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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: 1075665-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) used inappropriate language towards a vulnerable adult (VA) that included telling the VA to sit his/her “ass down” on a couch and on another occasion, during a meeting at the facility, said the VA was a “liar,” “thief,” “crybaby,” and “pedophile”. The VA was so distressed that s/he did not feel safe remaining at the facility and was placed in a crisis residence for stabilization. Date of Incident(s): Ongoing prior to April 7, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (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 May 10, 2023; from documentation at the facility; and through five interviews conducted with a supervisory staff person (P1), the VA’s case manager (CM), the VA’s guardian (G), the VA, and the SP. Attempts were made to obtain follow up information from the SP, but the SP did not respond to the calls. The facility’s records for the VA stated the VA enjoyed puzzles, watching TV and movies, going out to eat, and participating in Special Olympics. The VA was diagnosed with a traumatic brain injury. All staff persons interviewed were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Regarding the SP telling the VA to sit his/her ass on a couch: The VA said that on an unknown Thursday around 5 p.m., the SP told the VA, “Sit your ass on the couch,” and then made the VA sit on the couch for “about 45 minutes or longer.” The VA wanted to get up and leave but sat on the couch because s/he had no choice. The SP “hid” the VA’s lunchbox and then went through it to look for marijuana and gave it back to the VA. The CM said the VA told him/her that on a day prior to the meeting, approximately March 30, 2023, the VA was at the facility and the SP was upset with the VA because of a positive urinalysis (UA) the VA had. The SP took the VA’s lunchbox and told the VA, “Sit your ass down on the couch,” where the VA had to sit for about four hours and was not allowed to go into his room. P1 had never heard any staff persons including the SP tell a client to sit their ass down on a couch. P1 did not know anything about the VA having to sit on the couch for hours. However, “way long ago” about a year prior in February (2022), the VA smoked marijuana in his/her bedroom and a staff person had the VA sit in the common area of the facility because staff persons were directed by the VA’s guardian at the time (a different guardian than in this report), to search the VA’s bedroom. While staff persons searched the VA could not be in his/her bedroom. The SP was not working that day. The G heard from the CM that the VA told the CM that when s/he got home from work one day after not passing a UA for a job that the SP was upset with the VA and made the VA sit on a couch for several hours. The SP was not aware of a time where the VA had to sit on a couch for a long period of time. The SP did not know about any staff telling the VA to sit his/her ass down on a couch and the SP denied saying that to the VA. The VA frequently sat on a couch at the facility. The VA’s bedroom was searched more than once including one time when the police came to the facility to look for drugs and another time when staff were instructed to do so at the direction of the VA’s guardian at the time. A facility Incident Report dated March 30, 2023, stated “drug use” and that a staff person noticed the VA’s bedroom smelled of marijuana. The VA initially said s/he did not have any drug related items in his/her room, but then went to his/her closet and handed the staff person a container with marijuana in it as well as one “hitter pipe,” a vape container and a pack of cigarettes and a lighter. Law Enforcement was also called and came to the facility and removed the items the VA gave to staff. Regarding the SP using inappropriate language and causing distress to the VA during a meeting: The Individual Abuse Prevention Plan stated the VA was involved in an incident related to inappropriate touch of a minor and was not to be left unsupervised around children. The VA had a lack of understanding of sexuality. The VA was easily frustrated, very impulsive, susceptible to victimization, easily swayed, and had no thought of the consequences of his/her actions. The VA’s Coordinated Services Support Plan Addendum stated the VA had a behavior outcome to learn to manage his/her impulse control better through exploration of new coping skills. The target behaviors included “lying,” “verbal aggression,” and “inappropriate crying.” The lying included anytime the VA was “dishonest” about something, usually to “cover up other behavior.” An Incident Report dated April 3, 2023, stated “theft” and that the VA “admitted” to “stealing” his/her housemates “beverage.” The “plan of action” was to schedule a meeting. Information from all sources was consistent that on April 7, 2023, at 2:30 p.m. the CM, the VA, P1, and the SP held a meeting to discuss the VA’s positive UA which was a violation of the VA’s court order, a chemical assessment, and possible treatment. The VA said s/he “didn’t get along” with the SP and that during the meeting (April 7, 2023), the SP slammed his/her hands on the table and was “treating [the VA] really bad.” The SP raised his/her voice, yelled at the VA, and called the VA, “stupid.” The VA felt “scared” because s/he thought the SP was “just joking around, but s/he wasn’t” because the SP’s “temper” was “mad.” Prior to the meeting, the SP had never called the VA, “stupid.” During the meeting, the SP also said the VA was a “liar, a thief, a crybaby, and a pedophile.” P1 and the CM did