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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: 1070418-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) broke a vulnerable adults (VA) arm. During the investigation, it was reported that the SP asked the VA to engage in sexual contact. Date of Incident(s): May 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 (1); 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. 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 May 16, 2023, from documentation at the facility, from the VA’s medical records, and through four interviews conducted with the VA, the SP, two facility management staff persons (P1 and P2) and a facility staff person (P3). Although this investigator requested the law enforcement report, the report was not provided. The VA was not subject to guardianship. Documentation showed that the VA enjoyed listing to music and being around dogs. Documentation also showed that the VA had a traumatic brain injury (TBI) and issues related to “alcoholism.” The VA had two hours of unsupervised time in the community and information showed that the VA “ignores [his/her] personal safety when [s/he] is using illicit drugs or alcohol.” In addition, the VA “reports getting dizzy spells since [his/her] TBI, which can cause [him/her] to be unsteady.” As a result, staff persons were trained to remind the VA to “sit and rest a bit until the dizziness goes away to prevent falls.” P1 provided the following information: · On the day of the incident, May 7, 2023, the SP called P1 about 7 p.m. and stated that the VA was “drunk,” had been calling the SP “names” and after the VA “threw” a cup at the SP, the VA “fell.” The SP told P1 that the SP called P2, who advised the SP to call 9-1-1, so the SP did. Law enforcement transported the VA to the hospital. The SP also went to the hospital because s/he had some injuries. · When P1 talked to the VA, the VA stated s/he got upset with the SP because the SP did not help the VA get food when the VA requested it. When that happened, the VA called the SP a “lazy ass bitch” and then the VA “threw” the cup at the SP. After that, the SP “grabbed” the VA and “threw me on the ground and broke my arm.” P1 said that the VA would “lie” in terms of the VA’s drinking, but P1 was not certain if the VA was not truthful about other information. The VA provided the following information: · On May 7, 2023, prior to the incident, the SP went into the bathroom when the VA was in the bathroom. The SP “propositioned” the VA and asked if s/he could perform oral sex on the VA. When that happened, the VA said, “No,” and “Fuck you,” to the SP and “that’s what started everything.” The VA also acknowledged that s/he used “[racial] slurs” toward the SP and called him/her a “lazy fucker.” After that, the VA threw an object (the VA did not remember what it was) at the SP, but the object did not hit the SP. · The SP then “body slammed” the VA and “picked me up” to “body slam me on the floor in the living room.” After that, law enforcement was called, but the VA did not remember who called law enforcement. The SP provided the following information: · On the day of the incident, the SP began working at 4 p.m. and the VA was not at the facility. Shortly after, the SP was cleaning and the VA returned to the facility from the community. The SP realized that the VA was “drunk.” The VA began “yelling” at the SP, used racial slurs, and asked the SP why s/he was at the facility. · After that, the VA threw a cup at the SP, which hit the SP’s neck. The VA said that s/he was “going to kill” the SP. When that happened, the SP tried to redirect the VA to calm but was not successful. When the VA again tried to approach the SP, the VA was about five feet from the SP and the VA “fell” on his/her left shoulder.” The SP asked the VA if s/he was okay and the VA said, “No” and that s/he was “going to kill” the SP. After that, the SP called P2 and then called 9-1-1. · The SP denied having any physical contact with the VA, denied causing injury to the VA, and denied asking to perform oral sex on the VA. P3, who worked from 2-10 p.m. on the day of the incident, said that s/he left the facility at about 5:15 p.m. to go into the community with another client, but before P3 and the client left, the VA was “yelling” and using racial slurs toward the SP. When that happened, P3 initially “ignored” the VA thinking that the VA would stop, but that did not happen so the SP provided verbal redirection to the VA who was “really drunk.” P3 felt that the VA had calmed down enough for P3 to leave the facility with the other client. Shortly after P3 left, the SP called P3 and said that the VA was “acting crazy.” While P3 was on the phone with the SP, P3 heard the VA tell the SP that s/he was going to “kill” the SP. P3 told the SP that s/he and the other client would return to the facility and that the SP should call law enforcement. When P3 returned to the facility, law enforcement was at the facility and asked P3 to wait outside until they took the VA to the hospital. The SP told P3 that when the VA tried to “punch” the SP, the VA “might have tripped and fell down.” When P3 talked to the VA about the incident, the VA said that the SP “attacked” the VA, but that the SP did not pull the VA to the floor. P3 did not have knowledge of the SP making some type of sexual