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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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Jason Pehler/Kyle Youker 651-431-4056 Suspected Maltreatment Reported: It was reported that staff persons (P1 to P6) engaged in “excessive” and “unnecessary” force while conducting a manual restraint of a vulnerable adult (VA). Date of Incident(s): December 16, 2022 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 January 12, 2023; from documentation at the facility; and through nine interviews conducted with a supervisory staff person (P1), five facility staff persons (P2-P6), two community health care professionals (CHCP1 and CHCP2), and the VA. The VA had a history of self-injurious behaviors including multiple occurrences of foreign body ingestion. The VA had a history of physical aggression toward others. The VA enjoyed music, writing, art, and watching television. The locked facility had multiple units accessed by a central corridor. Each unit contained multiple client rooms and a day room area with tables and a television. The facility had numerous cameras and closed-circuit television (CCTV) on each unit. The facility had one security garage for ambulances or other vehicles to utilize, allowing access to the facility. The facility’s Use of Restraints for Transport Outside the Secure Perimeter policy stated that restraints included metal handcuffs, metal leg restraints, and transport belt such as a “D-Belt.” (A “D-belt” was a belt that went around the waist and was used in conjunction with handcuffs to keep the wearer’s hands at the mid-section area of his/her body.). Any restraint could limit the ability of the client to maintain balance or protect themselves. Staff persons were to maintain close physical contact and were to be prepared to assist the restrained client. The facility’s Restraint and Seclusion policy stated that a restraint was not the application of a temporary, non-controlling, touch applied to a client when the client was in their crisis cycle to support movement away from a trigger to a safe place or to maintain the safety of the area and everyone around. The VA’s Individual Abuse Prevention Plan (IAPP) specified that mechanical restraints were to be utilized outside of the facility. Facility documentation and CCTV footage provided the following information: · On December 15, 2022, the VA ingested a popsicle stick that another client had not thrown away. The facility contacted the local hospital and was told the VA would require an endoscopy to remove the item. The hospital recommended the VA be transported via ambulance the following day. · On December 16, 2022, an incident command system (ICS; staff persons were called to the unit for support) was initiated by the facility and an ambulance was dispatched to transport the VA to the hospital. The VA was placed into a tear-proof gown, leg shackles, and handcuffs with a “D-belt”. The VA was sitting in the day room area of the unit with P5 and P6. · When the ambulance arrived at the facility it was parked in the security garage. CHCP1 and CHCP2 wheeled a stretcher into the day room area of unit where the VA was present. P2 to P4 were near the doorway where CHCP1 and CHCP2 entered. Approximately 10 to 15 feet away from the doorway, in the center of the unit, the VA was standing between P5 and P6. · CHCP1 and CHCP2 wheeled the stretcher towards the VA and appeared to speak to P2. The VA began walking away from the stretcher, so P5 and P6 physically directed the VA towards the stretcher by each placing their left and right hands near the VA’s elbow area. P3 stood in-front of the VA and appeared to assist with guiding him/her to the stretcher, which was lowered to the floor. P5 and P6 assisted the VA to sit and then lay on the stretcher. P6 placed his/her hand on the VA’s shoulder. · The VA started moving from side-to-side while on the stretcher. P5 was bracing the VA’s legs with his/her hands and P6 was bracing the VA’s upper torso with his/her hands to prevent the VA from rolling off the stretcher. The VA rolled to the side of the stretcher where P5 and P6 were multiple times, nearly falling off, but being prevented by P5 and P6. P2 and CHCP1 were at the head of the stretcher, talking, while the VA was moving on the stretcher. · P5 and P6 moved the VA from the stretcher to the floor. P5 held the VA’s legs and P6 held the VA’s upper body. Once the VA was on the floor, other staff persons assisted