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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: 1070605-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070559-HCBS (Home and Community-Based Services) Investigator(s): Deb Neubauer-Hoffman/Emily Kearns Minnesota Department of Human Services Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at a vulnerable adult (VA) and dragged the VA across the floor by his/her ankles. Date of Incident(s): August 12, 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 (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 August 21, 2023; from documentation at the facility and through five interviews conducted with four facility staff persons (P1-P3 and the SP) and a family member/guardian (FM) of the VA. This investigator met the VA who declined to provide information regarding the incident. The VA’s support plans stated: · The VA’s diagnoses included a mild intellectual disability, unspecified bipolar disorder, and anxiety. At times, the VA used a wheelchair or walker for mobility purposes. The VA liked joking around, attending parades, eating at McDonald’s, going to garage sales, and spending time with his/her family. · When the VA was stressed, s/he sometimes became verbally and physically aggressive. The VA did not “target” peers but might aggress toward anyone who got close enough for him/her to reach. Staff persons were trained in behavior management and to give the VA space to work through his/her emotions as much as possible, and to maintain a presence to help peers stay out the VA’s space. The VA and three other consumers lived at the facility. The facility was a single-story residence with a basement that was only used by staff persons and for storage. The front door opened into a family room area and beyond that was a dining room. Off of the dining room was a small walkway to two of the consumer’s bedrooms, including the VA’s. While walking to the VA’s bedroom, there was a door that exited to a rear deck on the right and a closet/pantry straight ahead, both visible from the dining area. The flooring area was vinyl. No rugs were observed on the floor in the walkway or doorway where the alleged incident occurred. The phrases garbage can and recycling bin were used interchangeably by staff persons throughout this report. Documentation and an interview with P1 provided the following: · On August 12, 2023, the VA had a “typical morning” until approximately 11 a.m. when the SP talked to the VA about a “new [soda] pop limitation” that resulted from a recent physician’s order. The VA “appeared upset and went to [his/her] room.” The VA cried, “sounded upset,” and when the VA came out of his/her bedroom s/he made threats to “kill” P1, so the SP “escorted” the VA back to his/her bedroom. On two occasions the VA attempted to go outside on the deck (a calming place for the VA), but due to bees in the area, the VA was redirected away from the deck and went to his/her bedroom. At approximately 1 p.m., the VA came back out and as P1 was leaving the bedroom next to the VA’s bedroom, s/he saw the VA leave his/her bedroom “clutching a small plastic garbage bin” filled with garbage. The VA walked toward P2 (who was located between the hallway and dining room area) and P2 asked the VA if s/he was “recycling.” P1 remained in the hallway monitoring the interaction. At that point, the SP “swooped in and yanked” the garbage bin from the VA’s hands. The VA attempted to grab the SP’s hair and shirt and as the SP stepped away, the VA backed up and fell backwards onto the floor. While the VA was on his/her buttocks, the SP grabbed the VA by the ankles and “dragged” him/her by the ankles into the VA’s bedroom. The SP dragged the VA about four or five feet. · Once in the bedroom, the SP remained in the VA’s bedroom and in a “loud voice” was “lecturing” the VA. The SP told the VA that his/her family would not want to visit him/her when the VA was having behaviors, that the SP was going to turn off “things” in the VA’s bedroom, that the VA should not threaten or try to hit staff persons, and that the VA was to stay in his/her bedroom for 15 minutes. When the SP left the bedroom, the VA said, “I’ll kill you.” At that time the SP, “yelled” at the VA that the SP told him/her that the VA was not to threaten to kill staff persons. The SP remained in the VA’s bedroom for 10 to 15 total minutes “lecturing” the VA about his/her behavior until the VA started to calm and talked to the SP about being upset about the soda pop limitation. At approximately 1:20 p.m., the VA was calm, and the SP left the VA’s bedroom. · The VA had a history of bringing out his/her recycling bin and indicating that s/he wanted to throw out photos when s/he was upset. The VA’s behaviors/moods were known to change very quickly, and the VA would have “a look” on his/her face around the onset of an incident. The VA was also known to point at staff persons and make verbal and physical threats when upset, the VA’s threats were generally perceived as non-threatening due to the VA’s unsteady balance. · P1 did not believe that the SP’s actions caused the VA’s fall to the floor. P1 did not perceive “imminent danger” that would warrant any physical contact with the VA. The SP’s actions of dragging the VA across the floor by the ankles was not how staff persons were trained. P1 did not observe injuries to the VA. · Prior to the incident, P1 did not have any concerns about the SP’s interactions with the VA. P1 was not aware of any animosity between staff persons at the facility. P2 provided information that was consistent with the information provided by P1, with the following exceptions: · P2 stated that the incident happened in the morning rather than the afternoon and that when the VA approached the dining area with the recycling bin, the VA was holding the can at chest height so P2 did not think the VA was going to throw the bin. · At that point, the SP quickly came into the dining room and “turned” the VA around and guided the VA to his/her bedroom. The VA then “threw” him/herself on the ground. P2 stated that both P2 and P1 said, “We got this,” to the SP, indicating s/he did not need to intervene. · At that point, the SP grabbed the VA by the legs and “whipped [the VA] in a three-quarter circle.” The