concerns with the way the SP “treated” and spoke to the clients, including VA2. Around April 29, 2022, the SP “went off” on VA2 regarding VA2’s job. P3 believed it was over a work schedule that VA2 did not turn in and did not have his/her supervisor (at a fast food restaurant VA2 worked at) sign. As a result, the SP “went off” on VA2 and told VA2 that s/he “did not give a fuck,” that VA2 was a “fucking liar,” and for VA2 to “get the fuck out.” VA2 “did not say much” but “defended” him/herself. VA2 left the facility a couple of days after the incident. P3 recorded the incident on his/her cell phone to show P1 how the SP interacted with the clients (although P3 also said that P1 had “absolutely” seen the SP interact with clients in a similar manner on prior occasions). P3 said that the SP interacted with clients in this manner a “lot” and that it was “not okay.” The recording did not show faces but P3 said that the SP had a “distinct voice.” P3 said that s/he was in the background of the recording telling the SP, “Stop,” but the SP “kept yelling.” · At some point, P3 showed P1 the recording and P1 got “all weird” and asked P3 why s/he had the recording. However, P1 also said that s/he was going to address it and things improved with the SP for a “month.” P1 was typically “really good” at addressing things. P3 also showed P4 the recording. · Additionally, the incident between the SP and VA2 occurred in a main area of the facility and other clients were present. Some of the clients were “laughing” and some “walked away.” P3 did not recall if any other staff persons were present. · Aside from the incident P3 recorded, there were “hundreds” of similar incidents of the SP “snapping” with clients and staff persons. When the SP was in a “bad mood,” which was “every day,” the SP would “snap on a dime” and the SP could be heard throughout the facility. P3 had also seen the SP throw clients belongings outside and tell them to “get the fuck out.” The SP spoke to the clients like they were “nothing.” The SP called clients “fucking dumb,” and told them that they were “not fucking doing anything” and were “wasted space.” The SP also told clients that the facility was not a “fucking hotel” and to “get the fuck out.” P3 did not recall any specific client’s names who the SP interacted in this manner with, aside from VA2. The SP also told staff persons that they were “dumb” and did not know what they were doing. · P3 had not seen the SP slam a door in a clients face but said that the SP had “slammed doors.” P3 was not aware of the incident with VA1 or any incident where the SP yelled and screamed at a client during a UA, which then caused the client to leave. · Staff persons were “absolutely” not trained to interact with clients in that manner and were trained to interact with them with respect and not “cuss them out.” The clients were “addicts trying to get their lives together.” P3 said that the SP should not work at the facility and P3 was “surprised” that the SP was still at the facility because s/he was a “loose cannon.” P3 was also a former client at the facility and said that if s/he were treated in that manner, s/he would have “left.” The SP had not spoken to the P3 in a similar manner when P3 was a client. However, the SP was not in the same position s/he was currently in and the SP did not typically work with the clients when P3 was a client. · P3 was not aware of any reason why someone would say something about the SP that were not true. The undated audio recording had a person of the SP’s gender (which P2 and P4 each said was the SP) saying, “This is what’s gotta go on. Otherwise, pack your stuff and head out.” There was another voice that was inaudible. The SP said, “Do it man. Do it.” The other voice said something but was inaudible. The SP began yelling and said, “I don’t give a shit what a fucking manager tells me. I am the fucking [inaudible]. You understand me? Fuck you. Just do it.” There was a noise during this that sounded like someone slapped something down. The other person said, “Fuck you,” in a quieter voice. The SP said, “Do it. Then pack your bags.” The SP then said, “You were not taking responsibility dude. Just fucking do it or get out.” The recording ended. P2 provided the following information: · P2 worked at the facility on December 30, 2022, from 8 a.m. to 4 p.m. and did not recall any staff person yelling at VA1 and did not recall VA1 having any concerns with staff persons. The UAs were usually done in a bathroom next to P2’s office and P2 typically remained in the hallway outside of the bathroom during the UAs. P2 did not recall VA1 having a UA on December 30, 2022. P2 was not aware of any staff person slamming a door in a client’s face. However, P2 heard from other staff persons that VA1 and another client got into a “disagreement” and were yelling as VA1 was “using.” However, that did not involve the SP. It was P2’s understanding that VA1 left the facility because s/he was “using.” · It would not be appropriate for a staff person to yell at a client. Staff persons were trained to “help” the clients. P2 had not seen the SP yell at a client and felt comfortable telling someone if s/he had concerns. P2 said that P1 would say if s/he had concerns. P2 did not have any “problems” with the SP and said that the SP “goes above and beyond.” · If a client could not provide a UA, they were to sit in the living room until they could provide one. If they did not provide one, then staff persons were to document it and then the client was to take one during the night or the following day. Staff persons were not to get upset if a client could not provide a UA. · When there was a new client, staff persons went over “house expectations,” including mealtimes and medication times. P4 provided the following information: · P4 typically worked with the SP and P1. The SP was “overall” “pretty therapeutic” but at times, the SP was “somewhat unapproachable.” The SP had a “hard time regulating [his/her] emotions” and could get “irritated pretty easily” with staff persons and clients. The SP could be “intimidating” and “confrontational” to staff persons and the SP had yelled at P4. If the SP could treat a staff person like that, it would not “surprise” P4 that the SP interacted with clients in the same manner. · At some point, P4 received “several reports” that clients were “using.” Around lunch, P4 addressed this including that every client would need to do a UA. VA1 “admitted” that s/he was “using” and was going to fail his/her UA. P4 thanked VA1 for being “honest.” At some point, P4’s shift ended and VA1 had not yet taken a UA because VA1 was “hymning and hawing.” However, at some point, the SP did VA1’s UA. P4 was not aware of VA1 having any concerns with the SP. P4 had never seen the SP slam a door in someone’s face. P4 never saw the SP yell at VA1 but said that it would not “surprise” him/her if the SP did so. P4 thought that VA1 left the facility because s/he was “using” and not because of the SP’s interactions. If a client could not urinate for a UA, which was “pretty frequent” or if they refused, there were “accommodations” such as the client taking a blood test at a hospital. · Approximately two to three weeks prior to Christmas 2022, in the morning, P4 was in his/her office in the basement level of the facility with the door closed. P4 heard the SP yelling upstairs so P4 ran upstairs to “intervene.” P4 said that a client (who P4 thought was VA3 but was not sure) was discharging and had a TV stand in his/her room which s/he was not supposed to have. The client was asked “numerous” times to take the TV stand at discharge but instead the client put it in a dumpster at a “neighbor’s” but the SP discovered it. The client then put the TV stand in the bushes. The SP “totally lost it” and began yelling and “screaming” at the client. P4 could not “quote” what the SP said but it included that the client was “fucking ridiculous.” The client told P4 that s/he did not need someone yelling or screaming at him/her prior to leaving the facility. The client was “very upset” so P4 apologized to the client and told the client that s/he should not be “treated” like that. The SP should not have yelled or screamed at the client, and it was not an “appropriate response.” The SP should have talked to the client and told the client it was not “okay” to put his/her TV stand in the neighbor’s dumpster and figure out another way for the client to dispose of it. · P4 knew it was the SP’s voice on the recording because the SP’s voice was “very distinct.” P4 said that P3 took the recording of the SP because a lot of times, the SP spoke to clients in that manner when staff persons were not around. P3 was trying to make a “point” at how “severe and impactful” the SP’s interactions were to the clients. · P4 was not aware of any reason why someone would say things about the SP that were not true. · The clients were “vulnerable adults” and were “sick.” Staff persons were trained to interact with clients “therapeutically” and “calmly.” Staff persons were to also interact with clients in a “respectful manner.” The facility provided training, including how to work with “difficult people.” The SP also received that training. If the SP was frustrated with a client, s/he could have taken a break, talked about it later, or asked someone else to “intervene.” · New clients received orientation, including a “welcome folder” with the rules and “programming.” P4 had a “hard time believing” that a client did not receive this orientation as it had assignments and other important documents in it. P5 provided the following information: · P5 described the SP as “very unpredictable.” On “some days,” the SP was in a “good