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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: 1070710-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA) sustained a bloody nose after a behavioral intervention with a staff person (SP). Allegation Two: It was reported that the VA sustained bruising to the chest after a behavioral intervention with the SP. Date of Incident(s): April 1 and April 6, 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 (1): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 9, 2023; from documentation at the facility; and through five interviews conducted with two facility management staff persons (P1 and P2), two facility staff persons (P3 and SP), and the VA’s family member/guardian (FM). The VA was not able to communicate verbally or provide pertinent information for this investigation. The facility was a single-level home. There was a common living area, a kitchen, and a dining room. Off of the dining room there were four bedrooms, three of which were down a hallway. The VA’s bedroom was down the hallway, across from a bathroom. There were three recliners in the common living area. The VA’s support plans stated: · The VA’s diagnoses included autism. The VA was not able to communicate verbally. · The VA gave frequent hugs and was “very strong.” If the VA hugged a staff person, staff persons were trained to “push” the VA off with their forearms or hands to get away. When the VA would get “worked up,” staff persons would attempt to redirect him/her to his/her room to watch a movie to “cool down.” · The VA enjoyed spending time with his/her family, as well as taking baths and spending time in water. Allegation One: It was reported that the VA sustained a bloody nose after a behavioral intervention with the SP. The SP documented the following in an incident report on April 10, 2023, regarding an incident on April 1, 2023: Due to reoccurring behaviors, [the SP] was redirecting [the VA] to [his/her] room to watch a movie. [The VA] responded negatively to redirection. [The VA] would continue to bear hug, squeeze, and choke [the SP]. Though [the SP] was successful in keeping [the VA’s] hands by [his/her] side momentarily, [the VA] managed to deliver a headbutt to the top of [the SP’s] head, resulting in [the VA’s] nose to bleed for about five minutes. [The SP] cleaned [the VA] up and made sure no other damage was caused to said area. This allegation was assigned to be investigated in July 2023 so interviews with staff persons were conducted approximately four months after the incident occurred. The SP provided the following information in an internal review report and in an interview with this investigator: · The VA was exhibiting aggressive behaviors for an unknown reason. The SP asked the VA if the VA wanted to watch movies in his/her bedroom as in the past that was an effective strategy with the VA. The VA became more agitated and grabbed and hugged the SP from behind. The SP said that the VA put him/her in a “big strong bear hug with squeezing action.” The SP referred to the VA’s action as “squeeze therapy.” The SP said that s/he did not feel unsafe. The VA let go but continued to try to squeeze the SP while facing the SP. The SP placed his/her hands down on his/her sides and asked the VA to do the same. The VA did for a short time then continued to try to grab at the SP. At one point, while facing each other, the VA clasped both hands together around the back neck of the SP at which time their bodies were close but not touching. The VA then “pecked” the top of the SP’s head, causing the VA’s nose to bleed for about five minutes. After the incident, the VA calmed down and allowed the SP to clean the blood from under his/her nose. · The SP did not remember if anyone witnessed the incident. After the incident, the SP contacted P2 and the FM. The SP stated that his/her actions during the incident were consistent with what s/he was trained to do. P3 stated that s/he was coming in for his/her shift and was informed by the SP that the bloody nose happened on the prior shift. P3 did not remember anything else about the incident. P2 stated that the SP called him/her after the incident and reported that the VA came up behind the SP and grabbed him/her causing the SP to fall backward and hit his/her head on the VA’s nose causing the VA to get a bloody nose. The FM stated that on April 18, 2023, the FM met with the VA’s case manager and P2. P2 told the FM that the SP told P2 that the VA received a nose bleed when s/he hit his/her nose in a “pecking” motion on the top of the SP’s head. Facility documentation showed that the SP, P1, P2, and P3 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, training specific to the VA, and training on behavioral interventions. Conclusion Allegation One: On April 1, 2023, the SP stated that s/he was attempting to redirect the VA to his/her bedroom and the VA put the SP in a bear hug from behind. The VA let the SP go and then as they were facing each other, the VA continued to try to grab the SP. The SP put his/her hands to the side and asked the VA to the same. At one point, the VA clasped his/her hands around the back of the SP’s neck and headbutted the SP, resulting in the VA receiving a bloody nose. The SP stated that after the VA headbutted the SP, the SP assisted the VA in attending to the bloody nose and cleaning up after the incident. No one else witnessed the incident. (At the time of P2’s interview, which was four months after the incident, P2 said that the SP told him/her that the SP fell backward and hit his/her head on the VA’s nose, but at the time of the incident, P2 told the FM information that was consistent with what was documented by the SP.) It was not determined