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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: 1071996-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 vulnerable adult (VA) left the facility without supervision because a staff person (SP) was “unkind” to the VA. It was also reported that the VA had sexual contact with a community person and that the SP called the VA a “stupid fucking bitch.” Date of Incident(s): September 4-6, 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 (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 September 13, 2023, from documentation at the facility, from law enforcement records, and from the VA’s medical records; and through 12 interviews conducted with the VA, the SP, three hospital employees (HE1-HE3), the VA’s guardian (G) and six facility staff persons (P1-P6). The facility was a single level home and the VA lived at the facility with three other clients. The VA’s support plan showed that the VA enjoyed baking and cooking, talking with friends and families, and accessing the community. The VA’s Risk Assessment Detail showed that the VA had a mild developmental disability. A review of the VA’s plans did not show a history of the VA leaving without supervision. A review of the VA’s file did not indicate that staff persons were to check on the VA during overnight shifts. The facility’s staffing schedule provided the following information: · On September 4, 2023, P6 worked from 8 a.m. until 2 p.m., P1 worked from 8 a.m. until 2 p.m., P5 worked from 3 until 10 p.m., P3 worked from 2 until 10 p.m., and P2 worked the overnight shift. · On September 5, 2023, P1 worked from 8 a.m. until 2 p.m., P4 worked from 4 until 10 p.m., P5 worked from 2 until 10 p.m., and P2 worked the overnight shift. · On September 6, 2023, the SP worked from 8 a.m. until 4 p.m. and P1 worked from 8 a.m. until 2 p.m. P1-P6, the G, and the SP provided consistent information that prior to the incident, the VA had a half an hour of unsupervised time in the community and if the VA checked in with staff persons after the half an hour was over, the VA could have another half an hour of unsupervised time in the community. P1-P6, the G, and the SP also provided consistent information that the VA did not have a history of leaving the facility without supervision. P1 said that when s/he worked with the VA on September 4, 2023, the VA had a “really good day” and was “happy.” At about 10 a.m. that day, the VA asked to go to a local park (about a half mile from the facility) without staff persons and P1 said that was “fine.” The VA told P1 that his/her cell phone had low battery and “might die” while the VA was gone. The VA told P1 to “drive by” the park if the VA’s phone did not work. At 10:30 a.m., P1 called the VA but the VA’s phone was not on so P1 rove by the park and the VA was alone at the park and was “fine.” P1 went back to the facility. When the VA did not return to the facility at 11 a.m., P1 called the SP and asked him/her to drive by the park to check on the VA and the SP agreed to do so. Shortly thereafter, the SP went to the facility from the park. The SP was “mad” that the VA was at the park with a community person (CP) that was the opposite gender as the VA. The SP stated that when s/he got to the park at about 11 a.m., the SP told the VA, “You know the rules,” and that the VA was not supposed to be meeting persons that were the opposite gender as the VA. (Note: There was not information in the VA’s plans regarding who the VA could or could not be with at the park.) The SP, who remained in his/her car, told the VA that s/he needed to return to the facility. The SP saw the VA and the community person talking. The SP stated that s/he “raised” his/her voice, partly because the SP was in the car and the SP wanted the VA to hear the SP. The VA did not have a history of meeting persons of the opposite gender as the VA. The VA returned to the facility. The facility’s Incident Report provided the following information: · At 7:20 a.m., on September 5, 2023, the G received a text message from the VA which stated that the VA “could not live chained up all the time and was leaving.” At an unspecified time, the G called the SP to inform him/her of the VA’s message. The SP went to the facility, and it was determined that the VA had left the facility through a window in the VA’s bedroom. · When staff persons could not locate the VA, law enforcement was notified. At about 9 a.m., the VA sent a text message that s/he was “safe” and in Schafer, MN (www.mapquest.com showed the drive time between the facility and this location to be a one hour and 47-minute drive). The G told the VA that s/he needed to return to the facility by 2 p.m., but the VA stated that s/he and the CP were watching a movie at the CP’s home, and s/he would return later. · The VA returned to the facility at about 4 p.m. (information from the investigation showed that the community person brought the VA back to the facility) and the other person remained outside because his/her car had car trouble. P2, who worked the overnight shift between September 4 and 5, 2023, stated that although s/he did not see the VA that night, s/he heard the VA talking on the phone in the VA’s bedroom at about 5 a.m. on September 5, 2023. P1 stated that the VA was somewhat apprehensive about beginning school on September 5, 2023, and that when s/he arrived at the facility that morning, s/he noticed that the screen had been taken out of the VA’s bedroom window. P1 also said that when s/he was in the ER with the VA in the exam room, s/he did not hear any negative comments from the SP. The VA’s case notes and interviews