|
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: 1071623-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP1) dragged a vulnerable adult (VA) across the floor by his/her gait belt. It was also reported that a staff person (SP2) “screamed” at the VA, shoved the VA’s hands and feet toward the floor, and pushed the VA by the shoulder. Allegation two: It was reported that SP1 used a gait belt to tie the VA to his/her wheelchair. Date of Incident(s): Ongoing, prior to April 19, 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), clauses (1-4): 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. · 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. · Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and · Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 7, 2023; from documentation at the facility; and through eight interviews conducted with four facility staff persons (P1 – P4), an administrative staff person (P5), SP1, SP2, and the VA’s guardian (G). The VA enjoyed going on van rides, listening to music, and drinking coffee. The VA’s diagnoses included severe intellectual and developmental disabilities (IDD), disruptive behavior disorder, seizure disorder, and spastic infantile hemiplegia. According to the VA’s Community Support Plan, the VA required the assistance of the staff persons with transfers and mobility. The staff persons used a gait belt to assist the VA with walking. The VA also used a wheelchair when needed. The VA was able to use a few words to communicate. The VA preferred to follow a routine. According to the VA’s ISSA Assessment Detail, the VA was able to independently unbuckle his/her gait belt and remove it when it was not being used. The VA sometimes sat on the floor when s/he was asked to do something s/he did not want to do, such as sleeping in his/her bed. The G stated that the VA was non-verbal and had limited understanding of language. In March 2023, the VA moved into the facility after living in another residential program for over 30 years. The G felt that the transition to the facility was difficult for the VA. Allegation one: It was reported that SP1 dragged the VA across the floor by his/her gait belt. It was also reported that SP2 “screamed” at the VA, shoved the VA’s hands and feet toward the floor, and pushed the VA by the shoulder. SP1, SP2, P1, P2, P3, P4, P5, SP1, SP2, and the facility’s documentation provided the following information: · Consistent information was provided that the VA preferred to sleep in a recliner in his/her bedroom and typically refused to sleep in his/her bed. On April 16, 2023, SP1 worked at the facility with four residents, including the VA. That evening, SP1 assisted the VA to the bathroom prior to going to bed. The other residents were in their bedrooms. After using the bathroom, SP1 told the VA that it was time for bed and the VA said no, sat on the floor, kicked and yelled, and refused to stand. SP1 telephoned SP2 and told him/her the VA refused to leave the bathroom. SP2 told SP1 to try again after a few minutes, which SP1 did. SP1 sat on the floor near the VA and told the VA that the floors were cold and the VA should get off the floor. The VA refused to stand, so SP1 held onto the VA’s gait belt with one hand and the VA’s hand with another and turned the VA toward his/her bedroom, which was a few feet from the bathroom. The VA “smooshed” around and moved toward his/her bedroom and SP1 “helped” the VA move across the floor. The VA stated that s/he did not drag the VA and did not believe that the VA would allow the VA to drag him/her. Once the VA was in his/her bedroom, s/he refused to stand and SP1 was unable to lift the VA, so s/he again telephoned SP2. · At approximately 9 p.m., SP2 telephoned P1 and asked him/her to go to the facility and assist SP1 with moving the VA from the floor. When P1 arrived at the facility, P1 heard the VA “screaming” because s/he was angry. P1 found the VA sitting on the floor in his/her bedroom. SP1 entered the VA’s bedroom and asked the VA if s/he wanted to sit in his/her bedroom recliner. The VA flailed his/her arms, repeatedly slammed his/her hands and feet on the floor, and bit his/her right hand before curling into a ball and pushing him/herself to the wall, where s/he began to kick the wall. SP1 told the VA that s/he would hurt him/herself if s/he continued. The VA did not allow SP1 and P1 to assist him/her off the floor. · At approximately 9:30 p.m., P1 telephoned SP2 and told him/her that they were unable to assist the VA off the floor. SP2 asked P1 to put the telephone on speaker mode and began to “scream” at the VA to “stop acting like a child” and get into his/her recliner. SP1 suggested placing the VA’s mattress on the floor so s/he could use that to sleep on. Before they moved the mattress to the floor, the VA slammed his/her head on the floor, flailed his/her legs, and threw a vase at SP1, hitting him/her in the face. The VA then kicked SP1 in the face and SP2 told P1 and SP1 that s/he was coming to the facility. SP1 told P1 that earlier that evening, after the VA used the bathroom, s/he sat on the floor and refused to go to his/her bedroom to go to bed. SP1 then told P1 that