whether all of the SP’s actions during the incident were therapeutic conduct. However, the SP’s description of the VA’s actions during the incident were a reasonable explanation as to how the VA received the bloody nose. Therefore, there was not a preponderance of evidence whether the SP engaged in non-therapeutic conduct which caused pain or injury to the VA. It was not determined whether 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). Allegation Two: It was reported that the VA sustained bruising to the chest after a behavioral intervention with the SP. An incident report dated April 10, 2023, regarding an incident on April 6, 2023, stated the VA wanted to use the bathroom, but it was occupied by another consumer (C). The VA attempted to pull the C off of the toilet and as the SP tried to redirect the VA away from the C, the VA became angry, grabbed onto the SP, and headbutted him/her. P1 witnessed the incident. After the incident, the VA had bruising on his/her chest. According to an internal review completed on April 26, 2023: [The SP] wrapped their arms around [the VA] from the back and removed [the VA] from the bathroom so that [the VA] would not harm [C]. [The VA] then went to [his/her] room and [the SP] turned on a movie to help soothe [the VA]. [The VA] appeared unhappy and began to snap [his/her] fingers. [The SP] left [his/her] room to give [the VA] space to calm [him/herself]. [The SP] went into the kitchen to talk with [P1]. [The VA] came out of their bedroom and [the VA] came behind [the SP] and wrapped their arms over [the SP’s] shoulders and was choking [the SP]. [P1] redirected [the VA] to a recliner in the living room, to encourage [the VA] to relax. [The VA] went into the living room and sat down. [The VA] was still visibly agitated and was sitting on the edge of the reclining chair, starring [sic] at the staff. [P1] asked [the VA] to sit back and relax. At that point, [the VA] threw [him/herself] backwards into the chair with such force that the chair broke, and [the VA] was now laying in the broken chair, attempting to get up but struggling to do so due to the way the chair was broken. [The SP] immediately responded to [the VA's] aid and reported that they could see [the VA’s] legs and arms flailing in the air as [the VA] was attempting to get up. [The SP] went behind [the VA] to help get [the VA] out of the broken chair. [The VA] became more upset and was trying to choke [the SP] who was helping [the VA], so [P1] stepped in to help. [The VA] then did the same thing to [P1] and wrapped their arms around [P1]. [P1] was able to free themselves by raising their arms and guiding [the VA’s] hands away from [P1’s] body and spun out of the way. [The VA] was able to get up with [the SP’s] assistance, and was offered a PRN [as needed medication], and did calm down. P1 provided the following information: · P1 was in the kitchen when the SP assisted the C into the bathroom. The C was not able to walk on his/her own and used a walker and gait belt for staff person to assist him/her. The SP came to inform him/her that the VA was attempting to get into the bathroom that C was using and wanted to pull the C off of the toilet. The C had a bad hip and a fall off of the toilet “would not have been good.” The SP told P1 that s/he had to assist the VA out of the bathroom. P1 did not see when the SP assisted the VA out of the bathroom. After, the SP put a movie in for the VA in the bedroom and walked out to the kitchen. The VA then came out of his/her bedroom and wrapped his/her arms around the SP from behind the SP. The SP was able to get away from the VA, but the VA kept trying to wrap his/her arms around the SP. The SP held his/her arms and hand out to keep a safe distance from the VA. After a minute or two of the VA not being able to get his/her arms around the SP, the VA “stormed” into the living room and sat in chair and looked at the SP and P1. · The VA then stood up and went toward the kitchen at which point the VA was asked to go watch a movie and instead the VA went back and threw him/herself in the chair and fell backward in the chair. Initially the VA did not move and the SP went to assist the VA to get back up. The SP assisted the VA to stand up by going behind the chair and putting his/her arms under the VA’s arm pits and lifting the VA up off of the floor. The VA was not happy and struggled with the SP as the SP assisted to the VA to get up. · After the VA stood up, the C was out of the bathroom and the VA went and took a shower. After the shower, the VA calmed down. After the incident, the VA had bruising which P1 believed was caused when the SP assisted the VA up off of the floor. · The SP’s actions that P1 witnessed were consistent with facility protocol. The SP provided information consistent with the internal review and provided the following additional information: · To protect the C, the SP had to physically remove the VA from the bathroom. The SP grabbed the VA from behind, wrapped his/her arms around the VA with his/her hands clasped at the wrist and pulled the VA across the hall into his/her bedroom. (Note: the VA’s bedroom was immediately across the hall from the bathroom. Follow up attempts to reach the SP to see how long s/he had his/her arms around the VA were unsuccessful.) Once the VA was in his/her room, the SP let go, but the VA wanted to go back to the bathroom and was “like a charging bull” attempting to get back into the bathroom. The SP had his/her hands out to keep an arm’s length away from the VA. The VA then started “bouncing” him/herself off of the SP, whose arms were extended in front of him/her, making contact with the VA’s chest. During that time, the SP believed that another staff person (the SP