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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: 1068643-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) slapped a vulnerable adult (VA) on the face after the VA bit the SP. Date of Incident(s): March 18, 2023 (the Minnesota Department of Human Services received the report in June 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 12, 2023, from documentation at the facility and through five interviews conducted with the VA, the SP, a program management staff person (P1), another staff person (P2), and the VA’s guardian (G). The VA’s support plan showed that the VA was diagnosed with cerebral palsy and had a moderate developmental disability. The plan showed that the VA enjoyed gardening, working on art, and spending time with family members. The VA had a behavior plan that showed that the VA engaged in self-injurious behavior (SIB) and physical and verbal abuse toward others. Staff persons were to “remove others” and “remain calm and neutral.” The plan did not identify that the VA had a history of biting others. P2 provided the following information to this investigator and in the facility’s Internal Investigation of a Vulnerable Adult or Maltreatment of Minors Report: · On March 18, 2023, the VA and P2 went to a bookstore to buy a book for the VA. Shortly after returning to the facility, the VA wanted to go back to the store and return the book. When the VA was asked to wait, the VA began “pulling” his/her hair. As a result, P2 and the SP, who were working at the time, removed others from the area. · When P2 asked the SP to “step back,” the SP said, “Let [the VA] bite me.” After that, the VA bit the SP and then the VA went to his/her bedroom. When the VA came out of his/her bedroom a short time later, P2 told the SP, who was sitting on a couch in the living room, to “move away.” The SP told P2, “No.” After that, the VA “jumped” on the SP and bit his/her hand again. When the SP “felt the pain,” the SP “slapped” the VA’s mouth.” After that, the VA left the room and went back to his/her bedroom. · At about 6 p.m., the SP “tried to call on call,” but no one answered. The SP left the facility to seek medical care for the bite on his/her hand. While the SP did that, s/he called P2 to ask how everything was going. P2 told the SP that “things were bad” because the VA had a “run in” with another client. When the VA was interviewed by this investigator and for the facility’s Internal Investigation of a Vulnerable Adult or Maltreatment of Minors Report, the VA stated that after the VA and P2 returned from the bookstore, the VA was “upset” about the book that s/he purchased and wanted to return it, but was “unable.” The VA remembered biting the SP one time on the SP’s “arm,” but the SP “did not hit [the VA] on the mouth and did not touch [the VA] at all with [his/her] hands.” However, the VA said that the SP told the VA to stop biting and then “pinched” the VA’s “nose” for a “couple seconds” to get the VA to stop biting the SP, which the VA did. The VA stated that the SP’s action did not hurt the VA. The G stated that the VA called the G the day after the incident and told the G that after the VA bit the SP, the SP “plugged” the VA’s nose, but the VA did not tell the SP that the SP slapped the VA’s mouth. The G did not believe that the VA had any red marks or bruising as a result of the incident. When P1 talked to the VA about the incident, the VA did not mention anything about being slapped or that the SP plugged the VA’s nose. P1 did not see any red marks or bruising. A review of the VA’s case notes for March 18-20, 2023, did not show that the VA had any injuries, red marks, or bruises. The facility’s physical intervention training stated, “They will often grab your arm first,” and that if bitten, staff persons were to “push in, they don’t expect it,” and “activate the gag reflex.” The SP provided the following information to this investigator and in the facility’s Internal Investigation of a Vulnerable Adult or Maltreatment of Minors Report: · When the VA wanted to go to the bookstore on March 18, 2023, P2 told the VA, “No.” When that happened, the SP told P2 that s/he “could not say no.” As a result, P2 took the VA to the bookstore. When they returned to the facility, the VA began banging his/her head because s/he wanted to return the book. When the SP attempted to put a pillow under the VA’s head, the VA “grabbed” the SP’s hands and began “biting them.” When that happened, P2 told the SP to “back away and pull away,” but the SP told P2 no because the training told him/her to push in towards the mouth to get the person to release the bite. · After the VA released the bite, the VA went to his/her room and began banging his/her head on the floor. The SP followed the VA and attempted to put a mat under the VA’s head, but was unsuccessful and the VA bit the SP again. When that happened, the VA released the bite. When the VA appeared to be calm, the SP left the room and went to sit on the couch in the living room. · A short time later, the VA joined the SP on the couch and appeared to be calm, but the VA then “grabbed” the SP’s hand again and “started biting.” When that happened, the SP “pushed in towards [the VA’s] mouth, with one hand holding onto the hand being bitten, and pulled out to get [his/her] hand away again.” After the SP “gently” pushed on the VA’s nose, the VA released the bite and calmed down. · The SP denied encouraging the VA to bite him/her and denied slapping/hitting the VA’s mouth. 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, physical interventions, and the VA’s care plans prior to June 12, 2023. Conclusion: On March 18, 2023, P2 took the VA to a bookstore to buy a book. When they returned to the facility, the VA became upset because s/he wanted to return the book. According to the SP, the SP tried to place a mat near the VA’s head to prevent the VA from getting injured while the VA was banging his/her head, but the VA bit the SP. When the VA did not release the bite when asked to do so, the SP used his/her hand to push “gently” on the VA’s nose and when that happened, the VA released the bite and calmed down. However, P2 said that the SP said, “Let [the VA] bite me,” but the SP denied saying that. P2 also said that after the VA bit the SP, the SP “slapped” the VA’s mouth. The VA told this investigator and the facility that although the SP “pinched” the VA’s nose for a couple seconds after the VA bit the SP, the SP did not slap the VA and the SP did not hurt the VA. In addition, the VA told the G the day after the incident that the SP “plugged” the VA’s nose after the VA bit the SP, but that the SP did not slap the VA’s mouth. Although P2 stated that the SP slapped the VA’s mouth and the VA told the G that the SP “plugged” the VA’s nose, given that the SP was attempting to follow training to get the VA to release his/her teeth from biting the SP, that the SP stated s/he “gently” pushed on the VA’s nose, that the SP denied slapping the VA, that the VA did not have marks or bruising, and that the VA stated that the SP did not slap the VA and did not cause pain to the VA, there was not a preponderance of the evidence whether the SP’s actions were anything other than therapeutic conduct and could be reasonable expected to cause pain or injury.. 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 Investigation of a Vulnerable Adult or Maltreatment of Minors Report, which showed that policies and procedures were adequate, followed, and that P2 received “corrective action regarding failure to report allegations of abuse within the required 24 hours.” Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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