s/he “dragged” the VA from the bathroom to the bedroom. P1 was uncertain how SP1 would be physically able to drag the VA because the VA was a much larger person than SP1. P1 also did not think that the VA would allow anyone to drag him/her across the floor. SP2 did not believe that SP1 would be physically able to drag the VA and also believed that the VA would kick and hit any staff person who attempted to drag him/her. · P1 stated that when SP2 arrived at the facility, s/he “yelled” at the VA to stop “acting like a child” and being “ridiculous.” The VA began to kick his/her legs. SP2 took the VA’s hand and held it on the VA’s chest and told the VA to “stop it.” P1 also stated that SP2 then grabbed the VA’s shirt and pushed against the VA’s shoulder. SP2 suggested using the Hoyer lift to move the VA into his/her recliner so they placed the lift sling under the VA and hooked it to the lift. The VA attempted to roll away and P1 stated that SP2 “forcefully” pushed the VA’s legs down. The staff persons then used the lift to move the VA to his/her recliner and the VA became quiet. The staff persons left the VA’s bedroom and SP1 asked for assistance in documenting the incident because of language barriers which sometimes made it difficult for him/her to accurately document an incident. SP2 told SP1 that s/he would help SP1 complete the documentation about what occurred the following day. P1 stated that SP2 said, “None of this happened.” SP2 and P1 then left the facility. SP1 checked the VA for injuries, but did not see any injury. SP2 stated that s/he did not “scream” at the VA during the incident, but sometimes spoke in a “stern” voice. SP2 stated that s/he did not grab the VA’s hand and hold it down, did not push the VA’s shoulder or hands down, and did not tell the VA to “stop acting like a child.” SP1 stated that s/he did not see SP2 engage in any “abusive” actions with the VA. · P1 stated that in the days following the incident, s/he checked to see if SP1 or SP2 documented the incident, but they did not. SP2 stated that s/he planned to document the incident, but s/he forgot to do the documentation, but that s/he reported the incident to the facility’s nurse and his/her supervisor. P1 told P2 and P3 that SP1 said s/he dragged the VA and when P2 and P3 asked SP1 about it, s/he told P2 and P3 that s/he did not drag the VA, but that s/he “pulled” the VA to his/her bedroom. P3 did not see any injury to the VA other than those that were self-inflicted by the VA. P1 stated that prior to the incident, s/he had no concerns about SP1’s interactions with the residents. P4 stated that s/he had no concerns about SP1’s interactions with the residents. · P1 stated that SP2 frequently “screamed” at the residents and had pulled a resident by the gait belt to get him/her to sit. P2 stated that s/he had no concerns about SP2’s interactions with the residents except that s/he “yelled” at the residents. P3 stated that the only concern s/he had about SP2’s interactions with the residents was that SP2 acted like “a strict parent” with the residents. P4 stated that s/he had no concerns about SP2’s interactions with the residents and believed that SP2 was “good” with the residents. P5 stated that none of the staff persons brought concerns about SP1’s or SP2’s interactions with the residents to him/her. SP1 stated that SP2 was very good at his/her job, but had a loud voice. · SP2 stated that there were interpersonal conflicts between some of the other staff persons and SP1 and SP2. SP2 believed some of the other staff persons did not like that SP1 wanted to do things “[his/her] way.” SP2 believed that some of the other staff persons then became upset with SP2 because s/he did not insist that SP1 stop giving directions to the other staff persons. Facility documentation showed that SP1, SP2, P1, P2, P3, P4, and P5 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion for allegation one: On the evening of April 16, 2023, SP1 worked at the facility. When the VA sat on the floor in the facility’s bathroom, SP1 was unable to assist the VA to his/her feet and telephoned SP2 for assistance. SP2 then sent P1 to the facility to assist SP1. P1 stated that when s/he arrived at the facility, the VA was on the floor of his/her bedroom. While P1 did not see SP1 drag the VA, P1 stated that SP1 told P1 that s/he dragged the VA to the bedroom. SP1 stated that s/he did not drag the VA, but that the VA “smooshed” around and moved toward his/her bedroom and SP1 “helped” the VA move across the floor. When P1 and SP1 were unable to assist the VA from the floor, they telephoned SP2, who arrived at the facility and assisted P1 and SP1 with using a Hoyer lift to move the VA from the floor to his/her recliner chair. P1 stated that SP2 yelled at the, shoved the VA’s hands and feet toward the floor, and pushed the VA by the shoulder. SP1 stated that SP2 was not abusive to the VA and SP2 denied pushing the VA’s hands, feet, or shoulders, or yelling at the VA during the incident. Regarding the report involving SP1: While it was likely that SP1 assisted the VA to move from the bathroom to the VA’s bedroom in some manner, it was unclear how SP1 assisted the