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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: 1070622-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) said that a staff person (SP) hit him/her and had a bruise on his/her left elbow approximately the size of a fist. Date of Incident(s): Prior to March 31, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 2, 2023; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, and the SP), and the VA. Facility documentation showed that the VA was diagnosed with a traumatic brain injury and schizoaffective disorder depressive type and had a history of substance use and providing inaccurate information. The VA’s gait was unsteady, and s/he might have poor balance. Responsibilities requested of the VA in his/her plans included voicing his/her concerns if s/he was unhappy with the services s/he received, working toward plan goals, and participating in meetings. The VA was impulsive and if s/he was upset, s/he might decline to take as needed medications to calm him/herself, physically aggress toward others, or engage in property destruction. At the facility, the VA had one to one staffing, and staff persons were to be within 30 feet of the VA “ready to respond” if the VA made threats or demeaning comments to his/her housemates. In the community, staff persons were to be within 25 feet of the VA or closer if necessary. When the VA rode in the facility van, two staff persons were to be in the van at all times. Staff persons were permitted to block or redirect the VA’s limbs or body without holding him/her or limiting his/her movement to interrupt a behavior that might result in injury to the VA or others with less than 60 seconds of contact between the staff person and the VA. The VA’s access to items considered to be dangerous (silverware, knives, sharp items, baseball bats, yard tools, glass dishes, and machinery) was limited, and there was a rights restriction in place for him/her. The VA did not like rules and wanted to live in his/her own apartment because s/he wanted to be his/her “own boss.” Facility documentation and information provided by the VA, P1, P2, and the SP in interviews with this investigator, and the facility’s Internal Review, provided the following information: On March 31, 2023, the VA said that the SP “beat” him/her “up” on March 29, 2023, and pushed him/her onto a couch which caused a bruise the VA’s left elbow. The VA was upset and said that s/he was “feuding” with the SP. The SP said that at about 5:30 p.m. on March 29, 2023, the VA wanted to go on a community outing, but the SP said that they had to wait until P1 returned to the facility with the VA’s housemate so that two staff persons could accompany the VA in the van. The VA began “swearing” at the SP who redirected the VA, but the VA became more upset and told the SP to “shut the fuck up,” then tried to hit the SP. The SP raised his/her arms to protect his/her face/head, but the VA continued to swing his/her fists at the SP and tried to kick him/her. The VA lost his/her balance and fell backward onto the living room couch, then got up by him/herself. The SP did not notice an injury to the VA, the VA calmed, the SP “made a note” about the incident on the computer and gave a verbal report to P1 after s/he returned from the community outing with the VA’s housemate. The SP denied that s/he beat the VA up, pushed him/her onto the couch, or caused the bruise to the VA’s left elbow. The SP documented the incident timely by writing a document on the facility’s computer, but did not use the facility’s preferred form for documenting incidents with the VA. P1 said that the SP told him/her about the incident and his/her description of the SP’s interactions with the VA was consistent with the SP’s. A Progress Note written by the SP about the VA and dated March 29, 2023, showed that the VA was upset because s/he could not immediately go on a community outing. Later that day after the VA calmed and went on the outing. On March 31, 2023, P2, who was a supervisory staff person, asked the SP about the incident with the VA. The SP provided a copy of the note s/he had written to P2, who verified that the note was written shortly after the incident as described by the SP and reminded the SP that staff persons were to complete all charting or documentation on required forms at the end of their shifts to ensure proper communication with all staff persons. According to P2, the VA had a bruise on his/her left elbow on March 31, 2023, which s/he photographed and provided this investigator a copy of a photograph of the bruise. The photograph showed that that VA had an orange sized irregularly shaped bruise with colors that varied from brownish plum to yellow. The photograph showed no other bruises, and the VA had no open cuts or other observable injuries that were visible in the photograph. P2 said that the VA often stated that staff persons caused him/her harm. However, upon investigation of the VA’s concerns, it was determined that s/he inaccurately described incidents and situations which was consistent with information in the VA’s plans. Staff persons, including the SP, were trained to use Effective and Safe Engagement (EASE) verbal and physical de-escalation techniques with the VA. Placing hands and arms up to block hits to the head and face was consistent with EASE and there were no concerns with the SP’s use of this technique. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Staff persons were to use EASE techniques with the VA and move the VA away from others when s/he was upset. Conclusion: The VA said that on March 29, 2023, the SP “beat” him/her “up” and pushed him/her onto the couch, which caused a bruise to the VA’s elbow. However, information was consistent from the VA’s plans and P2 that the VA had a history of providing inaccurate information and P2 said that the VA previously made similar statements regarding staff persons that were later determined to be untrue. The SP said that on the date of the incident the VA was upset because s/he could not immediately go on a community outing. The VA swore at the SP and tired to hit and kick him/her. The SP protected his/her face and head by raising his/her arms/hands, and the VA lost his/her balance, falling onto the couch. The SP did not notice any injuries to the VA after the incident, took the VA on the outing later that afternoon, verbally notified P1 about the incident, and documented the incident but not on the facility’s required form. The SP denied that s/he “beat” the VA “up,” pushed the VA, or caused the bruise to his/her elbow. According to P1, the description of the incident the SP gave to him/her was consistent with the description the SP provided to this investigator and P2. Although the VA said that the SP beat him/her up and caused the bruise to his/her elbow, given that the SP completed timely documentation showing that the VA was upset prior to the incident and described the incident to P1, that the SP’s account of the incident was consistent over time to various persons, that the VA had a history of providing inaccurate information, and that P2 said the VA had made similar prior statements regarding other staff persons that were later determined to be untrue, there was a not a preponderance of the evidence whether the injuries the VA had were caused by the SP or sustained by any other means than accidental. It was not determined whether physical 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but not followed by the SP when s/he did not correctly document the incident with the VA. Staff persons were retrained on documentation expectations and the SP was given coaching regarding documentation of behavior, progress notes, and communication with his/her co-workers. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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