not “stop” the SP. However, the CM told the SP that was not right to treat the VA that way. P1 “just sat there and took it.” The VA “wanted to get out of there” so the CM took the VA out of the meeting and brought the VA to a family member’s (FM’s) house. The SP worked with the VA every day and the VA did not have any concerns with the SP until the incident during the meeting. The VA did not know why the SP was upset during the meeting, because the SP was nice and they had a good relationship. The CM provided the following information: · During the meeting (April 7, 2023), the SP appeared “very frustrated” and sat with his/her jaw clenched and arms crossed at the end of a table. The CM and P1 talked to the VA for about a half hour about getting the VA “out of the house” more, concerns regarding marijuana use, and the VA’s job loss. The VA was “pretty quiet” during that time, but said s/he wanted help and did not know what was “wrong” with him/her and wanted to feel like him/herself again. During the discussion, the SP “escalated,” interrupted, and said, “I don’t know why you guys keep talking about this, [s/he] knows right from wrong. I have known [the VA] for a long time and [s/he] just turns on the tears when [s/he] gets caught. [S/he] should have known better.” The SP “hit” his/her hands on the table and started counting on his/her fingers saying, “You’re a liar and you’re a thief and you’re a pedophile, that’s what you are.” The SP then said, “I am respectful to you every day and you just spit in my face.” The CM intervened and told the SP it was not okay to say that to the VA and it was “borderline abusive.” The SP then said, “I don’t care, you’re not my boss, these are just the facts.” The CM reminded the SP that the VA was at the facility because s/he had a disability that affected his/her judgment. The VA started to cry and looked at the CM and said that s/he could not stay at the facility and wanted to leave. The CM was “very upset” with the SP’s interactions at the meeting, and said the SP was not respectful to the VA and was “really unprofessional.” The CM ended the meeting and left with the VA for a drive. · The CM called a crisis response team and the G to discuss the situation. The CM also talked to facility administrative persons (P2 and P3) and told them about the incident. · The VA refused to go back to the facility because s/he was so “distressed” and thought the SP might verbally “attack” him/her again and that the VA might get “escalated” and lash out at the SP. The VA remained at a temporary crisis center and the G told the CM that s/he was supportive of that decision. The following week after the meeting, the CM met with the VA and the VA was “adamant” s/he did not wat to go back to the facility and was afraid the SP would “be after” the VA. (Note: The VA did not return to the facility and instead moved into another licensed program.) P1 provided the following information: · On April 7, 2023, sometime before 2:30 p.m., the VA told P1 that s/he was nervous about the meeting and stated that s/he did not know why s/he was “like this.” The VA also said that s/he did not want to live at the facility anymore because s/he did not like it there and s/he was going to break the house rules so that s/he could move. The VA wanted to be “assured” that the SP was going to be at the meeting and P1 confirmed so. · Later that day, around 2:30 p.m., the CM arrived at the facility for the meeting. The CM, P1, the VA, and the SP were at the meeting. The CM and the SP were seated at the heads of the table and P1 and the VA were adjacent to the CM and SP on opposite sides from each other. The CM stated s/he felt the reason the VA got into “trouble” with stealing and drug use was because the VA had “too much time on [his/her] hands.” The CM asked P1 how the VA spent his/her time and P1 said the VA liked to spend time outdoors and inside the home s/he liked to be “busy” and “stay active” and enjoyed books, games, and cards. The CM talked to the VA about community and group activities and P1 asked the VA if s/he wanted to attend some of them. At that “juncture,” the SP became frustrated because the purpose of the meeting was to discuss the VA’s drug use and job loss and they had been talking for 25 to 30 minutes and had yet to address it. The SP “piped up” and said, “This is bullshit,” because they were not talking about what they were there to talk about and just “going around the subject” not getting anything “accomplished.” At that point, it was just the SP and the CM talking to each other. The SP then “stated some facts” about “ongoing theft,” including the VA stealing a cellphone and starting it on fire, smoking marijuana and cigarettes inside the facility, and an incident with a minor and being charged with inappropriate sexual contact. The SP and the CM started “bantering” but not raising their voices or using threatening body language. The CM asked the SP questions regarding the VA and how the SP knew that information and the SP said the information was in the VA’s paperwork and explained s/he was with the VA in court. The SP said that the VA’s attorney made it “very clear” to “make sure” the VA understood the charges. The CM was upset about the statements the SP made, but the SP “assured” the CM that the s/he was not “adding information” and was “making statements” that were “clearly in writing.” The SP said the VA “knows better” and knew what s/he “was doing” and had admitted that s/he did. The CM asked the SP to “stop” because s/he was being “borderline abusive.” The VA then “broke down” and started crying and said, “I just have to get out of here.” The CM said s/he was ending the meeting because it was