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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: 1073196-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a staff person (SP) told a vulnerable adult (VA) that the VA was “urinating on [the VA] like a child” and asked if the VA liked eating like a baby. When the SP repositioned the VA, the SP was “rough.” On one occasion, the SP denied the VA a snack when the VA asked. Date of Incident(s): April 2023 and prior 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); and subdivision 17, paragraph (a): 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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 3, 2023; from documentation at the facility; and through eight interviews conducted with four facility staff persons (SP, P1, P2, P3), the VA’s case manager (CM), the VA’s family member (FM), an individual that lived at the home (C), and the VA. The facility was a one level home with a living room through the main entrance. There was a kitchen on the back side of the living room. To the right of the main entrance were the individuals’ bedrooms and the bathroom. The VA was diagnosed with spastic hemiplegia (paralysis) affecting the left nondominant side, nontraumatic intracerebral hemorrhage with cognitive social or emotional deficit, bipolar disorder, and anxiety disorder. The VA enjoyed spending time with his/her family. The VA had left side paralysis and was on a regular diet. The VA required physical staff person assistance in meeting all of his/her hygiene needs. The VA provided the following information: · The SP was really nice to the VA at first. One night the VA asked for a snack of chips and cheese before bed. The SP joked and said “Are you going to ask for that every night?” The VA said “Yes, probably.” The VA thought the SP was going to get the snack but the SP did not return. The VA rang a bell that s/he used to get staff person assistance. The SP came in again and the VA asked if the SP was going to get the snack. The SP asked what the VA wanted and the VA repeated “chips and cheese.” The SP said “Nope, no more cheese today.” The SP said goodnight, slammed the door, and left the bedroom. · On another occasion, the SP was changing the VA and the SP said the VA was peeing. The VA said s/he was not peeing, and the SP said that the VA was. Then the SP said “wow” and kept arguing with the VA. When this investigator spoke with the FM the VA was at the FM’s home and provided additional information through the FM including that staff persons were rough when they repositioned the VA and scrubbed the VA too hard during showers. The SP also said the VA ate like a baby. The Incident Report and Internal Review provided the following information: · Sometime during the week of March 20, 2023, P3 had a discussion with the SP about the SP calling the VA “heavy.” P3 indicated that that language needed to stop immediately, and the SP agreed. · On April 4, 2023, a patient advocate told P3 that the VA reported several incidents involving the SP. During one incident, the VA requested a snack in bed. The SP left but did not return to the VA’s bedroom. The VA rang a bell that s/he used to call staff persons and the SP came back. The SP said, “What do you want?” The VA asked for the snack again and the SP said no and left slamming the door. · On another occasion, the VA was left in bed to eat dinner although the VA wanted to join his/her housemates in the kitchen. When the VA finished the SP went into the VA’s bedroom and yelled at the VA about laying down while eating. The SP asked if the VA liked “eating like a baby.” · On a third occasion, the VA was in his/her bed and rang his/her bell. The SP came into the bedroom and asked what the VA wanted. The VA asked for his/her snack of choice. The SP said no and when the VA asked why, the SP said, “You don’t need it. The C said the SP was “good” in the beginning but then said s/he was the supervisor even though s/he was not. The SP talked stern to other staff persons. One time the SP and an overnight staff person got the VA into his/her bed and the VA asked for chips and cheese for a snack. The SP said that it was midnight, so it was too late and said something like, “How big do you want to get.” The SP complained to other staff persons about helping the VA because s/he was “overweight.” (It was unclear if the C heard these comments directly or if the VA told the C). One time the SP said to the VA that s/he was “too fat” to do anything. P1 provided the following information: · The VA had limited mobility and needed staff person assistance for any transfers and most activities of daily living. During meals the VA could choose to come out of the kitchen or remain in his/her bedroom and eat in there. The VA asked for snacks as needed. · P1 was not aware of any occasions when the VA did not receive his/her requested snack. P1 had not heard any staff persons refer to the VA’s behavior as that of a baby and had not heard anyone call the VA heavy, fat, or large. P2 provided the following information: · At some point, the VA told P2 that the VA did not like the way the SP treated the VA. The VA told P2 that on one occasion, that VA said that the VA was in the living room in his/her wheelchair. The SP did not move the VA to his/her bedroom before the other evening staff person left. When the overnight staff person arrived late, the overnight staff person and the SP moved the VA to his/her bedroom. The VA asked the SP for a snack, but the SP said no and something like, “No it’s getting late, I am not going to give you snacks, you