VA. Consistent information was provided that the VA was physically much larger than SP1 and that the VA would kick and hit staff persons who attempted to make the VA do anything s/he did not want to do, so it would be difficult for SP1 to drag the VA across the floor. SP1 also denied dragging the VA. After the incident, no injuries to the VA were observed. Therefore, was not a preponderance of the evidence as to whether SP1’s actions could reasonably be expected to produce physical pain or injury or emotional distress to the VA. It was not determined whether physical or 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: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and/or 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. Regarding the report involving SP2: While P1 stated that SP2 “screamed” at the VA, shoved the VA’s hands and feet toward the floor, and pushed the VA by the shoulder, given that SP1 did not see SP2 engage in any abusive actions with the VA and had no concerns about SP2’s interactions with the VA and that SP2 denied screaming at the VA or pushing the VA’s hands, feet, or shoulders, there was not a preponderance of the evidence whether SP2’s actions could reasonably be expected to produce physical pain or injury or emotional distress to the VA. It was not determined whether physical or 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: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and/or 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. Allegation two: It was reported that SP1 used a gait belt to tie the VA to his/her wheelchair. · P2 stated that in April 2023, s/he arrived at the facility for his/her work shift and saw the VA sitting in his/her wheelchair outside. SP1 had tied the VA’s gait belt across the arms of the VA’s wheelchair so that the VA was unable to stand. P2 believed SP1 left the gait belt tied on the wheelchair for approximately one hour. P2 stated that the VA was not upset and was enjoying being outside. SP1 stated that on one occasion, s/he took the residents, including the VA outside, one at a time. The VA’s wheelchair did not have a seat belt and the VA was “rocking” back and forth with excitement because s/he was going outside. SP1 was afraid the VA would fall from his/her chair while SP1 assisted the other residents outside, so s/he tied the VA’s gait belt across the arms of the wheelchair so that the VA was unable to stand or fall from the wheelchair. SP1 stated that the gait belt was tied on the wheelchair for “a minute” while s/he assisted the other residents outside. · P3 stated that s/he also frequently saw SP1 pull the VA’s gait belt to pull the VA into a chair. SP2 stated that s/he was only informed about one occasion when SP1 used a gait belt to hold the VA in his/her wheelchair, which was when s/he took the VA outside and was afraid the VA would fall from the wheelchair. SP1 told SP2 that it only occurred one time. SP2 told SP1 that in the future SP1 was not to use a gait belt in that manner. Relevant Rules and Statutes: Minnesota Statutes, section 245D.06, subdivision 5, state that the license holder is prohibited from using chemical, mechanical, or manual restraints, time out, seclusion, or any other aversive or deprivation procedure as a substitute for adequate staffing, for a program to reduce or eliminate behavior, as punishment, or for staff convenience. Conclusion for allegation two: Consistent information was provided that on one unknown date, SP1 tied the VA’s gait belt to his/her wheelchair’s armrests to prevent the VA from standing and/or falling out of his/her wheelchair when SP1 took the VA outside and was assisting other residents with going outside. Given that P2 stated that SP1 left the gait belt tied to the VA’s wheelchair for approximately one hour and SP1 stated that s/he removed the gait belt after “a minute,” it was unclear how long the gait belt was tied across the arms of the VA’s wheelchair. Using a gait belt to restrain the VA in his/her wheelchair was a violation of Minnesota Statutes, section 245D.06, subdivision 5 and inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. However, given that SP2 used the gait belt on one occasion as a way to ensure the VA did not accidentally fall from his/her wheelchair and that the VA did not sustain harm during the incident, there was not a preponderance of the evidence whether SP1’s actions produced or could reasonably be expected to produce physical pain or injury or emotional distress to the VA. It was not determined whether physical or 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 any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and/or the use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825). Action Taken by Facility: The facility completed an internal review and determined that the facility’s polices were adequate, but were not followed by the staff persons. After the incident, all of the staff persons were retrained on the facility’s policies. SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: A correction order was not issued for the violation in this report because the facility immediately addressed the incident and discontinued its use.
|