with P1 and P2 provided the following information: · On September 5, 2023, during the overnight shift, P2 talked to the VA and the VA told P2 that while the VA was at the CP’s home, the CP began “kissing” the VA and “things escalated to sex.” The VA also stated that s/he had told the CP “No,” but the VA “eventually was forced to give in.” · At 7:45 a.m. on September 6, 2023, P1 came to the facility and after talking to P2 who told P1 what the VA said, P1 called the SP to inform him/her of what the VA told P2. Shortly thereafter, the SP came to the facility and “yelled” at the VA to get ready to go to an emergency room (ER). According to case notes, the SP yelled that the VA “needs to understand the consequences.” Also, law enforcement and the G were notified. The G arrived at the facility and drove the VA to the ER at about 10:10 a.m., while the SP and P1 followed them to the ER. Shortly after arriving at the ER, the G left. When the VA was seen in the ER, the SP and the VA “got into an argument” but P1 did not hear everything that was said because P1 was trying to listen to medical professionals assessing the VA. At some point, the VA stated that s/he wanted the SP to leave the room, which the SP did, but the SP was “visibly upset” according to P1. The VA “answered all questions” during the exam but did not agree to all aspects of the exam according to P1. At about 3 p.m. when the VA was ready to be discharged from the ER, another staff person came to the ER and took the VA home. HE1 stated that when s/he was called to the ER to assess the VA on September 6, 2023, the VA stated that s/he had left the facility the night before, September 5, 2023, and returned the next day. The VA denied that s/he was “raped,” but stated that the SP was “very rude” to the VA and the SP was the “reason” why the VA left without supervision and that if the SP was the person giving the VA a ride back to the facility, the VA planned to “walk.” HE1 did not ask the VA specific questions about the SP’s treatment of the VA, but the VA told HE1 that the SP told the VA that s/he was a “fucking bitch,” but the VA did not say when the SP said that. HE2, who was also in the room in the ER when the VA was assessed, stated that when the SP was asked to leave the room, the SP looked at the VA and stated, “God, you’re such a fucking bitch.” HE3, who was also in the room in the ER when the VA was assessed, stated that the VA told him/her that the sexual contact was “not rape.” The VA “refused” to complete a full exam. At some point, HE2 told HE3 that s/he heard the SP tell the VA that s/he was a “fucking bitch,” but HE3 did not hear that. The VA’s medical records, dated September 6, 2023, stated that the VA “was forced to have sex yesterday,” and that the VA “did not suffer any injuries when this occurred.” The VA stated that s/he was “not raped.” The records stated that when the VA left the facility without supervision, the CP picked up the VA at the “park” and that the VA did not tell staff persons that s/he was leaving. The VA provided information that was consistent with the information in the facility’s Incident Report but added that when the SP came to the park to tell the VA that s/he needed to return home, the SP “yelled” at the VA and the CP, which “embarrassed” the VA., but the VA did not remember what the SP said. When the VA got back to the facility that day, the SP again yelled at the VA, but the VA did not provide information as to what the SP said. The VA stated that s/he left the facility, through the VA’s bedroom window, at about 10 p.m. and returned the following day and that s/he and the CP had consensual sex. The VA stated that when the SP left the exam room in the ER, the SP called the VA a “little bitch.” The SP provided the following information to this investigator: · On the day before the VA left the facility, the SP got a phone call from P1 to check on the VA at the park. When the SP did that, the VA and the CP were “holding hands” at the park. The SP, who remained in his/her car, acknowledged that s/he “did raise my voice” by telling the VA, “You need to get home.” When the SP was asked to describe the tone of his/her voice, with a one meaning that the SP was talking quietly and a ten meaning that the SP was yelling very loudly, the SP described the tone of his/her voice as being a four. When the SP talked to the VA after the VA returned to the facility, the SP told the VA, “No more [unsupervised] time,” and “You’ve messed this up until further notice.” · On September 5, 2023, P2 called the SP about 7:20 a.m. to say that the VA was gone from the facility. When the SP got to the facility shortly thereafter, P1 was at the facility looking for the VA, but the VA was gone. The SP contacted law enforcement and throughout the day, the SP got updates from the G about the VA’s whereabouts, but the SP did not contact the VA because the SP did not have the VA’s cell phone number. · When the VA returned to the facility, the VA spent time with the CP across the street from the facility because the CP’s car was not operable. The SP told the VA to get his/her “butt” back inside the facility, but denied yelling at the VA. The VA “ignored” the VA, but eventually came inside the facility and when that happened, the SP “didn’t engage” with the VA. · The following day, when the SP learned about the VA’s sexual contact with the CP, the SP went to the facility. When the SP told the VA that s/he needed to go to the ER, the VA initially said no, but agreed to go later. Law enforcement officers arrived at the facility at about 8:30 a.m. and talked to the VA, the G and the CP separately. · Shortly after