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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: 1071993-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) yelled at two vulnerable adults (VA1 and VA2). Date of Incident(s): Prior to May 1, 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 eight interviews conducted with the SP, VA1, VA2, VA2’s legal representative (G2), a management staff person (P1) and three facility staff persons (P2-P4). Although this investigator contacted VA1’s legal representative (G1), G1 did not respond to requests to be interviewed. VA1, VA2, and another client lived at the facility. VA1’s Support Plan showed that s/he enjoyed socializing with peers and staff persons, baking, coloring, and shopping. In addition, the plan showed that VA1 was diagnosed with a mild developmental disability. VA2’s ISSA Assessment Detail showed that VA2 enjoyed swimming and that some of his/her diagnoses included a mild developmental disability, depression, and anxiety disorder. The Minnesota Department of Human Services (DHS) received an anonymous report that the SP “yelled” at VA1 and VA2. Although VA1 provided limited information to this investigator, VA1 stated that the SP “hollers” at VA1 “all the time” about the snacks that VA1 ate. When VA1 was asked how that made him/her feel, VA1 said, “Not too good.” VA2 said that the SP “yells all the time” when VA2 did “something wrong.” VA2 gave an example in which the SP would “yell” at him/her if VA2 did not complete his/her laundry before the SP arrived at the facility. When VA2 was asked how the SP’s actions made him/her feel, VA2 said, “Upset, annoyed, irritated, and frustrated.” P1 described the SP as being a “very loud person” who was “sometimes misconceived as yelling,” but that P1 had not heard the SP yelling at VA1 or VA2. P1 also stated that about six months prior, concerns were brought forward regarding the SP’s interactions with VA1 or VA2 (similar allegations to this report). As a result of that, P1 provided “sensitivity training” to the SP and since that time, no staff persons had brought concerns forward to P1. P1 also stated that the other client that lived at the facility did not have concerns related to the SP and spent most of his/her time in his/her bedroom because s/he chose to. P1 also said that when s/he talked to the other client, the client said that s/he had not witnessed the SP yell at VA1 or VA2. When P2 was asked to describe the interactions between the SP and the VAs, P2 said that “quite a bit” of the time the SP was seen “joking around” with the VAs, but that there were times that the SP’s tone of voice came off as being “aggressive” and that the SP had a “loud voice.” P2 gave an example in which the SP became “extremely frustrated” with VA1 because the SP wanted VA1 to do something, but VA1 ignored the SP. On a “few” occasions, P2 told the SP to lower his/her voice when talking to VA1 or VA2. P3 and P4 provided information that was mostly similar to the information provided by P2. G2 stated that VA2 had not told G2 about any concerns related to staff persons at the facility and had not told G2 about anyone yelling at VA2. The SP denied yelling at VA1 or VA2 and stated that his/her “voice is louder than others.” The SP also stated that P1 and P4 had previously told him/her that the SP’s tone of voice was loud and because of that, the SP had worked to “bring that down.”
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 VA1 and VA2’s care plans prior to May 10, 2023. Relevant Rule and/or Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) stated that consumers have the right to be treated with courtesy and respect. Conclusion: DHS received an anonymous report that the SP yelled at VA1 and VA2 but without specific information. VA1 stated that the SP “hollers” at VA1 about the snacks VA1 ate, which made the VA feel “not too good.” VA2 stated that the SP “yells all the time” at VA2 such as if VA2 did not complete his/her laundry before the SP arrived at the facility. VA2 stated that the SP’s comments made him/her feel “upset, annoyed, irritated, and frustrated.” The SP denied “yelling” at VA1 and or VA2 and said his/her voice was “louder than others.” P1-P4 provided mostly consistent information that the SP had a “loud” voice that sometimes came off as “aggressive.” P1 did not witness the SP yell at VA1 or VA2. P2 provided an example where the SP’s voice sounded “aggressive” because the SP was “frustrated” with VA1. The other client who resided at the facility did not witness the SP yelling at VA1 or VA2. Information showed that at times, the SP likely had a tone of voice toward VA1 and VA2 that was loud and came off as being “aggressive.” Although the SP denied yelling at VA1 or VA2 and stated that s/he had a “loud” voice, the SP’s conduct was inconsistent with the role of a professional caregiver in a program licensed by the Minnesota Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that P1 said the SP’s loud voice was “sometimes misconceived” as yelling, that the SP denied yelling at VA1 or VA2, and that P1 and the other facility client stated they did not hear the SP yell at VA1 or VA2, there was not a preponderance of the evidence whether the SP’s conduct could reasonable 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’s internal review showed that policies and procedures were adequate, followed, and that additional training was provided, but the type of training was not identified. Action Taken by Department of Human Services, Office of Inspector General: On July 19, 2023, the facility was issued a correction order for the violations outlined in this report.
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