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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: 1092994-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a staff person (SP) was “very rough” with a vulnerable adult (VA) and said the VA “deserved to be shot in the head.” Date of Incident(s): May 12, 2023; other dates unknown
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) and (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: · 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 7, 2023; from documentation at the facility; and through interviews conducted with the VA’s guardians (G1 and G2) who were also the VA’s family members, facility staff persons (the SP and P1), and a supervisory staff person (P5). The VA was not interviewed due to his/her limited communication skills. Attempts by telephone and mail to contact and interview staff persons (P2, P3, and P4) were unanswered by the completion of this investigation. P2 and P3 provided information for the facility’s Internal Review and that information was included in this report; P4 did not provide information for the facility’s Internal Review. The VA’s support plan and support plan addendum provided the following information: · In 2021, the VA moved into the facility seeking supports and services relating to his/her diagnoses, which included anoxic brain injury and cognitive communication deficit. · “[The VA] is in a chronic vegetative state caused by lack of oxygen to [his/her] brain during cardiac arrest. This caused muscle spasticity, jerking in [his/her] body, and inability to use [his/her] limbs … [The VA] is cognitively impaired and does not verbally communicate.” · “[The VA] is dependent on staff and [his/her] family for all cares and supports … [The VA] relies on staff to position [him/her] or purposefully move [his/her] limbs. [The VA] can call out when [s/he] is uncomfortable.” · “[The VA] might have difficulties with sight and hearing. [S/he] appears to prefer staff to announce their presence and talk to [him/her] during cares.” · “[The VA] is a vulnerable adult in every way. [S/he] is unable to protect [him/herself] or speak for [him/herself.] [S/he] is unable to defend against or report any kind of abuse. [The VA] would be unable to recognize or respond to an unsafe or dangerous environment or situation. Staff are aware of [the VA’s] susceptibility to abuse and do not leave [him/her] alone at home and when in the community. [The VA] would be unable to defend [him/herself] if aggressed upon. [S/he] is non-verbal and would not be able to report abuse. If staff were to witness [the VA] being physically abused, they would immediately intervene, tell the aggressor to stop, block the aggressor from making physical contact, and/or move [the VA] to a safe area. Once in safe area, staff will assess for injury and provide necessary first aid. Staff will seek further medical evaluation if needed.” At the time of the site visit, this investigator met the VA. The VA was lying in his/her bed while a staff person prepared to transfer him/her into his/her wheelchair using a mechanical lift. The staff person was wiping the VA’s arms with a washcloth. The VA’s hands were affected by muscle contractures, and his/her body movements appeared spastic or uncontrolled. The VA made intermittent eye contact with this investigator and unintelligible noises but did not respond verbally or interact in an understandable manner. P1 provided the following information: · P1 worked one shift with the SP and was “appalled … astounded … disgusted” by the SP’s conduct. P1 discussed his/her concerns with other staff, including P3, who had similar concerns. · The SP was training P1 on the VA’s support plans and protocols. The SP told P1 to give the VA “the bare minimum care” because of the VA’s history and past transgressions prior to moving into the facility. The SP then told P1 about the VA’s past. P1 did not believe the VA heard the SP say these things. · The SP told P1 that the VA “deserved to be shot in the head,” and that emergency medical professionals should not have revived the VA when s/he needed help in the past. The SP said that the VA’s family “hates” him/her and “is keeping [him/her] alive to punish [him/her].” P1 did not believe the VA heard the SP say these things. · P1 saw the SP interact with the VA in a “very rough” manner. “[The SP] was throwing [the VA] around.” When the SP was changing the VA’s brief, s/he lifted the VA’s legs “really high” like someone might do when changing a baby’s diaper. “[The VA] started hollering when [the SP] did this. [The VA] was hollering in pain.” The VA had a gastrointestinal tube (G-tube), which, according to P1, meant that holding the VA’s legs “really high” was “not safe and not okay” for the SP to do. · At one point, the SP went to replace a chucks pad underneath the VA in bed. The SP rolled the VA and “smacked” the VA’s face on the bed railing. The left side of the VA’s face and shoulder struck the railing. The SP “roughly pushed” the VA towards the wall. · P1 more than once attempted to redirect the SP’s conduct. P1 was not aware of the VA sustaining a physical injury from the SP’s conduct. The facility’s Internal Review contained interviews with other staff persons, and included the following: · P2 heard the SP making “loud barfing sounds” outside of the VA’s bedroom door and talking about how “bad [the VA] stinks.” P2 believed the VA could hear the SP. “[The VA] must hear that.” This type of conduct had been occurring since the VA moved in but P2 did not say anything sooner because s/he “wasn’t comfortable.” · P3 heard the SP state, “[The VA’d] be better off dead if [s/he] wasn’t suffering.” [Note: The Internal Review did not state whether it was known if the VA heard the SP saying this.] · Another staff person described the SP as being “weirdly aggressive” with all of the clients. The SP provided the following information: · The SP worked the overnight shift, during which, the VA was typically sleeping but might be awake at various points. Typically, the SP’s interactions with the VA, included repositioning, using a suction to minimize phlegm build-up, and providing water twice nightly via the VA’s G-tube. · The SP denied making statements, like the VA deserved bare minimum care or to be shot in the head. “That is false. I would never say that.” · The