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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: 1091064-H_CRS (Home and Community-Based Services-Community Residential Setting) 1068173-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) hit a vulnerable adult (VA) while in a facility vehicle. The SP was also observed dropping the VA onto the ground, and the VA crawled into the facility. Date of Incident(s): September 28, 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); 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. 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 November 1, 2023; from documentation at the facility, and law enforcement (LE) records; and through four interviews conducted with a community person (CP), a facility supervisor (P), the VA’s guardian (G), and the SP. The VA was observed at the facility, but was unable to be interviewed as s/he had limited verbal communication skills. During the Site Visit this investigator observed the SP near the VA, and the VA appeared to have a positive interaction with the SP. Facility documentation showed the VA enjoyed using his/her iPad, and interacting with others. The VA liked going out to eat, having staff persons’ full attention, and used a heat pad to relax. The VA “may react negatively” to a tone that was strong/assertive. The VA’s client specific information showed the VA “may not be able to escape, avoid or protect” him/herself from physical abuse. The VA also engaged in self-injurious behavior when s/he was upset, including hitting him/herself in the head. The VA also may “suck” on his/her fingers while agitated. The VA had a difficult time with his/her balance, and had an unsteady gate. The VA used a wheelchair, or staff persons would assist the VA with walking. The VA had difficulty transitioning from activities, and staff persons would prepare the VA for a change in activity. The VA was diagnosed with developmental disabilities. The VA’s Individual Abuse Prevention Plan (IAPP) stated the VA engaged in self-injurious behaviors such as slapping his/her head when s/he was “really upset.” If the VA engaged in the behavior staff persons would “block the slapping.”
The facility was located in a residential area with a business next door, approximately 50-100 feet from the facility. The business had multiple large windows which were in direct view of the facility’s driveway. The CP provided the following information to LE and this investigator: · The CP said s/he was inside the business next door, and had a “clear” view of an incident in the facility driveway on September 28, 2023, around 9 a.m. The CP saw the VA in the facility’s vehicle (passenger seat), and the VA was looking forward out of the front windshield. The CP said it appeared the VA was “just sitting” in the passenger seat, and did not witness the VA hitting anything inside the vehicle. The CP said the SP, who the CP provided a physical description of, sat next to the VA in the driver’s seat and used his/her right hand, closed fist, and hit the VA in his/her shoulder/chest “four or five times” while in the facility vehicle. The CP did not see the SP grab the VA’s hand(s) during the incident, but the VA “leaned away” from the SP during the incident. · After the SP hit the VA the SP exited the vehicle, and went to the passenger side of the vehicle where the VA was sitting. The SP assisted the VA out of the vehicle, but “let” the VA fall to the pavement, and did not assist the VA into the facility. The CP said s/he had previously seen staff persons assist the VA by walking with the VA, or holding the VA’s arms/hands. However, the CP said the VA was “forced to crawl” to the facility’s entry door. · The CP had observed the VA multiple times, but this was the only incident in which s/he witnessed anyone hitting the VA. Th SP said s/he had observed staff persons let the VA fall to the ground “several” times. During those incidents the VA was “forced” to crawl into the house. The CP said s/he had seen this occur ten times during the previous month. · The CP said the first incident where the VA crawled into the facility occurred in approximately July or August 2022. The VA dropped to the ground and the SP did not assist the VA into the house. The VA crawled, but the CP was unsure if the VA needed or wanted assistance. The facility completed an Internal Review which provided the following information:
· The SP said that on the day of the alleged incident, at around noon s/he and the VA had returned to the facility. The VA did not want to get out of the vehicle, and pulled on the seatbelt to remain in the vehicle. The VA was also opening and shutting the glove compartment, and slapping the front dash/airbag area. The SP assisted the VA out of the vehicle, and the VA sat down and did not want to walk inside the facility. The SP proceeded to pick up the VA and carried him/her into the facility. · The VA did not have any marks or bruises that were observed. · The VA was unable to provide information related to the allegation, however the SP and the VA were observed at the facility, and it appeared they enjoyed being around one another. The P provided the following information: · The P said there were no observed injuries to the VA on or around September 28, 2023. The P thought someone may have seen something, but was confused on what they observed or mistakenly thought the VA’s hand was the SP’s. · The P was not at the facility when the incident occurred, but said s/he had worked with the SP “a lot” and was “very confident” the SP would not hit the VA. The