with holding the VA. The VA appeared to be struggling as staff persons held the VA’s upper body and legs while on the floor. The VA then began striking his/her head onto the unit floor. P4 immediately handed a foam pad to P6, and s/he placed it under the VA’s head. CHCP1 walked away from the stretcher and made a phone call. CHCP2 was near the head of the stretcher while CHCP1’s back was to the VA and stretcher while making the phone call. · After the VA was restrained on the floor, s/he appeared to become calm. The VA was then assisted to his/her feet by staff persons, and s/he walked over and laid on the stretcher without incident. The VA was secured to the stretcher and brought to the ambulance in the security garage. Law enforcement officers (LEO) arrived at the security garage and appeared to speak with CHCP1 and P3. The VA was transported to the hospital via ambulance. LEO did not investigate the incident. Interviews with the VA, CHCP1, CHCP2, and P1, P2, P3, P4, P5, and P6 provided the following information: · The VA stated when the facility activated an ICS, it “stresses” the VA out, due to the additional amount of staff persons who come to the unit. The VA described the incident as “nothing compared to what most of my incidents are like.” The VA stated s/he was trying to get off the stretcher when s/he rolled around. The VA stated s/he was on the floor for less than one minute. The VA was “sore” from the shackles and handcuffs but was not injured. · CHCP1 stated, “There was no real reason what we should have been requested to come emergent” because the VA did not have any “priority symptoms” though CHCP1 later stated, “It’s kind of subjective.” CHCP1 and CHCP2 described the VA as “cooperative.” CHCP1 stated that P1 to P6 were “hesitant” to provide information and “weren’t telling me what was going on.” · CHCP1 stated the VA told him/her that s/he didn’t want to go to the hospital. CHCP1 stated the VA turned and started slowly walking away from the stretcher. CHCP1 stated the VA was “grabbed” and “thrown onto the stretcher” by P5 and P6. CHCP1 began “announcing” to staff persons, “This is inappropriate.” CHCP1 stated the VA was not trying to hurt him/herself or others. CHCP1 described the force used to put the VA onto the stretcher as “aggressive.” · CHCP1 told P5 and P6 “countless times” to stop holding the VA on the stretcher and called LEO because s/he felt the VA was being “assaulted.” CHCP1 stated the VA “fell” off the stretcher and estimated the distance the VA “fell” was approximately 18 inches. CHCP1 stated the fall was “relatively soft.” CHCP1 stated the VA being “held down” on the stretcher caused the VA to fall onto the floor from the stretcher. While on the floor the VA “appeared distressed” but did not make any indications to CHCP1 or CHCP2 that s/he was in pain. After a few minutes an unknown staff person talked to the VA, and s/he stood up and got on the stretcher. · CHCP2 stated that staff persons were “rude” to CHCP1 because they gave “short answers” when CHCP1 was asking questions about the situation. · CHCP2 stated that the VA “wiggled” and slid off the side of the stretcher and did not “fall hard” when the VA “rolled” off the stretcher to the floor. The VA went to the ground. The VA did not want to be on the stretcher. A staff person (CHCP2 did not know the staff person’s name) was speaking to the VA “very calmly” and was able to convince the VA to stand and sit on the stretcher. · CHCP2 stated that staff persons were not “communicating much” to the VA. It “seemed” like the VA was being held down when it “wasn’t necessary” to hold him/her down because the VA would have “in [his/her] own time,” sat on the stretcher. · P1 stated s/he was in charge of the ICS that was initiated for the VA’s transport to the hospital. P1 had the VA placed in handcuffs, leg shackles, and a D-belt for transport outside the facility. P1 stated the VA’s gait was “physically impeded” and the VA would not be able to take a “normal stride,” while in leg shackles. P1’s goal of P5 and P6 “escorting” the VA to the stretcher was to walk with and physically assist the VA so the VA would not fall. P1 stated when the VA was in mechanical restraints, staff persons were not allowed to let the VA move freely for safety. P1 stated that manual restraint began when the VA became “combative” on the stretcher and was transferred to the floor. P1 talked to the VA, “providing encouragement,” while s/he was on the floor. · P2 stated that