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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: 1071672-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) routinely locked a vulnerable adult (VA) in a facility’s (Facility A’s) basement when the VA had aggressive behaviors. The VA broke his/her toe when s/he kicked the basement door, trying to get out of the basement. The VA was later hospitalized and then received crisis services from a second facility (Facility B). Date of Incident(s): Prior to May 16, 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 (3) and (4); 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: · 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. 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 June 22, 2023; from documentation at facility A and the VA’s medical records; and through six interviews conducted with facility A’s staff persons (P1, P2, P3, P4, SP1, and SP2). The VA used gestures and one-word statements to communicate his/her wishes. However, the VA was hospitalized in a unit of a hospital that provided services to persons with mental illness when this report was received and at the time of the site visit. The site visit and tour of facility A on June 22, 2023, showed that three individuals resided at facility A with the VA and the overnight shift was an asleep position. The door to the basement/lower level (referred to as the basement in this report) had been replaced prior to the site visit, but according to P1, an administrative staff person, when the incidents occurred the basement door could be locked from the outside with a push button lock, which would lock anyone in the basement, inside it because the door could not be unlocked from inside. P1 visited facility A on May 17, 2023, and observed “damage” to the inside of the basement door and what might have been small amounts of blood on the door and wall of the stairs. P1 photographed the door and stairs and provided the photos to this investigator. The photos showed that the door was covered in a veneer that was separated from the bottom of the door on both sides. An unknown person had reattached the veneer to the outside of the door with screws, but the veneer remained separated on the inside of the door, that one would see from inside the basement. The small amounts of blood described by P1 were not readily visible in the photos and the inside door handle/lock was not pictured. The VA had several hospitalizations recently and currently resided at facility B which provided support services to individuals in acute mental distress who needed immediate help. However, at the time of the site visit, the VA was hospitalized in the unit of a hospital that provided care to persons with mental illness. It was unknown whether the VA would return to facility A. Facility A’s documentation showed that the VA’s diagnoses included autism, depression, “psychosis,” and obsessive-compulsive disorder. The VA climbed stairs unassisted and used handrails when they were present, but staff persons supported the VA when s/he walked on uneven surfaces. The VA was vulnerable to all forms of maltreatment and had a limited ability to communicate. It was important to the VA to spend time with people s/he knew well and cared about. A good day for the VA might include spending time outside, going bowling, going to get tea, or visiting his/her family members. When there were changes or transitions to the VA’s routine, s/he might have a “bad day” and staff persons could use a change board with pictures to help the VA make transitions. According to the VA’s Action Plan, calming strategies that worked for the VA included receiving deep pressure massage/head massage, being brushed, taking warm baths, listening to a metronome, rocking, or using a weighted blanket or vest. Quiet environments were best for the VA and staff persons were to speak with the VA using low soothing tones of voice while keeping environmental noise to a minimum. When the VA was upset, s/he might become physically aggressive toward others and staff persons were to be at facility A 24 hours a day when the VA was present. Indications that the VA was becoming upset included removing his/her clothing when in the community or common areas of facility A, leaving the facility without supervision, physical aggression, and yelling in a high-pitched voice. At times, the VA pinched, grabbed, squeezed, and scratched staff persons and other individuals who resided at facility A, and pulled their hair. Staff persons were to separate the VA and the other individuals when the VA was upset and might place their own arms and hands behind their backs when the VA attempted to pinch, grab, squeeze, or scratch them. When redirecting the VA, staff persons were to use limited words while keeping their voices low. The VA might request to be alone and staff persons were to grant the VA’s wish but remain in the area. When the VA was evaluated at medical facilities, s/he might hit other patients, staff persons, health care professionals (HCPs), physicians, and security persons employed at the medical facilities. Incident Reports showed that the VA had recently been upset and in April and May of 2023, was admitted to the units of hospitals that provided care to persons with mental illnesses. Facility A’s documentation, the VA’s medical records, and interviews with this investigator provided the following information: P2 said that SP1, who was a supervisory staff person, instructed others to lock the VA in the basement for unknown reasons and SP2 followed SP1’s directions. However, P2 left the basement door unlocked because s/he thought it would be a rights restriction to lock anyone in a room, and s/he was unsure what other staff persons did. When staff persons worked the overnight shifts, they were to sleep in the staff person bedroom in the basement and redirect the VA to keep a regular sleep schedule if the VA left his/her bedroom. The VA often paced and slammed doors at facility A, and the frequency of those behaviors increased when the SPs locked the VA in the basement. The VA had scrapes on his/her hands, feet, and knees but P2 thought those injuries were sustained when the VA did not wear shoes when s/he exited facility A without supervision or fell in the facility. After