comment to the VA because the VA had not mentioned that to P3 and P3 did not heard the SP make any sexual comments. When P3 was asked to provide information about the VA’s ability to provide information, P3 stated that when the VA was “drunk,” the VA “spills everything,” which meant information that was “very personal” to the VA. P2 stated that s/he got a call from the SP at about 6:20 p.m. on May 7, 2023. The SP told P2 that the VA was “heavily drunk,” was “chasing” the SP “around the house” and that the SP “wasn’t feeling safe” due to the VA. P2 told the SP to call 9-1-1. The VA’s medical records, dated May 7, 2023, stated that the VA “reports injuring [his/her] right shoulder while in a physical altercation earlier today. [The VA] states that [s/he] fell on the shoulder and heard a crack” and that the VA had “pain to the upper portion of the shoulder.” In addition, the records showed that the VA had a “right proximal humerus fracture. Minimally displaced. Treatment likely to be nonsurgical. Will place in a sling at this time. Will recommend ibuprofen and acetaminophen for analgesia.” The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to May 7, 2023. Conclusion: Regarding alleged sexual contact between the SP and the VA: Although the VA stated that on May 7, 2023, the SP “propositioned” the VA and asked if s/he could perform oral sex on the VA, the VA stated s/he told the SP, “No,” and that sexual contact did not occur. The SP denied asking the VA this and P3, who was also working that day, stated that the VA had not mentioned that to him/her and had not heard the SP do so. Given that the VA stated sexual contact did not occur, and the SP denied saying this to the VA, and that there was no further information to support or refute either account, there was not a preponderance of the evidence whether sexual contact occurred or whether there was a failure to provide the VA with reasonable or necessary care or services. It was not determined whether sexual abuse or neglect 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; 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 allegation that the SP broke the VA’s arm: According to the VA, on the day of the incident, the VA was upset with the SP because the SP asked the VA to engage in sexual contact (referenced above) which the SP denied doing. The VA told P1 that s/he was upset with the SP because they SP did not help the VA get food when the VA requested. The SP stated s/he arrived at the facility at 4 p.m. the day of the incident and the VA was still in the community. When the VA returned, the VA was “drunk.” The VA began “yelling” at the SP, used racial slurs, and asked the SP why s/he was at the facility. The VA acknowledged yelling at the SP and using racial slurs. The VA and the SP both stated that the VA then threw a cup at the SP but provided conflicting information regarding what happened next. The VA told this investigator that the SP “body slammed” the VA and “picked me up” to “body slam me on the floor in the living room.” The VA told P1 that the SP “grabbed” the VA and “threw” the VA on the floor. The VA told P1 that the SP “attacked” the VA. The SP stated that the VA threatened to “kill” the SP so the SP tried to redirect the VA to calm down, but was not successful. The SP called P2 and said the VA was “heavily drunk” and “chasing” the SP around the facility. After that, when the VA tried to approach the SP, the VA was about five feet from the SP and then the VA “fell” on his/her left shoulder.” The SP called P1 and said that the VA was drunk and then fell. The SP called 9-1-1 and the VA was later diagnosed with an arm fracture. P3 was also working the day of the incident and heard the VA yell and use racial slurs toward the SP. P3 stated that the SP was verbally redirecting the VA and that the VA was “really drunk.” The VA calmed for a bit so P3 left the facility with another client. Shortly after, the SP called P3 and told P3 that the VA was “acting crazy.” P3 heard the VA threatening to kill the SP. When P3 returned to the facility, law enforcement was there and the VA was going to be transported to the hospital. The SP told P3 that when the VA tried to punch the SP, the VA “might have tripped and fell down.” Although the VA fell and was diagnosed with a fractured arm and said that the SP threw him/her on the ground, given that the SP denied physical contact with the VA and provided consistent information that the VA fell, that the VA was intoxicated, that the SP attempted to redirect the VA while the VA was upset which P3 witnessed, and that no one else witnessed the incident so there was no further information to confirm or dispute either account, there was not a preponderance of the evidence whether the SP engaged in non-accidental or non-therapeutic conduct or whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether neglect or physical abuse 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 or conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility’s Internal Investigation Report Form stated that policies and procedures were adequate, followed, and that additional training was provided to all staff persons pertaining to “EUMR (emergency use of manual restraints)” and “positive support interventions.” Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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