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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: 1071709-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a racially derogatory term (referred to as the “n-word” throughout the remainder of the report) in reference to a vulnerable adult (VA). Date of Incident(s): April 28, 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 31, 2023; from documentation at the facility; and through six interviews conducted with one facility staff person (P1), two supervisory staff persons (P2 and P3), the VA’s guardian (G), the VA and the SP. The VA’s file stated s/he was interested in horses, being outside, and using his/her iPad. The VA’s also liked fishing, shopping, and going to concerts. The VA was diagnosed with cerebral palsy, spastic quadriplegic, and an intellectual disability. The VA said that on April 28, 2023, s/he heard the SP ask P1 if s/he was going to give “this [n-word]” a shower. The VA thought that maybe the SP did not know the VA heard him/her say that. The VA was “caught off guard” by the SP’s language and thought the SP knew s/he was “in the wrong.” The following Monday, May 1, 2023, the VA told P2 what s/he heard the SP say. The VA did not hear the SP used the “n-word” again. However, there was one time the VA heard the SP say, “Shit,” to him/herself while working. The VA was not of the race that the n-word was typically used towards as a derogatory term. P1 provided consistent information during his/her interview and in the Internal Review that about one month prior to June 1, 2023, sometime during the evening, while P1 and the SP were working at the facility, the SP said to P1, “Can you get this (n-word)” to bed or a shower (P1 could not remember bed or shower.) The VA was nearby and heard what the SP said. The SP was still learning English and P1 felt the SP did not know the “proper use” of words. After the SP said that, P1 “waved” at the SP and told him/her not to say that word again. P1 could immediately see in the SP’s face that s/he was “remorseful.” The VA asked the SP what the SP said, and the SP did not repeat him/herself. According to P1, the VA did not like the SP. P1 did not have any other concerns with the SP and had not heard the SP use other inappropriate language. However, the VA told P1 that the SP said other things, but did not specify to P1 what they were. P2 said that on a Monday (either April 24, 2023, or May 1), the VA told P2 that the previous Friday, the VA heard the SP asked P1, “Are you going to give this [n-word] a shower?” P2 thought the VA was more in “shock” than anything but was not visibly “angry” or “crying.” According to P2, there were no previous concerns with the SP. However, P2 heard (could not remember from whom) that the SP swore once or twice but did not know if it was in front of clients. P2 did not talk to the SP but said that P3 did so and when s/he did that the SP denied saying the “n-word.” P2 thought there was some interpersonal conflict between the SP and P1 due to P1 being on a lifting restriction and therefore could not do shower transfers. P1 thought that maybe the SP thought P1 was just trying to get out of doing “work.” P2 had no reason to believe that the VA would have made up the allegation. P3 said that on an unknown date, sometime in the morning, the VA told P2 that on a previous date, the SP asked P1 in front of the VA, “Can you shower this [n-word]?” P1 told the SP, “We don’t use that word,” and corrected the SP. The VA was able to communicate information to staff persons and was very capable of reporting information. The VA had a history of some “little white lies,” but staff persons were able to “catch” the VA providing incorrect information. P3 was not aware of any interpersonal conflict between P1 and the SP except for P1 was unable to “lift” the VA so the SP had to do all the “lifting.” When P3 talked to the SP, the SP denied using the “n-word” and “swore on [his/her grandparent’s] grave [s/he] did not say it.” P3 never heard the SP swear to any clients. However, one time, P3 heard the SP “cuss” while on a personal phone call, so P3 told the SP to take it outside. The G said that on April 28, 2023, around 6 a.m., a staff person (the G did not know which staff person) said to P1, “Do you want to give this [n-word] a shower?” The VA was offended by the derogatory language and told the G s/he was upset. The VA also told P2 what s/he heard the staff person say. The VA was “capable” of “deciphering” information and was “very communicative.” The SP provided consistent information during his/her interview and in the Internal Review that s/he was accused of something s/he did not do and that no one listened to his/her story. On Friday, April 28, 2023, the SP mentioned showering the VA and said that a staff person (the SP did not know the staff person’s name) and the VA lied about the SP using the “n-word” and that the VA “took” the staff person’s “side of the story.” The staff person was always trying to tell the SP to do “everything.” The SP found out about the allegation from P3 and was “shocked.” The SP said the VA had “made up stuff” in the past. The SP stated that s/he did not “get along” with P1 and that P1 did not help him/her during their shifts together. The SP denied using the “n-word” and accused P1 of “lying.” The SP also stated that s/he did not “cuss” or “use that term.” All staff persons interviewed were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The VA and P1 provided consistent information that sometime around the end of April 2023, the SP used the “n-word” in reference to the VA when speaking to P1. Although the “n-word” is a highly derogatory and untherapeutic word and both P1 and the VA said they heard the SP use the “n-word” which was credible, given that there was some interpersonal conflict between the SP and P1; that P1 said the SP was still learning English and felt the SP did not know the “proper use” of words, and P1 could immediately see in the SP’s face that s/he was “remorseful;” that the word was not directly spoken to the VA; and that the SP denied the allegation, it was unclear to what extent or level of emotional distress it caused the VA who was not of the race the word was typically used towards as a derogatory term. Therefore, there was not a preponderance of the evidence whether the SP’s single use of a derogatory word overheard by the VA caused emotional distress to the VA. 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 completed an Internal Review and found that their policies and procedures were adequate but not implemented as applicable. Additional staff training was also needed. P1 was retrained on maltreatment reporting. 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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