not going anywhere. The SP said s/he was giving information that was supposed to be talked about and told the CM s/he was not his/her supervisor/boss. The CM told the VA to get his/her “stuff” and that they were going for a “ride.” The VA put his/her shoes on and said, “I thought you were a nice [person]” to the SP. The CM and the VA left the facility a couple minutes before 3 p.m. · P1 said there was no “rudeness” or interruption from the CM or the SP, but P1 could tell they were both “agitated.” The meeting “could have been handled better on both parts” and there was “culpability” on both the CM and the SP. P1 did not witness any “thwarting” or “tense body language” or raised voices from the CM or the SP. Anything the SP stated, which were “all facts,” the CM had a “rebuttal” for. The things the CM and the SP talked about at the meeting were things that the VA had previous talked about and known. · P1 did not remember the SP say “pedophile,” “cry baby,” or “stupid” during the meeting. When the SP was speaking to the CM, the SP said the VA knew right from wrong and worded things such as s/he “chose to lie,” “chose to steal,” and “chose to smoke marijuana.” · The VA never got “emotional” at the meeting until after the CM said the SP was being “borderline abusive.” · The VA was “very attached” to the SP in a “buddies” way and had known the SP for many years. When the VA moved into the facility, the VA was “thrilled” the SP worked there. Anytime the VA “confessed” to anything, s/he waited to tell the SP because the SP was the VA’s “comfort zone.” · P1 saw the words “pedophile” and “sex offender” written in the VA’s court documents. · P1 worked closely with the SP and was the SP’s supervisor for many years and had no concerns with the SP. The SP was one of those people who remained calm in a “crisis situation,” but was also very “speak the truth.” · The VA had the ability to report accurate information, but P1 did now know if s/he would because the VA thought things would end back on him/her and “go negative” for him/her and be his/her “fault.” Depending on who the VA was talking to, the VA could be “very fabricated” and tell what s/he thinks a specific person needed to hear and, in some situations, would “deliberately lie.” The VA joined in and went along with whatever a conversation was at the time and would “be on the team” that s/he was on at the time. If the VA got confronted on something, “everyone” was his/her enemy. · When the CM left the meeting with the VA, the CM did not say where s/he was taking the VA or when they would be back. P1 was concerned that the CM took the VA out of the facility without communicating any additional information. P1 did not know what to do, but because the VA was in his/her care at the time, P1 called P2 to tell him/her about what happened at the meeting. P2 told P1 to call the G. Around 4:30 p.m., P1 called the G who was unaware of the situation and told P1 s/he would call the CM and call P1 back. When the G called s/he told P1 that the CM initially took the VA to the FM’s house but then to an emergency crisis facility. The G said the CM told the VA s/he would have a ten day stay at the crisis facility but would return to the facility afterwards. The VA said s/he was okay with that. About 30 minutes later, the CM called P1 and confirmed the information. · At some point during the meeting, the VA wanted to see a list of “house rules” because s/he wanted to know which “house rules” s/he was “breaking” so s/he could “continue” to “break rules” so s/he could get “kick[ed]” out of the facility. The CM told the VA that every facility was going to have “rules” such as no drugs in the home. The G said P1 and the CM told him/her about the incident. The CM told the G that the meeting got “inappropriate” when the SP called the VA a pedophile and other inappropriate things, so the CM ended the meeting and brought the VA to the FM’s house and then to a crisis facility. The CM also told the G that the VA did not feel safe going back to the facility. The G did not have concerns with staff persons at the facility, but had only met them a handful of times and the VA had never reported anything to the G. The VA’s ability to accurately report information depended on what was being asked to him/her. The G thought the VA was “somewhat” of a good reporter but also acted like s/he knew what was being talked about when maybe s/he did not and would “kind of” agree with what was being said and could be easily manipulated. The G was not aware of any situations where the VA made things up but was more of a “lack of understanding.”
The SP provided the following information: · The CM reached out to the SP and P1 via email to set up a meeting about the VA failing a drug test and losing his/her job. On April 7, 2023, for the first 30 minutes of the meeting, the SP did not “say much” because the CM was talking about getting the VA out in the community and was not talking about the things the meeting was set up for. Eventually the SP said they needed to talk about the issues with the VA including the VA’s behaviors including “stealing lying, doing drugs, and child molestation.” The CM stood up, pushed his/her chair back, and pointed his/her finger at the SP and told the SP s/he was being “borderline abusive.” The VA then started crying. The SP told the CM, “I don’t feel I am,” and “I’m just stating facts” about what the meeting was for. The CM then said to the VA that they were going to go for a ride. As they were walking out the door, the VA said to the SP, “I thought you were a nice [person].” The SP was concerned that the VA was taken out of the house with the CM and did not know where they were going or when