SP dragged the VA, with his/her legs in the air, into the VA’s bedroom. P2 believed that the SP pulled the VA approximately 13 feet. After the VA was in the bedroom, the SP began speaking towards the VA in a “demeaning” manner and that the SP’s voice was not only loud, but also “intimidating.” P2 heard the SP tell the VA in a “demanding” manner, “I am going to turn all of your stuff off; you are going to stop this behavior.” · The VA did not like things quiet in his/her bedroom and had the radio or TV on unless sleeping. · On prior occasions, there was animosity between the SP and P2. The FM stated that the VA had a short-term memory and did not say anything to the FM about the incident. P3, a supervisory staff person, did not witness the incident but after the incident talked with P1, P2, the SP, and the VA. P3 stated the following: · Both P1 and P2 told P3 that they had the trash can situation under control before the SP intervened. · The SP told P3 that s/he moved the VA because s/he did not feel safe in the common area and that there was “imminent risk.” The SP did not mention grabbing the VA’s ankles. · Staff persons were trained to use the least intrusive intervention and P3 told the SP that “dragging” was not an approved option. · The SP generally talked in a loud voice. · The week after the incident, when asked by P3, the VA told P3 that s/he had a “great weekend.” When questioned about the incident, the SP remembered two different incidents, but initially was not sure which of the two incidents was the one being investigated. Based on details given about both incidents, the SP provided the following about the incident witnessed by P1 and P2: · The VA was preparing to throw a trash can at the SP, and s/he had the can at “shoulder level.” The VA frequently filled his/her garbage can and threw contents away when upset and frequently fell to the floor on his/her own. During the incident, as the SP attempted to move the garbage can downward, the VA “started shoving it towards me” so the SP grabbed the garbage can and put it on the ground. · The SP initially stated that s/he did not hang onto the VA’s ankles and that if s/he touched the VA’s ankles or legs, it would have only been while the VA was “attacking” the SP. Later in the interview, the SP stated that s/he “turned [the VA] a bit” and touched the VA’s ankles when doing so because of how the VA was positioned to be able to safely redirect the VA to his/her bedroom. When the SP was asked if spinning the VA around by the ankles was how the SP was trained, the SP responded, “No one really trained me for that situation.” · When the SP was asked if s/he was speaking in a “humiliating” manner to the VA, the SP replied that s/he “would not seek to humiliate [the VA],” and “the only time I raise my voice is to literally be heard over things,” such as “[the VA’s] TV and radio”. · After the incident, no injuries were observed on the VA, but the SP and the VA sat in the VA’s bedroom and the SP let the VA “scream and holler at me” to which the SP said nothing back to the VA. The SP wanted the VA to sit quietly for five minutes with the SP. The SP turned down the volume on the electronics in the VA’s room so that the VA could hear the SP and the SP believed that the volume of the electronics in the VA’s room “seemed to be overstimulating” the VA. When asked if the SP told the VA that s/he had to stay in his/her bedroom for 15 minutes, the SP denied that s/he did. When the SP was asked about the volume of his/her voice, the SP said, “I have struggled, my voice carries and resonates.” · The SP provided information that there was animosity between P2 and the SP. Facility documentation showed that P1, P2, P3, and the SP each received training on the VA’s program plans, and on the Reporting of the Maltreatment of Vulnerable Adults Act. Conclusion: Regarding physical abuse: Inconsistent information was provided by P1, P2, and the SP relating to an incident on August 12, 2023, where P1 and P2 said that the SP “swooped in and yanked” a garbage can from the VA’s hands, then dragged the VA by his/her ankles. The SP admitting to touching the VA’s ankles but denied dragging the VA by the ankles. There were no injuries found on or reported by the VA. There were some discrepancies between P1, P2, and the SP as to the SP’s physical contact with the VA. However, because P1 and P2 each stated that the SP grabbed the VA by the ankles and dragged the VA across the floor, there was a preponderance of the evidence that the SP did drag the VA across the floor.
The SP’s actions of grabbing the VA’s ankles and dragging him/her across the floor was not therapeutic conduct and was not behavior consistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. However, it was not determined whether those actions would reasonably be expected to cause the VA physical pain and there was no injury to the VA. Therefore, there was not a preponderance of the evidence whether physical abuse of the VA occurred. 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 and P2 each stated that after the SP and the VA went into the VA’s bedroom, the SP turned off all of the VA’s electronics, raised his/her voice and was “lecturing” and “yelling” at the VA. The SP admitted that generally s/he talked loudly and that s/he did not turn the volume down on the electronics in the VA’s bedroom. Based on P1’s and P2’s description of the SP’s verbal interactions with the VA, not all of the SP’s actions were therapeutic conduct. However, there was not a preponderance of the evidence that the SP used repeated or malicious language toward the VA which would reasonably be expected to cause the VA emotional distress. It was not determined whether emotional abuse occurred (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) occurred. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but were not followed. The facility determined that additional staff person training was needed regarding the VA, the Program Abuse Prevention Plan (PAPP), and expectations for these types of incidents. Training was to take place in September 2023, to address mandated reporting and behavioral intervention training. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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