mood” with the clients and at other times, the SP was “mad” and would “take it out on the clients.” P5 provided an example and said that a “couple months” prior to May 2023, P5 was in the lower level of the facility with P4 when they heard “screaming” and a “super loud commotion” upstairs. P4 and P5 then ran upstairs and saw the SP “screaming” at VA3 telling VA3 to “get the fuck out.” P4 and P5 tried to “diffuse the situation” and then the SP left the facility. P4 and P5 met with VA3 and VA3 said that the SP “got in [his/her] face” and began “screaming” at VA3. P5 did not know “what led up” to the incident. P4 and P5 also notified P1 about the incident. Because of the incident, VA3 left the facility. VA3 was close to graduating but left prior to doing so. · P5 had heard the video footage and knew that it was the SP on the recording due to his/her “voice.” · If a client was “escalated,” staff persons were trained to “step away” or ask another staff person for help. The clients were from “all walks of life” and did not have the “same coping skills” as someone else. The SP did the “opposite” of how staff persons should interact with the clients. · P5 thought that there was a “lot of hush hush” and protection with the SP due to his/her role at the facility. This included that the supervisors, including P1, acted like “nothing happened.” There was also “fear of retaliation.” · P5 was not aware of anyone who would provide inaccurate information regarding the SP. P5 said that P4 was “very similar” to P5 in that s/he knew the rules and “statutes” and would not “just go with the flow.” However, prior to P5’s interview with this investigator, P1 told P5 to be “careful what you say” and “other weird comments.” P1 did not want P5 to say “a whole lot” to this investigator. P5 told P1 that s/he would say the “truth” and what s/he “saw.” P1 provided the following information: · P1 was not at the facility on December 30, 2022. However, a client told P4 that clients, including VA1, were “using.” Because of this, a UA was done for all the clients and it was discovered that four to five clients, including VA1, were “using.” P2 and P4 were both at the facility and both would have said something if they had concerns with the SP. On December 31, 2022, VA1 chose to discharge. P1 was not aware of VA1 having any concerns while at the facility. · Staff persons tried to have UAs done within one hour but “sometimes” it took the clients “hours” to provide a urine sample. When this occurred, staff persons kept the clients “in sight” so that they did not alter the UA or use someone else’s urine. · P1 said that s/he was not aware of the audio recording prior to this investigator playing it for P1. P1 said that the audio recording sounded like the SP. P1 thought that the audio recording could have been from an incident regarding a client’s significant other who was “stalking” him/her. P1 was not present for that incident but “heard about it.” P1 was told that this person came to the facility and was “argumentative.” The SP told this person to “leave” but this person was “screaming” at the SP, so the SP then told the person to “get the F out.” Staff persons were trying to “protect” this person’s significant other who was a client. The SP was “mad” because this person was trying to “push” his/her way in so the SP had to “kick” that person out. P1 said that no one should talk to “anyone like that” but the person was not a client. · The SP did not “fly off the handle” but talked loudly when s/he was “mad or excited” which was the only concern P1 was aware of with the SP’s interactions. The SP was not “demeaning” and was “straight forward” when speaking. P1 had not heard the SP talk similar to the audio, including swearing “like that” at a client. The SP swore in general but not at the clients. It would not be appropriate to yell or swear at a client. P1 had not heard the SP or any staff person yell at any clients, including VA1. However, clients would yell at staff persons and the clients would get “mad” if staff person’s “caught them using.” The SP had “confronted” a few clients about this. P1 felt comfortable reporting if s/he had a concern with the SP. · P1 said that the facility doors were “loud” when they shut and clients had asked P1 if s/he was “mad” when s/he shut his/her office door. P1 was not aware of the SP slamming a door in VA1’s face. · P1 had not seen any staff person, including the SP, throw a client’s belongings out. The SP was “really picky” with the client’s belongings. · P1 thought that clients, including VA1, may have said things about the SP that were not true so that they did not get in trouble with their probation officers. Additionally, staff person may be “jealous” of the SP because s/he was in a “higher position.” The SP and P3 also “bumped heads” and each “complained” about one another. They “clashed” and both had a “loud [and] bossy personality.” · Clients received a “packet” with “house expectations.” Staff persons then went over the packet and the clients signed when they read over it. The SP did this with VA1. The SP provided the following information: · The SP did not know VA1 by name but said that VA1 was not a client at the facility long. The SP did not recall the date but on a Friday, around lunch, P4 made an “announcement” that clients were “using” and that they were going to do UAs on all the clients. The facility used a UA company but that person had left for the day so the SP did the UA’s because s/he was the only staff person who was the same gender as the clients. It took a “little longer” to do VA1’s UA because VA1 thought that the SP was “watching” VA1, which staff persons were trained to do. The SP tried getting VA1’s UA starting at 12:30 p.m., and it took nine and a half hours for VA1 to provide a urine sample. Around 9:30 p.m., it got to the “point” where the SP told VA1 that s/he “did not care what [VA1] did” and to put some “urine in there” so that the SP could go home. The SP then shut the bathroom door. Then when VA1 provided the urine s/he said s/he had used. The SP denied yelling at VA1 but said that towards the “end,” around 9:30 p.m., the “conversation got loud.” The SP had been at the facility since 7:30 a.m. and it was a “long Friday.” · Around 5 a.m. the next morning, the SP received a text message from a staff person that VA1 got into an “argument” with other clients and left the facility. · The SP was not aware of VA1 having any concerns with the SP’s interactions. The SP was not aware of VA1 being “afraid” because of the incident. The SP shut the bathroom door “hard” but the SP “did not know if [s/he] slammed it.” · The SP said that at some point, s/he told VA3 “eight times” to remove a TV stand and VA3 threw it in a neighbors garbage can. The SP said that s/he yelled at VA3 because VA3 kept “lying” to the SP. When this investigator asked the SP if it was appropriate to yell at VA3, the SP said, “I guess,” and said that s/he did not “know how many times” s/he needed to ask VA3 to remove the TV from the garbage can. · The SP described him/herself as “pretty laid back” and “easygoing.” However, the SP said that “everyone wears down.” The SP typically joked with the clients. The SP said that s/he “maybe” swore at a client or might say “shit” and provided an example that if s/he stubbed his/her toe. The SP did not think that it was appropriate to swear at a client but said, “I suppose if they are swearing at you,” but that s/he “generally” did not do it. The SP said that supervisory staff persons “maybe” spoke to him/her about his/her interactions with the clients but s/he did not know for sure. When this investigator asked the SP why someone would have concerns with his/her interactions with the clients, the SP said that s/he “maybe comes on strong sometimes.” When “defusing” an argument, the SP “always went by the golden rule” of treating people the way s/he would want to be treated. The SP denied throwing out client’s belongings. The SP denied screaming or swearing at staff persons or any other clients aside from VA3. If there were concerns with the SP’s interactions, P1 would address those things with the SP.
· When this investigator played the audio recording of the SP, the SP said that s/he “did not really recognize” his/her voice or know who the client was. The SP said that “no one sits and yells like that for no reason” but that if it was him/her, s/he was “probably kicking” a client out of the facility if the client was “being disrespectful” or “threatening” people. Typically, law enforcement assisted with “kicking” a client out but they were not doing so lately. The SP was not aware of this recording prior. The SP said that the interactions on the recording would “probably not” be an appropriate way to speak to a client. · The SP did not know why there were multiple concerns with his/her interactions with clients. The SP was not aware of any clients leaving due to the SP’s interactions with them. · The SP went over the facility rules with new clients during intake and then the clients signed when they went over it. This was also discussed “every Tuesday” in group. VA1 “should have” gotten an intake folder as s/he was at the facility for “over a week.” The Client’s House Expectations said that the house expectations were developed to promote a safe and harmonious living environment. This included that drug possession and usage were prohibited and grounds for “immediate discharge.” There was a UA “collector” every morning from 7 to 10 a.m. Clients were to stay within “eyesight” of the requesting staff and the UA was to be taken within one hour of being asked, otherwise, it was considered a refusal. Any client using violent or threatening