SP1 was no longer employed at facility A, staff persons stopped locking the VA in the basement, but the VA’s behavior had declined, and s/he was hospitalized. P3 said that SP1 instructed staff persons that they could lock themselves into the basement with the VA at night when they slept but were to wake when the VA left his/her bedroom. However, SP1 stayed downstairs with the VA during overnight shifts and SP2 usually slept downstairs or on the couch in the common area at the top of the stairs when s/he worked overnight. P3 did not lock the VA into the basement but heard that unknown other staff persons did, or that some unknown staff persons who were no longer employed at facility A placed “something” on the stairs to the basement while they were in the basement with the VA, to prevent the VA from going upstairs and exiting facility A without their knowledge. P3 was unaware of any staff persons locking the VA into the basement while they remained on facility A’s main level and had no information that the VA might kick doors. It was common for the VA to fall, suddenly drop to the floor, or attempt to pull staff persons onto the floor with her/himself when s/he fell, and s/he sometimes sustained scrapes or bruises when s/he fell. P4, a supervisory staff person, said that the VA was difficult to care for because s/he experienced symptoms of mental illness and was non-verbal. P4 thought that SP2 locked the VA in the basement during overnight shifts then slept upstairs on the couch but P4 instructed SP2 that the VA could not be locked in the basement. SP2 then said that if s/he could not lock the VA in the basement, s/he was leaving, and left facility A when s/he was scheduled to relieve P4, who had just worked a double shift. P4 told SP1 what SP2 had done but “nothing happened” with SP2. SP1 said that s/he had known the VA for a couple of years and the VA enjoyed watching television with him/her. Recently, the VA had changes in his/her behavior including leaving facility A abruptly then attempting to get into staff persons’ cars in the driveway. On one recent occasion, the VA was inappropriately dressed when s/he went to the driveway, entered facility A’s van, and was redirected to return to facility A. The VA might grab staff persons’ hands or arms and pull them and become agitated if s/he was unable to communicate his/her wishes to staff persons. If the VA hit staff persons, they were to protect themselves by shielding their faces and heads with their arms and hands. Staff persons could sleep during overnight shifts but were expected to wake if the VA or the other individuals needed assistance. When SP1 worked overnight shifts, s/he might be awake “half the night” with the VA because the VA had difficulty sleeping. There was a lot of arguing and disagreement between staff persons and P4 told SP1 that SP2 said s/he would quit if s/he could not lock the VA into the basement and left facility A, but SP1 had no firsthand information regarding SP2’s statements. SP1 denied that s/he locked the VA in the basement and said that s/he did not instruct others to do so. SP2 said that s/he had a blunt, direct, style of communication and had a loud voice that caused some to misinterpret his/her intentions or dislike the way s/he approached topics. However, SP2 had successfully worked with the VA for about three and a half years but noticed that the VA’s behavior had recently declined, which s/he attributed to the high turnover and number of “new faces” at facility A. The VA had begun staying up at night and leaving facility A during the day, to go to the driveway to try to get into staff persons’ cars. SP2 denied that s/he locked the VA into the basement but had been concerned that someone had because the bottom of the basement door on the inside was damaged and SP2 thought that the VA might have pushed against the door. SP2 disliked sleeping in the staff person bedroom in the basement because it was very dark which was “scary” to him/her. SP2 often used pillows and blankets to prop the basement door open, then slept on the couch in the common area just outside the basement door on the upper level, but the basement door was open. SP2 gave documentation to this investigator showing that there was interpersonal conflict between staff persons at facility A including contention between him/herself and P2, which SP2 said had begun when s/he and P2 were youths prior to working at the facility. The documentation also showed that P2 asked whether s/he was allowed to place a bench in front of a door if the VA tried to leave facility A and SP1 had specifically stated in the documentation that staff persons were not to block exits, and that the issues being raised should be discussed further in person during work hours. In addition, SP2 said that there was interpersonal conflict between him/herself and P4, that began on a date SP2 could not recall when P4 referred to the VA as a “cuckoo banana chick” (which was reported to the Minnesota Adult Abuse Reporting Center) several times in the presence of the VA, other staff persons whose identities SP2 could not recall, and the individuals who resided at facility A. P4 was upset because the VA had multiple behaviors during his/her shift and there was no one available to work the next shift. SP2 told P4 that s/he should not use those words to describe the VA and said that s/he was unable to work the overnight shift that P4 asked him/her to work because that would mean that SP2 would not be able to sleep before s/he had to work a shift at another service location operated by the same program as facility A. P4 was upset with SP2 and angry that s/he had to work the overnight shift since there was no one to relieve him/her. SP2 denied that s/he locked the VA in the basement and denied that SP1 told staff persons that they could lock the VA in the basement. The VA’s medical records showed that on May 26, 2023, the VA was evaluated at a hospital for a fall and reasons not related to this report that were investigated in report 202304565 and it was determined that s/he had a change of mental status and closed fracture of a right rib. The VA was admitted to the hospital and was very active and impulsive there. A computerized tomography (CT) scan and a physical examination of the VA’s entire body completed