are getting too fat, not going to give you the snack you eat too much,” and left the VA’s bedroom. · The VA said on another occasion the SP was changing the VA and said the VA’s “brief stinks” which made the VA feel bad. · P2 had not witnessed any behavior by staff persons toward the VA that s/he considered disrespectful or was concerning. P2 had not heard anyone refer to the VA as a baby. P3 provided the following information: · P3 talked with the VA and the VA said that the SP refused to give the VA snacks when the VA requested. The VA told P3 that on one occasion, the VA wanted to get out of bed and come out and eat in the kitchen, but the SP said no and made the VA eat in his/her bedroom, the SP then asked if the VA liked to eat like a baby in bed The SP also told the VA that s/he was fat. · The SP had some conflicts with other staff persons in the facility, but no staff persons had shared any concerns about the SP’s interactions with the VA. P3 had not seen any inappropriate behavior towards the VA by the SP. The SP provided the following information: · On one occasion, the SP had asked if the VA wanted to go to bed around 9 p.m. The VA declined and the staff person that worked the evening shift left. At approximately 11:30 p.m., the overnight staff person had not yet come to the facility. The SP called P3 to ask what the SP should do. The SP got the VA into his/her bed using the VA’s Hoyer lift. The SP did not say anything to the VA about the VA’s weight or deny the VA a snack. · On another occasion, the SP was changing the VA when the SP said something like, “Did you pee?” The VA said, “No,” and they laughed about it. The SP said there was no argument between the SP and the VA, and the SP just changed the VA’s clothes and brief. · The SP had never denied the VA a snack or called the VA fat or heavy. The SP only showered the VA on one occasion and the SP did not feel that s/he was rough with the VA when completing cares. All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: Regarding the SP calling the VA names: The VA provided consistent information to this investigator and several people that on one occasion, the SP said something about the VA eating like a baby when the VA was laying down in bed. On another occasion, the VA had a wet brief and the SP commented that the brief stunk and/or argued with the VA about if the VA had peed or not. The VA also told the C and P2 that one time when the VA asked for a snack the SP made a comment similar to, “You are getting too fat,” or “How big do you want to get?” The SP said that on one occasion the SP changed the VA’s brief and said something like, “Did you pee?” The SP said that the VA and the SP laughed about it and did not argue. The SP changed the VA’s clothes and briefs. The SP said s/he never called the VA fat or heavy. While it was possible that not all of the SP’s interactions with the VA were entirely therapeutic which was inconsistent with the VA’s Coordinated Service and Support Plan- Addendum, and with the role of a professional caregiver in a facility licensed by the Minnesota Department of Human Services; and a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6), given that each P1, P2, P3, did not have any concerns regarding the SP’s interactions with the VA and that although the VA provided information to various people, the words and phrases given to each varied, there was not a preponderance of the evidence whether any of the words, phrases, and/or context the SP used could be reasonably expected to produce emotional distress. Regarding the SP being rough with the VA during repositioning: The VA said that that staff persons were rough when they repositioned the VA and scrubbed the VA too hard during showers. The SP said s/he only showered the VA on one occasion and the SP did not feel that s/he was rough with the VA when completing cares. Although the VA said the SP and/or staff persons were rough when showering and completing cares with the VA, given the SP did not feel s/he was rough, that the VA sustained no injuries, and that there was not any further information, there was not a preponderance of the evidence whether any of the SP’s interactions would be expected to produce physical pain or injury. It was not determined whether emotional or 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: 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 SP denying the VA snacks: The VA said that the SP had failed to provide the VA a snack after s/he asked for a snack on at least one occasion later in the evening. The VA provided similar accounts of this to P2 and the C and that one incident had occurred later in the evening around 11:30 p.m.-12:00 a.m. before an overnight staff person arrived The SP said s/he remembered one occasion where the SP had to put the VA to bed alone when the overnight staff person had not arrived at approximately 11:30 p.m., but there was never a time when the SP denied the VA a snack. Although the VA said the SP had denied him/her a snack on at least one occasion, given the SP said s/he never denied the VA a snack and that there was no further information, there was not a preponderance of the evidence whether the SP failed to provide the VA with food which would be considered reasonable and necessary for his/her physical health. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult’s physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given the facility took immediate action to address the violations outlined in this report, a Correction Order was not issued.
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