the VA, the G, the SP and P1 got to the ER, the G left the ER. When the SP was asked to leave the exam room, the SP looked at the VA and said, “quit being bitchy.” The SP denied saying that the VA was a fucking bitch. Although this investigator obtained the law enforcement report, the report did not provide information that was pertinent to the investigation. The G also stated that the VA was “anxious” about starting school on September 5, 2023, that the VA had lost his/her unsupervised time in the community on September 4, 2023, due to “not being honest.” The G stated that the VA would “usually” become upset with a staff person if they made requests of the VA, such as asking the VA to clean his/her bedroom. P2 had not observed any interactions between the SP and the VA, prior to the incident, that were concerning to P2. P3, who worked the evening shift on September 4, 2023, described the VA as having a “pretty calm night.” When P3 was asked to describe the SP’s interactions with the VA, prior to the incident, P3 stated that there was one previous incident in which the SP was upset with the VA and another client. During that incident, the SP’s face was “red,” and the SP was “pointing” his/her fingers at the VA and the other client because the SP thought they had opened mail addressed to the SP. When that happened, the VA began “started crying.” P4 stated that s/he had not observed any interactions between the SP and the VA that were “alarming.” P5, who was working at the facility when the VA returned with the CP, stated that s/he heard the SP tell the VA, “You’re just mad because I caught you at the park yesterday,” and that the VA needed to come inside. When that happened, P5 told the SP that s/he needed to “calm down.” P5 described instances in which the SP’s tone was a ten (prior to the incident). When those instances happened, the VA usually responded by saying, “I’m done with you,” and the VA would walk away. P6 described the SP as being a “very nice person,” but said that there were instances in which the SP got “mad.” P6 also said that there were times that the SP “goes off without thinking” and made comments such as, “I’m not going to play your games,” and that the VA usually got “very mad” at the SP and “will scream” at the SP, but P6 also said that the VA “blows a lot of things out of proportion.” 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 care plans prior to September 4, 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: Prior to September 5, 2023, the VA had up to one hour of unsupervised time in the community and no history of leaving without supervision. On September 4, 2023, the VA went to the park without staff persons. When the VA did not return to the facility, the SP checked on the VA and found the VA and the CP holding hands at the park. The SP remained in his/her car and told the VA to return to the facility, which the VA did. The next day, although there was a discrepancy in terms of how long the VA was gone from the facility, information from the investigation showed that the VA left the facility through his/her bedroom window sometime after 5 a.m. on September 5, 2023, was at the CP’s house, and returned to the facility later that afternoon. Later that night, the VA provided information to P2 that the VA and the CP had sexual contact and that the sexual contact was not consensual. As a result of that, the SP, law enforcement and the G were notified, and it was determined that the VA should be assessed in the ER. While in the ER, HE2 asked the SP to step out of the room and when the SP did that, HE2 heard the SP tell the VA, “God, you’re such a fucking bitch.” The SP denied saying that and said that s/he said, “quit being bitchy” to the VA. P1, who was also in the room at the same time, did not hear the SP say anything to the VA. Regarding Neglect: Although the VA left the facility without supervision and went to the CP’s house, given that the VA left out his/her bedroom window without staff persons knowledge, that the VA did not require overnight checks by staff persons, and that when the VA was discovered missing staff persons took immediate action, there was not a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care and services. It was not determined that 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). Regarding Emotional Abuse: Information from the investigation showed that the SP likely raised his/her voice when talking to the VA and called the VA a “bitch” or told the VA not to be “bitchy,” both which was a violation of Minnesota Statutes, 245D.04, subdivision 3, paragraph (a), clause (6). Although the SP called the VA a “bitch” or said the VA was being “bitchy,” which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, given that it was a single occurrence and not repeated, that there were no details regarding other occasions of the SP using similar language toward the VA, there was not a preponderance of the evidence whether the SP’s conduct was repeated or represented treatment that could be reasonable expected to cause 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 review and determined that policies and procedures were adequate, followed, and that additional training was provided to the SP related to “culture of respect” and “conflict resolution.” In addition, the SP no longer worked at the facility, but was transferred to another home within the organization. Action Taken by Department of Human Services, Office of Inspector General: A Correction Order was not issued for the violation outlined in this report because the facility took corrective action.
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