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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: 1094765-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a staff person (SP) hit a vulnerable adult (VA) in the face causing a small cut to the top of the VA’s nose. Date of Incident(s): 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 (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 June 16, 2023; from documentation at the facility; and through six interviews conducted with two facility staff persons (SP, P), the VA’s case manager (CM), the VA’s guardians (G1, G2), and the VA. The VA was diagnosed with Intellectual Disabilities and enjoyed watching sports. The facility was a one-story home with a living room area through the main entrance. The living room area had two couches and a chair surrounding a fireplace. To the right of the living room was a dining and kitchen area containing a dining table with chairs. The VA’s bathroom and bedroom were in the basement of the home. The Individual Abuse Prevention Plan indicated that the VA may not identify dangerous situations and/or leave an area if something dangerous was occurring and may not defend him/herself against abuse as it was happening. The VA may be aggressive to others which could provoke abuse. The VA provided the following information to this investigator and through the Internal Review: · The VA came out into the living room and the SP was sweeping the floors and the VA wanted the SP to stop cleaning. · The VA said the SP punched the VA because the SP was mad at the VA because the VA spit in the SP’s face. The VA then watched TV while the SP continued to clean. · When asked if the SP’s hand or the mop hit the VA, the VA demonstrated a punching fist. The P and the Internal Review provided the following information: · The P worked at the facility for an hour or two on the morning of the incident until the SP arrived to work. At approximately 3 p.m., the P returned to the facility to relieve the SP and work the evening shift. During the morning hours, the P did not notice a cut on the VA’s nose. · When the P returned to the facility, the VA was sitting on a chair in the living room watching TV and the SP sat on a couch. The SP talked with the VA about needing to shower. The SP mentioned that the VA spit on the SP, which the P thought was odd as typically the VA only made a spitting sound and did not actually spit. The SP left the facility shortly after the P arrived. · At approximately 5 p.m., the P noticed a small cut on the VA’s nose and asked him/her what happened. The VA said “[s/he] got mad and punched me.” When asked who punched the VA, the VA said s/he did not know the staff person’s name. The P asked the VA if it was the staff person that just left (SP) and the VA said yes. The VA “physically mimed” a punch. · Later, during the shift the VA was out in the garage with the SP. The SP asked the VA if s/he was sure about what happened. At that time, the VA said it was an accident and that s/he got hit by the mop. · The P found a paper towel with a bit on blood on it in the basement area that the VA had likely used to wipe his/her nose. The VA did not need any medical care. The SP provided the following information to this investigator and through the Internal Review: · The SP was cleaning the dining and living area with a broom and a mop. The VA came into the dining room and yelled at the SP to stop cleaning the floor but the SP continued to sweep. The SP asked the VA to move to a different chair so the SP could continue to clean in that area. The VA got close to the SP and tried to stop the SP from cleaning. The SP told the VA to go take a shower as the VA had not showered in a few days. The VA refused to leave the area and started to yell. When the SP did not walk away the VA spit in the SP’s face. The SP then went and sat on the living room couch. · The SP was not sure how the VA got a cut on his/her nose and did not notice the cut before s/he left his/her shift. · The SP said s/he did not have any physical contact with the VA and did not punch the VA. The SP did not think the broom/mop handle hit the VA at any point. G1 said that s/he believed that if something happened the VA would provide the information. G2 said s/he was not sure if the VA would provide accurate information as s/he was difficult to interview and struggled to clearly communicate. A photo provided by the facility showed a ½ to ¾ inch horizontal cut on the right side of the VA’s nose near the bridge. Text messages to the P from an individual that lived at the facility sent at 12:35 p.m. on the date of the incident indicated that the SP was trying to tell the VA to take a shower and the VA was getting “so mad” and “throwing stuff.” All staff persons were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and the facility policies prior to the incident. Conclusion: The VA provided information that the SP used his/her fist and hit the VA in the nose causing a small cut on the bridge of the VA’s nose. The VA relayed this information to the P and to this investigator who investigated with law enforcement. At some point the VA also told the P that the cut was caused by the mop that the VA was using. The SP said s/he not sure how the VA got a cut on his/her nose. On the date of the incident, the SP remembered that s/he was in the kitchen sweeping and when s/he asked the VA to move the VA got upset. The VA spit in the SP’s face. The SP said s/he then removed him/herself from the area. The SP denied punching the VA, or having any physical contact with the VA. The SP did not think the broom/mop handle hit the VA and the SP never noticed a cut on the VA’s nose before s/he left his/her shift. Although the VA provided information that the SP punched him/her in the nose causing a cut on the bridge of his/her nose, given that at some point the VA also said the cut was caused by the mop, that the SP denied punching the VA, and that without further information or any other witnesses to the incident to confirm or dispute either account, there was not a preponderance of the evidence whether the injury was caused by anything other than accidental means. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by SP when s/he did not give the VA space when the VA was upset. All staff persons were retrained on the VA’s plans and policies. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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