the VA had engaged in self-injurious behaviors, including foreign body ingestion. P2 stated when CHCP1 and CHCP2 entered the unit, the VA became upset and did not want to go to the hospital. The VA walked away, and staff persons stepped in front of the VA to direct him/her to the stretcher. · P3 stated the interaction between CHCP1 and himself/herself was “hostile.” P3 stated CHCP1 tried to “take over” and tell staff persons what to do. P3 stated when CHCP1 and CHCP2 arrived, the VA tried to walk back to his/her room. The VA then “begrudgingly” sat on the stretcher. Once on the stretcher the VA “started to buck” and “resist us.” P3 stated staff persons manually restrained the VA while on the stretcher. The VA was then “transitioned” to the floor and manually restrained for two minutes by staff persons. P3 did not see the VA have any marks or bruises and the VA did not state s/he was hurt. P3 stated CHCP1 walked away from the stretcher while staff persons were restraining the VA. · P4 did not have any interactions with CHCP1 or CHCP2 and did not recall the interactions between staff persons and CHCP1 and CHCP2. P4 grabbed knee pads when the VA began hitting his/her head while on the unit floor to place under the VA’s head. · P5 stated when CHCP1 and CHCP2 walked onto the unit the VA attempted to go into his/her room. P5 stated s/he and P6, “initiated an escort” to move and sit the VA on the stretcher. The VA started “thrashing” when on the stretcher simultaneously as CHCP1 was “yelling” at staff persons to let the VA go. P5 and P6 “lowered” the VA to the floor and manually restrained the VA. · P6 stated that s/he “escorted” the VA to the stretcher. When the VA was on the stretcher s/he became “bucky” and the VA was “struggling” and “trying to flop out” of the stretcher. P6 stated that when the VA was on the floor s/he was in a “resting position,” where the VA was on his/her stomach and “pushed off” to his/her side to allow for breathing. P1, P2, P3, P4, P5, and P6, each stated that no staff person used excessive force. P1 to P6 were each trained on the VA’s plans and the policies outlined above. P1 to P6 were each trained on the Maltreatment of Vulnerable Adults Act. Conclusion: Staff persons and facility documentation provided consistent information that on Decmeber 15, 2022, the VA injested a popsicle stick. Staff persons contacted the hospital and were instructed to transport the VA via ambulance the following day. On December 16, 2022, an ICS was initiated and an ambulance was called to the facility. P1 to P6 were part of the ICS on the unit to assist in transporting the VA to the hospital. The VA was placed into mechanical restraints in accordance with the VA’s IAPP. When CHCP1 and CHCP2 arrived at the facility in the security garage, they wheeled a stretcher onto the unit where the VA was waiting, while in mechanical restraints. P5 and P6 were standing on either side of the VA. The VA turned around and attempted to walk away from the stretcher. P5 and P6 “escorted” the VA back to the stretcher. Use of Restraints for Transport Outside the Secure Perimeter policy required staff persons to “maintain close physical contact” and “assist the restrained patient.” P1 stated the VA’s gait was “physically impeded,” while in the mechanical restraints. Staff persons stated that while the VA was on the stretcher s/he began “thrashing” and was unsteady. The VA was assisted to the floor by staff persons and manually restrained by P5 and P6. While on the floor the VA was hitting his/her head on the floor and P4 brought a foam knee pad and placed it under the VA’s head. The VA calmed and was assisted to his/her feet and secured onto the stretcher, brought to the ambulance and transported to the hospital. Although there were concerns that “excessive” force was used during the incident, given that video showed that staff persons intervened as necessary when the VA was not safe on the stretcher, that the VA was not injured, that no staff persons stated anyone used excessive force, and that video footage was consistent with the information provided by P1 - P6, there was not a preponderance of the evidence whether staff persons engaged in conduct that could be reasonable expected to cause physical pain or injury. 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 conducted an internal review and determined the policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: No further action.
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