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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: 1108425-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 a vulnerable adult (VA), hit the VA on his/her arm, and then threw a water bottle at the VA after the VA hit the SP in the face. Date of Incident(s): June 21, 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 July 26, 2023, from documentation at the facility and through five interviews conducted with the VA, two management staff persons (P1 and P2), a facility staff person (P3) and the VA’s guardian. Although this investigator contacted the SP, the SP did not respond to requests to be interviewed. The VA was diagnosed with schizoaffective disorder, post-traumatic stress disorder, and borderline personality disorder. Information from the investigation, including the VA’s support plan, showed that the VA had two staff persons assigned to work with him/her during waking hours, primarily due to the VA engaging in behavioral incidents, such as verbal/physical aggression to others and leaving without supervision. The plan showed that the VA enjoyed spending time with family and friends and accessing the community. The facility’s Internal Review and interviews with P1 and P2 provided the following information: · At 8:34 p.m., on June 21, 2023, the SP called P2 and stated that the VA “hit” the SP in the face during a community outing. · P2 told P1 about the discussion with the SP and P1 asked P2 to call P3, who was also on the outing, to see what happened. · When P2 talked to P3, P3 said that while P3, the SP, and the VA were at a community activity, the SP was “speaking very loud” and “got up and left the building.” After the outing, while in the vehicle, the SP was “talking loudly” on his/her phone. (Information from the investigation showed that P3 drove the vehicle, the SP was in the front passenger seat, and the VA sat behind the SP). The VA asked P3 to turn up music on a radio. When that happened, the SP ended his/her phone call because the “music is too loud.” The VA then said, “Yes, and you were also speaking very loudly on your phone throughout my entire activity.” The SP replied, “I can talk on my phone whenever I want, I am not a child.” After the SP and the VA were “arguing back and forth,” the SP “turned around” and hit the VA in the arm and the VA then hit the SP in the face. After that, the SP threw a “filled water bottle” at the VA and it “hit” the VA, but the VA did not tell P3 where it hit him/her. There was no apparent injury and after that happened, everyone returned to the facility. P3 did not say anything to the SP or the VA about the incident.
· When P2 talked to the VA the day after the incident, the VA provided information that was similar to the information that P3 provided to P2. · The following day, the VA had a bruise on his/her left upper arm that was about two inches by one inch and “purple, green.” According to P1, the VA did not have that bruise prior to the incident. The VA provided information to this investigator that was mostly consistent with the information provided in the facility’s Internal Review, but added that the SP threw the water bottle at P3 first, and it hit P3 in the face, but did not hit the VA. After that, the SP turned around and started “punching me” in the left shoulder three times with a “closed” fist. When the SP hit the VA, the SP did not say anything, and the SP did not swear at the VA. P3 provided information that was mostly consistent with the information provided in the facility’s Internal Review, and provided the following information: · When the SP turned around, the SP “slapped” the VA one time on the VA’s left arm, but later in P3’s interview, P3 said that the SP “hit” the VA. P3 then described it as being with an “open hand” and said that the SP was “very angry” during the incident.
· When P3 was asked about the water bottle, P3 said that the SP threw it at P3 and it did not hit P3, but went toward the back seat where the VA was, but P3 did not know if it hit the VA. Pictures of the VA’s bruises were taken on June 22, 2023, by P1, and showed two small bruises on the VA’s left shoulder. Although the G stated that s/he did not remember when s/he initially talked to the VA about the incident, the VA stated that because the SP was talking loudly on his/her phone, the VA asked P3 to turn up the music and when P3 did that, the SP ended the conversation and hit the VA in the face. After that, the VA hit the SP in the face and later, the SP threw a water bottle at the VA, but the VA did not say whether it hit the VA. The facility’s training records showed that all staff persons interviewed for this investigation, including the SP, were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to June 21, 2023. Conclusion: A. Maltreatment: On June 21, 2023, P3, the SP, and the VA went on a community outing. Information from the VA and P3 showed that the SP talked loudly on his/her phone during the outing. On the drive back to the facility after the outing, the SP continued talking on his/her phone so the VA asked P3, who was driving, to turn up the music. After P3 did that, the SP ended the conversation and the VA and the SP got into a verbal altercation that escalated when the SP turned around and hit the VA’s left arm. There was some conflicting information provided. P3 told P2 that the SP threw a water bottle at the VA and that it “hit” the VA, but the VA did not tell P3 where s/he got hit. However, when P3 was interviewed by this investigator, P3 said that the water bottle did not hit the VA. Also, the VA told this investigator that the SP hit him/her three times, but when the VA was interviewed by management, the VA stated that s/he was hit one time by the SP. Regardless, the following day, the VA had a bruise on his/her left arm in the area where the SP hit the VA. Given that the VA and P3 each stated that the SP hit the VA, there was a preponderance of the evidence that the SP engaged in conduct that was not accidental and could be reasonable expected to produce physical pain or injury. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Facility’s training records showed that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated abuse for which the SP was responsible was not recurring maltreatment because it was a single incident but was serious maltreatment because the VA sustained bruising. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review and determined that although policies and procedures were adequate, they were not followed. In addition, the facility did not believe that additional training was needed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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