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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: 1087682-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) banged on a vulnerable adult’s (VA) door, yelled at the VA, threatened the VA, went after the VA with a broken hanger, and was demeaning to the VA. In addition, when the VA stated that s/he was going to kill him/herself, the SP stated, “You don’t have the fucking balls to kill yourself, so I’m not worried.” Date of Incident(s): Prior to May 6, 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); 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 June 1, 2023, from documentation at the facility and through six interviews conducted with the VA, the SP, the VA’s guardian (G) and three facility staff persons (P1-P3). The VA’s support plan showed that s/he enjoyed spending time with family and friends, going out to eat, and being outside. One of the VA’s goals was to “keep my mental health stable.” In addition, the plan showed that the VA’s diagnoses included post-traumatic stress disorder. The VA’s Individual Abuse Prevention Plan showed that the VA had a history of “superficial cutting or burning” and “suicidal tendencies.” As a result, staff persons were trained to assist the VA with providing “structure” to the VA’s day. Staff persons were also trained to provide verbal redirection, as needed. P1 provided the following information: · Although P1 did not remember the date, s/he remembered that s/he, P2, and the SP were working at the time of an alleged incident. While P1 and P2 were outside on a deck, P1 heard the VA “yelling” inside the facility that s/he was going to “kill” him/herself. When the VA, who was facing the SP, said that, the SP said, “You don’t have the fucking balls to do it I’m not worried about it.” When the VA kicked a wall, the SP also told the VA to “stop fucking kicking the wall.” Shortly after P1 went inside, P2 followed P1 inside the facility. · P1 told the SP and the VA, “We needed to stop,” “We needed to disengage,” and “We needed to walk away from each other.” The SP and the VA did so. · P1 said that the VA made suicidal statements “all the time” and P1 believed that the statements were “behavioral attention seeking.” Another staff person (P4) provided the following information in a written statement: · On May 5, 2023, the SP was “banging” on the VA’s door, “yelling” at the VA, “threatening” the VA, and “went after” the VA with a “broken hanger” in a “violent manner” that “scared” the VA. · On unspecified dates, the SP would not let the VA attend medical appointments or refused to take the VA to those appointments. and that The VA had been “self-harming, eating less, doing less, and hasn’t been engaging with staff [persons].” · Although this investigator contacted P4 to obtain more information, P4 did not respond to requests to be interviewed. The facility’s time sheet records showed that the SP worked from 7 a.m. until 4 p.m. on May 5, 2023. The VA provided the following information: · When the VA engaged in property destruction or self-harm, the SP “tries to talk to me the best” and that “sometimes it sounds aggressive, but [the SP’s] really trying to help me out.” The VA described the SP’s tone of voice as “not quite yelling.” · When the VA was asked whether the SP made an inappropriate comment when the VA threatened harm to him/herself, the VA did not remember whether the SP made the comment. · The VA did not remember whether anyone banged on his/her door, yelled at him/her, or used demeaning language toward the VA. The VA denied that the SP went after the VA with a hanger and said, “I’m the one who does that stuff.” · The VA did not remember a time that the SP, or any person, did not take the VA to a medical appointment, as needed. P2 provided the following information: · P2 did not have concerns related to how the SP interacted with the VA, did not see the SP yell at the VA, did not hear the SP demean the VA, and did not see the SP go after the VA with a hanger. · P2 denied that s/he heard the VA threaten suicide and denied hearing the SP say anything to the VA related to suicide. P3 provided information that was mostly consistent with the information provided by P2. The G stated that the VA had not said anything to the G regarding how the SP talked to the VA. The SP denied banging on the VA’s door, yelling at the VA, threatening the VA and demeaning the VA. When the SP was asked if s/he made a comment that the VA did not “have the fucking balls to kill” him/herself, the SP said, “That never came out of my mouth.” The SP also stated that P1 “hates” the SP’s significant other. The SP also denied not taking the VA to medical appointments. The facility’s Internal Review provided information that was mostly consistent with the information provided in this report, but added that “there would not be any corrective action taken for [the SP] as the allegations were found to be inaccurate.” 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 June 1, 2023. Conclusion: Although P1 stated that after the VA threatened suicide, the SP said, “You don’t have the fucking balls to do it I’m not worried about it,” the VA did not remember the SP saying that, P2 stated s/he did not hear the SP say that, and the SP denied it. Although P4 stated that that the SP banged on the VA’s door, yelled at the VA, threatened the VA with a broken hanger, and refused to take the VA to medical appointments, P4 did not respond to requests to provided additional information so there was no information regarding dates of occurrences. The VA stated that although the SP’s tone of voice was “not quite yelling,” the SP “tries to talk to me the best” and was “really trying to help me out.” The VA also stated that s/he did not remember anyone banging on his/her door, yelling at him/her, using demeaning language toward him/her, threatening him/her with a hanger or not taking him/her to medical appointments. The VA denied that the SP made inappropriate comments when the VA threatened harm to him/herself. The SP denied all of the allegations. Given this and that there was no further information to confirm or dispute information provided, there was not a preponderance of the evidence whether the SP engaged in non-therapeutic conduct that could reasonably cause the VA emotional distress or whether the SP failed to provide the VA with reasonable and necessary care and services. It was not determined whether emotional abuse or neglect 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; 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). Action Taken by Facility: The facility’s Internal Review showed that policies and procedures were adequate, followed, and that no additional training was needed. Action Taken by Department of Human Services, Office of Inspector General: No action taken at this time.
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