P described the SP as “level-headed,” and was “great” with the vulnerable adults at the facility. The P added that s/he did not believe the SP would have the VA crawl from the driveway to the facility. · The P said if there was an incident between the VA and another person, the VA would not want that person around him/her. The P had not observed any change in the interactions between the VA and the SP. · The P was not aware of any other incidents in which any staff person had the VA crawl from the driveway to the facility. The P said the VA had a history of property destruction and hitting the van. The G said s/he had not observed any injuries to the VA, and if the VA did not like something a staff person had done, the VA would be “very reluctant” to go with that staff person. The G had not seen the VA react negatively toward the SP. The SP provided the following information to LE and this investigator: · The SP denied punching or harming the VA during the alleged incident. The SP also denied dropping the VA and having him/her VA crawl from the vehicle into the facility. The SP said s/he had a very close relationship with the VA, and the VA showed affection toward the SP. · The SP heard the incident occurred at 9 a.m., but the SP thought the incident occurred around 11 a.m. There were no other staff persons or vulnerable adults in the vehicle. The SP described the incident and said after the SP and VA arrived back at the facility the VA was upset s/he did not go out to eat and started hitting the dashboard/airbag in the front passenger seat and attempted to bite his/her own hands. During the incident the SP initially attempted to verbally deescalate the VA, but once the VA started attempting to bite his/her hands the SP tried to block the VA from engaging in the self-injurious behavior. The SP said s/he moved the VA’s hands to his/her knees and away from the VA’s mouth. However, the VA continued to engage in the behaviors and continued to hit the inside of the van. The SP exited the vehicle, went to the passenger side, and attempted to assist the VA out of the vehicle. However, the VA did not use the SP’s assistance and slid out of the vehicle seat, and onto the ground. The SP picked the VA up and carried the VA inside the facility at that time. The SP said the incident lasted approximately three minutes, and the VA was not harmed during the incident. · The SP said the VA had a history of property destruction such as throwing his/her eyeglasses or throwing a tablet, and would also attempt to bite his/her own hands. · The SP was not aware of the VA ever crawling on the driveway to enter the facility. · The SP said s/he was not having a “bad day,” and would not “hold anything” against the VA due to his/her behaviors. LE referred charges to the County Attorney, however the County Attorney declined to charge the SP. Conclusion: It was reported that on September 28, 2023, the VA was in the facility vehicle and was hit by the SP, and thereafter the SP dropped the VA, and did not assist the VA into the facility. The VA crawled from the driveway into the facility. The CP said s/he had observed the incident, and saw the SP hit the VA with a closed fist, and the SP allowed the VA to fall to the ground. The CP added the SP did not assist the VA up, and the VA had to crawl to the facility from the driveway. The CP said prior to the incident the VA appeared to be “just sitting” in the passenger seat. The VA was unable to provide any information related to the alleged incident, however the G did not observe any injuries to the VA. The G said the VA would be “very reluctant” to go with that staff persons if an incident like that had happened. The SP denied s/he had hit the VA during the incident, and the VA was engaging in behaviors such as hitting the vehicle’s dashboard, and attempted to bite his/her own hands. The SP said s/he tried to both verbally deescalate the VA and move the VA’s hand away from his/her mouth, but did not physically harm the VA. The SP exited the vehicle and tried to assist the VA into the facility, however the VA slid to the ground, at which time the SP picked the VA up and carried the VA inside the facility. Although the CP had no incentive to provide false information and the SP had reason to minimize his/her actions, given the distance the CP viewed the incident from, that there was no injury to the VA, that the SP provided consistent information to LE and this investigator that s/he did not hit the VA, that information was consistent that the VA’s interactions with the SP would have been affected if the SP hit the VA and they were not and that there was no further information to confirm or dispute either account, there was not a preponderance of the evidence whether the SP engaged in conduct that could reasonably be expected to produce physical pain or emotional distress to the VA or whether the SP failed to provide the VA with reasonable and necessary care and services. It was not determined whether neglect and physical abuse 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; 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 and determined the policies and procedures were adequate and were followed. The facility completed staff person training on allowing the VA time to deescalate prior to transitioning into the facility. There were no previous similar events and additional no corrective action was needed by the program to protect the persons that received services. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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