they would be back. · The SP said the CM did not like the SP’s choice of words, but the SP was being “frank.” The SP said to the CM during the meeting that they needed to “deal with the facts of [the VA] being a thief, a liar, a drug user, and a pedophile.” The SP did not know the “proper politically correct term,” but said the words such as “pedophile, child molester, and sex offender” were used by “everybody” involved in the VA’s case. The VA “definitely understood” what those words meant. The VA’s lawyer previously instructed the SP to read the VA’s court paperwork to the VA so that the VA understood them and during the meeting the SP did not say anything that s/he or others on the VA’s team such as judges, lawyers, and the VA’s family members, did not already talk about with the VA prior. · At one point during the meeting, the SP said that it was bullshit referring to the half hour spent on subjects not related to what the meeting was for. · The SP felt s/he “rubbed” the CM the wrong way but that was not the SP’s “intention.” The problem was a “clash” between the SP and the CM, and they could have stepped aside to talk instead of continuing at the table. The SP also felt like the meeting did not have to “turn” as it had. The SP said that maybe s/he could have said something a “little different” but s/he was not sure how to do so with the VA. The SP was just trying to convey his/her point about what the meeting was for. There were no raised voices during the meeting from either the CM or the SP. · The SP felt the meeting was “calm” and there was no “drama” until the CM’s statement about “abuse” and then the VA had a visible reaction to that word. The SP did not think that specific incident had a huge impact on the VA, but the VA was “caught up” in the “fact” the CM got “upset” because no one else was “upset.” · The SP worked with the VA at the facility for over a year but had known the VA for more than ten years. The VA thought the SP was a “good” person. The SP was not aware of the “trouble” the VA was in when s/he moved into the facility. The SP treated the VA with respect, and they were “pretty buddy buddy.” · The VA was very “high functioning” and if a situation came up where the VA got “caught” doing something s/he would “shut down.” The SP did not know how accurate the VA was with information and one of the VA’s goals was to work on the VA’s “lying.” Conclusion: Regarding the SP telling the VA to sit his/her ass on a couch: The VA provided consistent information during his/her interview and to the CM said that on an unknown Thursday around 5 p.m., the SP told the VA, “Sit your ass on the couch,” and made the VA sit on the couch for between 45 minutes and 4 hours. P1 had never heard any staff persons including the SP tell a client to sit their ass down on a couch and did not know anything about the VA having to sit on the couch for hours. However, there was one occasion when the VA smoked marijuana in his/her bedroom and a staff person had the VA sit in the common area of the facility because staff persons were directed by the VA’s guardian at the time (a different guardian than in this report), to go through the VA’s bedroom. The SP was not working that day. The SP denied telling the VA to sit his/her ass down and denied making the VA sit on the couch for an extended time. Although the VA said the SP told him/her to sit his/her ass down on a couch, given there was no information to corroborate the VA’s information; that according to the G, P1, and the SP, the VA’s ability to report information was questionable depending on the situation; and that the SP denied the allegation, there was not a preponderance of the evidence whether the VA was told to sit his/her ass down on a couch where s/he had to remain for an extended period of time. 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). Regarding the SP using inappropriate language and causing distress to the VA during a meeting: Information from the VA, the CM, and P1 was consistent that at a meeting to discuss the VA’s recent UA and job loss, the SP became frustrated when the meeting seemed to go off topic. The SP said that it was “bullshit” that they were not talking about what the meeting was set up for and listed the subjects that were to be discussed. According to the CM, the SP told the VA, “You’re a liar and you’re a thief and you’re a pedophile, that’s what you are,” which caused the VA to cry. The VA said the SP yelled, called him/her stupid, a liar, a thief, a crybaby, and a pedophile which made him/her feel upset, scared, and worried and it was clear something during the meeting caused the VA emotional distress. Although the words used by the SP may not have been the most professional, given that both P1 and the SP said the SP’s words were stated as “facts” and not directed at the VA; that P1 did not hear the SP say “pedophile,” “cry baby,” or “stupid;” that P1 said the VA never got “emotional” until the CM said the SP was being “borderline abusive,” it was unclear if the VA’s response was caused from the SP’s words or from the interaction between the CM and the SP. Therefore, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or whether the single incident 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). Action Taken by Facility: The facility completed an Internal Review and determined its policies and procedures were adequate but not followed and there was need for additional staff training for the SP in regard to the Maltreatment of Vulnerable Adults Policy and Procedures and Service Recipient Rights Policy and Procedures. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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