SP might have made a statement about the VA’s family and their care for the VA. “It seemed like they don’t care;” they did not typical visit the VA; and last winter, the VA needed a winter hat, but the family declined to provide funds for this purpose. “I just thought, [s/he] needs a hat.” The facility ended up using an old hat that had belonged to someone else. · The SP talked to the VA while completing his/her cares. “I’ll say, ‘Hey, good morning’ … I’m explaining to [him/her] what I’m doing.” The SP did not know what degree the VA was able to understand what others were saying. The VA typically “just stares off into space.” · When the VA needed assistance with his/her brief, the SP might lift his/her legs “carefully” but not “really high” in the air. However, “[The VA] can be hard to change. Sometimes you have to” lift his/her legs. · The VA had a history of hollering when having his/her brief changed. The VA had “sensitivity to touch” and could not communicate verbally. “[S/he] does holler out when you change [him/her]” but this was because s/he did not like to be changed. If the SP determined the VA was hollering in pain, s/he would immediately put the VA down and/or try a different position. The SP was not aware of times when the VA hollered in pain during a brief change. · The SP was a “gagger” and had a history of gagging when the VA “is vomiting phlegm.” “I have gagged. I’m being honest. A lot of people do. I’ve vomited in [his/her] bedroom.” However, the SP “absolutely [did] not” vomit or gag intentionally or with the intent of having the VA hear. · The SP believed the allegations were made against him/her because there were staff who did not like him/her. P5 provided the following information: · The SP had worked for the facility for many years. · The SP had a history of being “rude” to staff and clients and being “pretty rigid” with household tasks. The facility provided corrective coaching to the SP about these concerns. In 2021 or 2022, a staff person reported hearing the SP make “racial comments” to the VA. The facility completed an internal investigation regarding this and did not substantiate or determine a need for corrective action at that time. P5 was not aware of prior concerns of physical aggression by the SP. · The VA was not able to communicate. S/he might “cry out” when uncomfortable or in pain. “[The VA] is not able to tell us really what [s/he] prefers or doesn’t.” · P5 was not aware of the VA sustaining any injuries because of the SP’s conduct. G1 and G2 provided the following information: · The facility took “good care of” the VA. However, G1 and G2 had a few items of concern. · At least once, G1 and G2 saw an unexplained bruise on the VA’s right arm. This occurred a few months prior to this investigation. G1 and G2 each said that the VA’s right arm was affected by muscle contractures, making it difficult for the VA to cause his/her own bruises. G1 and G2 did not know what caused the bruise but deemed it noteworthy considering this investigation. · G1 and G2 also expressed concern about staff having access to information about the VA’s history or past transgressions. G1 and G2 believed this information was not necessary for staff to know and had a potential to impact a staff’s interactions with the VA. · G1 and G2 each said that the VA was able to hear what others said but was not able to verbally communicate back to the person. It was not known to what degree the VA understood what s/he heard. Facility documentation stated that P1-P5 and the SP received training on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. P2-P5 and the SP received training on the VA’s support plan and support plan addendum. At the time of the incident, P1 was a new employee, and had not yet completed all trainings so did not have unsupervised direct contact with clients. Conclusion: Regarding physical abuse: P1 provided information that the SP’s conduct, included handling the VA in a “very rough” manner, “throwing [the VA] around,” “smack[ing]” the VA’s face against a bed railing, and “roughly push[ing]” the VA into a wall. P1 also saw the SP lift the VA’s legs “really high” while changing his/her brief causing the VA to “holler in pain.” The SP denied the allegations, and although G1 and G2 had concerns about unexplained bruises, it was not determined what caused the bruises, including if by accidental means. P2 and P3 provided statements concerning the SP’s conduct for the facility’s Internal Review, but they did not respond to this investigator’s requests for interviews. In addition, although P5 said the SP had a history of being “rude” and “pretty rigid,” the SP worked for the facility for many years and P5 was not aware of prior concerns of physical aggression by the SP. Therefore, without additional direct witnesses or information to support P1’s account, there was not a preponderance of the evidence whether the SP’s conduct included actions that produced or could reasonably be expected to produce physical pain or injury for the VA. 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). Regarding emotional abuse: P1 provided information that the SP’s conduct, included statements that the VA “deserved to be shot in the head,” that emergency medical professionals should not have revived the VA, and that the VA’s family “hates” him/her and “is keeping [him/her] alive to punish [him/her].” The SP denied the allegations, and although, P2 and P3 provided statements concerning the SP’s conduct for the facility’s Internal Review, they did not respond to this investigator’s requests for interviews. In addition, P1 did not believe the VA heard the SP's statements and there was no information to suggest otherwise. therefore, without additional direct witnesses or information to support P1’s account, there was not a preponderance of the evidence whether the SP’s conduct included the use of repeated or malicious oral, written or gestured language toward the VA or treatment which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 determined that policies and procedures were adequate, but not followed. The facility provided additional training to staff persons regarding their reporting requirements per the Reporting of Maltreatment of Vulnerable Adults Act. 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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