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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: 1071626-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 (VA1) when VA1 urinated in his/her bed and that the SP yelled at another vulnerable adult (VA2) to get back into bed. During the investigation, it was reported that the SP yelled at another vulnerable adult (VA3). Date of Incident(s): prior to July 11, 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 (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: 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 August 10, 2023; from documentation at the facility; and through six interviews conducted with VA1, VA3, VA2’s guardian (G2), VA3’s guardian (G3) and two facility staff persons (P1 and P2). Although this investigator met the SP, the SP chose to not conduct an interview to provide information. Although this investigator contacted VA1’s guardian and another staff person (P3), they did not respond to requests to be interviewed. VA2 was non-verbal and unable to provide information in an interview. VA1’s Individual Abuse Prevention Plan (IAPP) stated that VA1, who was diagnosed with a mild developmental disability and cerebral palsy, enjoyed spending time with family and accessing the community. VA1’s plans further showed that VA1 may have some issues related to incontinence. VA2’s support plan showed that s/he enjoyed watching videos, shopping, and working on puzzles. VA2’s plans showed that s/he was diagnosed with autism, was ambulatory, and needed some assistance with completing activities of daily living, such as showering and dressing. VA3’s support plan showed that s/he enjoyed “building different things,” interacting with his/her family, and participating in leisure activities in the community. The plan showed that VA3 was diagnosed with autism. VA1 provided limited information to this investigator. The VA stated that the SP told him/her to “quit doing bad things and do nice things.” VA1 also said that the SP “yelled” at VA3, but VA1 was unable to provide examples. VA3 stated that if s/he got on the SP’s “bad side,” the SP “takes it the opposite way” and would be “mad all day long.” VA3 said that the SP was “very stern,” and that his/her tone made VA3 feel “pretty sad.” VA3 also said that there were times that the SP was “nice.” P1 said that s/he received a call from P2 on an unspecified date. During the discussion, P2 told P1 that VA1 approached P2 and said that the SP had been “yelling” at VA1 and VA2, but specific information was not provided. P1 also stated that some previous concerns had been reported related to the SP’s tone of voice, which P1 described as a “harsher tone.” The facility provided additional training to the SP regarding those concerns. P2 provided the following information: · On an unspecified date, P3 called P2 and stated that “the individuals had a very rough morning” and that the SP “was very mean” to VA1 when s/he had an incontinence accident in his/her bed. · P2 did not often work with the SP but noted that s/he had been at the facility on occasion to observe the SP’s interactions. On one occasion when one of the clients (P2 did not recall who) arrived back to the facility, the SP began “arguing” with the client. When that happened, P2 redirected the SP to talk more positively to the client.
· When P2 talked to VA1 about the allegations for this investigation, VA1 told P2 that s/he felt “a lot better” since the SP “is not here anymore.” · On previous occasions, P2 talked to the SP “several times” because of the SP’s tone of voice and during those discussions, the SP told P2 that s/he would “try [his/her] best.” However, there were times that the SP “argued” with P2 when P2 expressed concerns that had been raised related to the SP’s tone of voice with the clients. · P2 described the SP as being “very negative” and that the SP was no longer working at the facility, so it was “pretty mellow now” and that the clients were “happy” now. P3 provided the following information: · On an unspecified date, P3 observed VA3 to become “escalated” so the SP tried to calm VA3. However, when VA3 did not calm, the SP and VA3 “both would get escalated.” P3 described that as “no screaming” by the SP, but that there was “yelling” between the SP and VA3. P3 gave another example in which the SP told VA3 to turn the volume of the television down and VA3 did not comply, so the SP and VA3 would “bicker back and forth.” · P3 gave an example in which one of the clients had “negative behavior” and when that happened, the SP raised his/her voice, but was not “screaming.” · When P3 was asked to describe the tone of voice the SP used with a rating scale of one being quiet and ten being yelling very loudly, P3 described the SP’s tone of voice as a “six.” · When clients exhibited maladaptive behaviors, staff persons were trained to provide verbal redirection or a period of time in which the client could calm on his/her own, but the SP typically did not do that. Instead, the SP would continue to engage “again and again” with the clients, which often times led to situations escalating. G2 stated that on one occasion, s/he was visiting VA2. While G2 was in VA2’s bedroom, G2 heard the SP “yelling” at VA3 on the other side of the facility. G2 described the SP’s tone of voice as being a “seven or eight,” using the same one to ten rating scale. G3 stated that there were instances in which the SP called G3 because VA3 had some type of behavioral incident and when that happened, G3 told the SP that s/he need to “drop it” and let VA3 calm in his/her bedroom. G3 also shared one time in which s/he thought the SP was being “crabby to a client.” In that situation, the client kept taking his/her pants off and the SP used a “not very nice tone.” The facility’s Internal Investigation provided the following information: · P4 stated that on July 9, 2023, the SP was “yelling” at VA2 to “get up from the floor” and when the SP noticed P4, the SP’s mood “immediately changed and [s/he] wasn’t yelling anymore.” · P3 provided information that was similar to the information that s/he provided to this investigator. · The SP stated that s/he had a “stern tone of voice,” but denied yelling at the clients. The facility’s training records showed that all staff persons interviewed for this investigation were trained on The Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to August 10, 2023. Relevant Rules and/or Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that consumers have the right to be treated with courtesy and respect. Conclusion: Concerns were raised that the SP “yelled” at VA1-VA3 and had a harsh tone of voice. VA1 said that the SP told him/her to “quit doing bad things and do nice things.” VA3 said that the SP was “very stern” and that his/her tone made VA3 feel “pretty sad.” P2 provided information that the SP had a tendency to “argue” with the clients. P3, G2, and G3 provided information that the SP used a loud voice when talking to the clients and G3 described the SP’s tone as “not very nice.” The SP, who denied yelling at the clients, likely used a loud and or harsh tone of voice which was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), and not behavior that was consistent with the standard of a professional caregiver in a facility licensed by the Department of Human Services. Although the SP had “argued” with clients and had a raised tone of voice, given that the SP denied yelling at clients, that there was limited information regarding specific occurrences detailing what the SP said to the clients, and that there was no information that the SP used malicious language, there was not a preponderance of the evidence whether the SP’s conduct represented the treatment of vulnerable adults that would be considered by a reasonable person to rise to the level of causing emotional distress. 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 Investigation and determined that although policies and procedures were adequate, they were not followed by the SP and that additional training was needed. The facility provided training to the SP and the SP no longer worked with VA1-VA3. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because the facility took corrective action.
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