thought it was P3, but other information showed that it was P1) got the C out of the bathroom. Once the C was safely out of the bathroom, the SP allowed the VA to go to the bathroom. Once finished in the bathroom, the VA sat down in the recliner chair in the common living area “with a lot of force” and tipped the chair backwards resulting in the chair breaking. After the VA fell, the SP wrapped his/her arms around the VA’s arms and pectoral area to assist the VA to his/her feet. · As a result of the incident, the VA sustained bruising on his/her chest and side. When the SP was asked how s/he believed the VA sustained the bruising, the SP stated that it was from his/her arms wrapping around the VA and from the VA falling in the chair. Prior to that, the SP did not push the VA, the VA only ran into the VA’s outstretched arms. · The SP did not believe that his/her actions were consistent with training, but believed they were “necessary given the circumstances,” as s/he was worried about the safety of C who would not have tolerated a fall off of the toilet. The SP received information regarding behavioral interventions during training. Regarding manual restraints, the SP said that s/he was “not supposed to do it” unless it was a “last resort and the only option.” · The SP stated that s/he received training specific to the VA.
The FM stated that on April 8, 2023, s/he was with the VA and P1 told the FM about bruising on the VA’s chest. The FM then took pictures of the VA’s upper body. (The pictures showed that the VA had bruising in several areas in the upper chest region. The VA also had some bruising on his/her left side below his/her arm pit.) An administrative staff person (P4) told the FM that the VA’s actions caused the bruising and P2 told the FM that the bruising was caused when the VA threw him/herself into the SP and when the SP assisted the VA up off of the floor. The FM stated that the VA’s injuries “[did] not line up” with what facility staff persons reported to the FM occurred. According to the facility’s Emergency Use of Manual Restraints Policy, staff persons were to use the least restrictive alternative possible to redirect a consumer’s behavior. If a consumer was engaging in in behavior that was a threat to him/herself or others, staff persons were able to physically block or move a consumer’s limbs or body, without holding the consumer, as long as the staff persons did not have more than 60 seconds of physical contact with the consumer. If the consumer’s behavior did not pose a threat to themselves or others, staff person were able to physically redirect the VA as long as the staff person did not have more than 60 seconds of physical contact with the consumer. Conclusion Allegation Two: On April 6, 2023, the C went to use the bathroom. After the C was in the bathroom, the VA attempted to go into the bathroom and remove the C from the toilet. The SP stated that s/he intervened to protect the C. The SP stated that s/he grabbed the VA from behind, wrapped his/her arms around the VA with his/her hands clasped at the wrist, and pulled the VA out of the bathroom and across the hall into his/her bedroom. The SP stated that once the SP got the VA back into his/her room, the SP continued to prevent the VA from going back to the bathroom by physically blocking his/her exit by extending his/her arms in front of his/her body. The VA continued to run into the hands of the SP until the C was finished using the bathroom and it was safe for the VA to leave the room. After using the bathroom, P1 and the SP each stated that the VA tried to grab the SP and then sat down in a recliner causing the recliner to tip over and the VA to fall to the floor. The SP helped the VA up off the floor by lifting him/her up underneath his/her arms and around his/her chest. The VA struggled with the SP while the SP was assisting the VA to stand up. After the incident the VA had bruising on his/her chest (photographs taken by the FM on April 8, 2023, showed the bruising to be in the upper areas of the VA’s chest and along the left side of the VA’s chest). The SP stated that the bruising was likely from when had his/her arms wrapped around the VA to assist him/her to stand up after the VA’s fall from the chair. The SP never pushed the VA, the VA only ran into the VA’s outstretched arms. P1 believed that the bruises were caused when the SP assisted the VA up off of the floor. It was likely that the bruising was caused during the incident from a combination of the SP moving the VA from the bathroom to the bedroom, the SP assisting the VA up off of the floor, and from the VA running into the SP’s arms. Although it was likely that the injuries were caused by the SP’s actions, given that his/her actions were reasonable to protect the C and later assist the VA up off the floor, and that both times that the SP wrapped his/her arms around the VA were brief and likely did not violate the facility policy (if a consumer was a threat to him/herself or others of not having more than 60 seconds of contact move the consumer), there was not a preponderance of evidence whether the VA’s injuries were caused other than in the provision of therapeutic conduct. 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). Action Taken by Facility: The facility completed an internal review of both incidents and determined that in each incident, their policies and procedures were adequate and followed. Staff person were to review the Emergency Use of Manual Restraints Policy and an interdisciplinary team meeting was held to discuss concerns. At the time of the investigation, the VA no longer lived at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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