behavior towards staff or clients were not tolerated and may be grounds for immediate discharge. The Employee Code of Ethics said that “all” staff persons were to maintain the highest degree of professionalism at the facility. The Disciplinary Action said that disparaging or disrespecting clients could result in disciplinary action by the facility. Facility documentation showed that the SP, P1, P2, P3, and P4 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, ethical boundaries, abuse prevention plan, and client rights. The SP’s Employee Performance Appraisal dated January 1, 2021, said that the SP “exceeds standards” regarding communication with clients and that the SP had “respect” for clients and staff persons. Relevant Rules and/or Statutes: Minnesota Statute, section 245G.15, subdivision 1, states that residents had the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: Initial information received by the department said that on December 30, 2022, during a UA, the SP “screamed” at VA1. Because of this, VA1 said that s/he was “afraid” to use the bathroom. VA1 also said that because of this, s/he left the facility, relapsed, and became homeless. Although no staff person was aware of the incident with VA1, VA2 and an audio recording obtained from P3 and P4 provided consistent information that the SP yelled at VA2 in a similar manner. P1, P3, P4, and P5 each identified the SP as the person on the recording which also had the SP swearing stating, “I don’t give a shit” and “fuck you.” VA2 said s/he left the facility due to the SP’s interactions. VA3, P4, and P5 also said that around December 2022 or the beginning of 2023, the SP was yelling and screaming at VA3, including that VA3 was “fucking ridiculous.” VA3 said that the SP called him/her “all kinds of names” including “stupid,” a “fucking moron,” and “asshole.” P4 said that VA3 was “very upset” and VA3 said that as a result of this, VA3’s “mental health was not in a good state” and VA3 had a “difficult time” and was “hurt.” The SP denied yelling at VA1 but said that the “conversation got loud.” The SP said that s/he “maybe” swore at clients or might say “shit” and provided an example that if s/he stubbed his/her toe, but s/he “generally” did not do that. The SP did not know if it was him/her on the recording but that it may have been when s/he was kicking a client out of the facility but that interaction would not be an appropriate way to interact with a client. The SP also said that s/he yelled at VA3 because VA3 “kept lying,” and when asked if it was appropriate to yell at VA3, the SP said, “I guess.” The SP’s actions of yelling and swearing at VA1, VA2, and VA3 were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, inconsistent with the facility policies and procedures, and were a violation of Minnesota Statutes, section 245G.15, subdivision 1. Given that the SP yelled and/or swore at VA1, VA2, and VA3 on multiple occasions which was not accidental or therapeutic, there was a preponderance of the evidence that the SP’s conduct was repeated oral language that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be excepted 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. 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 responsible for the care of VA1, VA2, and VA3 at the time of the incidents. The SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, ethical boundaries, abuse prevention plan, and client rights. The SP acknowledged yelling at VA3. The SP was responsible for the maltreatment of VA1, VA2, and VA3. In addition, given the SP’s significant administrative and supervisory authority over the operation of the facility and maintaining compliance with Minnesota Rules and Statutes, the facility was also responsible for the 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 a facility meets the statutory criteria to be determined as “serious” and 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 and the facility were responsible did not meet statutory criteria to be determined as recurring or serious. The SP’s pattern of yelling at VA1, VA2, and VA3 was considered a single incident which did not meet the definition of serious Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. However, the facility was to provide an “all staff training” regarding client rights and using “proper” body language and tone of voice with the clients. There were no similar prior concerns with staff persons or clients. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Additionally, the SP was regulated by a health related licensing board. The health related licensing board was notified upon issuance of the investigation memorandum that the SP was determined to be responsible for maltreatment. On June 28, 2023, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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