while s/he was sedated showed that s/he had an acute minimally displaced left nasal bone fracture, dislocation of the right clavicle (described as chronic), anterior right rib fractures, and knee abrasions “thought to be sustained in a fall.” Physicians were unable to determine when the VA sustained rib fractures which were described as non-displaced buckle fractures of the right seventh and ninth ribs and “old” fractures of the right fourth and fifth anterior rib. In addition, the VA had various bruises and scratches on his/her extremities and bruising/swelling to both feet and the left ankle. There were no fractures to the VA’s toes and the VA did not show signs of tenderness or pain in the areas around his/her injuries, but was agitated, difficult to redirect, attempted to leave the hospital, pushed past HCPs, and hit him/herself on the head. “Soft restraints” were placed around the VA’s wrists and ankles and hospital employees consulted with the VA’s guardian (G) and an HCP who was part of a behavioral emergency response team that worked to de-escalate high risk behaviors in high-risk situations. The VA received treatment for the left nasal bone fracture secondary to a forward fall and it was determined that no surgical intervention was needed for the dislocated clavicle. His/her medications were adjusted to better manage the symptoms of mental illness experienced by the VA. Facility A’s Internal Review showed that the individuals who resided with the VA did not require checks from staff persons during the overnight hours. Facility A’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents. Conclusion: The VA received services at facility A in early May of 2023, then s/he temporarily moved to facility B to receive crisis services there and was later hospitalized. There were concerns that SP1 and SP2 locked the VA in the basement of facility A, and that the VA had broken his/her toe when s/he tried to get out of the basement. P1 determined that at the time of incident, the door to the basement could be locked from the upper level of facility A thereby locking anyone inside the basement, into the basement until the door was opened from the outside. P2 said that SP1 instructed staff persons to lock the VA in the basement and SP2 followed SP1’s directions. After SP1 was no longer employed at facility A, staff persons stopped locking the VA into the basement. However, P3 said that SP1 told staff persons that they could lock themselves in the basement with the VA during overnight shifts, and s/he thought that SP1 and SP2 usually slept downstairs with the VA or on the couch in the common area on the upper level. P3 did not lock the VA into the basement but heard that others did or that others blocked the stairs to prevent the VA from exiting the basement during their shifts. P4 thought that the SPs locked the VA in the basement during their shifts and said that SP2 told him/her that s/he would not work a shift if s/he could not lock the VA in the basement. SP1 and SP2 provided consistent information that there were disagreements among staff persons and SP2 added that there had been interpersonal conflict between him/herself and P2 since they were youths. SP1 and SP2 each denied that they locked the VA in the basement and SP2 had a blunt direct style of communication and a loud voice which might cause others to misinterpret his/her actions or dislike his/her approach to topics. In addition, SP2 provided documentation showing that SP1 specifically instructed staff persons not to block exits at facility A. SP2 said that interpersonal conflict between SP2 and P4 occurred when P4 referred to the VA as a “cuckoo banana chick” and s/he declined to work an overnight shift for P4 since SP2 would likely be awake most of the night then have to work a day shift the following morning. The VA’s medical records showed that s/he did not have a broken toe, but s/he was hospitalized in the unit of a hospital that provided care to persons with mental illnesses, then discharged to facility B for crisis services, where s/he was subsequently hospitalized for treatment of symptoms of mental illness. Regarding locking the VA in the basement: Although the door to the basement at the time of the incidents would have permitted staff persons to lock the VA in the basement, given that the VA was unable to provide information regarding the incidents, that the basement door was damaged on both sides, that staff persons provided inconsistent information regarding whether the SPs locked the VA in the basement, that SP1 and SP2 each denied locking the VA in the basement, and that interpersonal conflict between staff persons might have influenced statements made during the investigation, there was not a preponderance of the evidence whether the SPs confined the VA to the basement against his/her will engaging in unreasonable confinement or any other adverse/deprivation procedure or whether there was a failure to provide the VA with care and supervision that was reasonable and necessary to obtain or maintain his/her health or safety. It was not determined whether abuse or neglect 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: 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.; or 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). Regarding the VA’s broken toe: Although it was reported that the VA sustained a broken toe when s/he was locked in facility A’s basement, given that information was consistent that staff persons had no concerns regarding the VA’s toe and that the VA’s medical records showed no such injury, there was a preponderance of the evidence that the VA’s toe was not broken. It was determined that neglect did not occur (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: Facility A completed an Internal Review which determined that its policies and procedures were adequate but were not followed. Staff persons were retrained on facility A’s policies and procedures, facility A’s Program Abuse Prevention Plan was updated, and it was planned to change the asleep overnight shift to an awake shift if the VA returned to facility A. When this report was written, SP1 and SP2 were no longer employed at facility A. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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