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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: 1070393-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) pinched and yelled at a vulnerable adult (VA). There were also additional concerns that the VA had unexplained bruising. Date of Incident(s): July 20, 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 16, 2023; from documentation at the facility and through nine interviews conducted with one administrative person (P6), one supervisory staff person (P5), four facility staff persons (P1 – P4), another client (C) who also lived at the facility, the VA’s guardian (G), and the SP. This investigator met the VA, but the VA was unable to provide information due to his/her diagnoses. The VA’s file stated that s/he enjoyed music, dancing, watching movies, doing puzzles, coloring, painting, crafting, and baking/cooking. The VA was diagnosed with an intellectual disability and osteoporosis. The VA’s file stated that staff persons noticed bruises on the VA’s legs and at times on his/her arms, however, the VA also pinched him/herself. The VA’s filed also stated that s/he engaged in pinching and aggression when a person entered his/her personal space. When this occurred, staff persons were to ask the VA what s/he needed. In a “firm” voice staff persons should tell the VA that they want to help him/her but could not do so if s/he was kicking, pinching, or hurting others. Staff persons were to offer the VA positive redirections to a quiet area where the VA was able to “self-calm.” P4 provided the following information: · Sometime around March 2023, P4 first noticed bruises on the back of the VA’s arms/forearms that looked like “prints.” P4 saw the bruises “several times” between March and June 2023 and said they would go away and then come back. P4 mentioned the information to P3 and another unnamed staff person but did not tell any supervisory staff persons because P4 thought no one would believe him/her that the bruises could have come from staff persons. P4 “thought” s/he documented the bruises did not remember if s/he actually did so. · Sometime in March 2023, P5 trained P4 on the VA’s shower routine and P4 noticed that P5 touched the VA’s arms, and was a "little too aggressive" or "rough" with the VA. The VA’s response to P5 was making “noises” and P4 could tell the VA was “frustrated” and “irritated” by P5’s approach. P4 said that it was unnecessary for staff persons to touch/have physical contact with the VA during his/her shower routine and that when P4 helped the VA with his/her showers, the VA got him/herself into the shower. · P4 did not know where the bruises came from but suspected that they maybe came from P5 due what s/he witnessed as stated above. P1 provided the following information: · On July 20, 2023, around 4 p.m., s/he and the SP were in the living room at the facility. The SP was helping the C with his/her tube feeding/medications and seemed frustrated/struggling with it. The VA was also in the living room sitting in a chair. “For whatever reason,” the VA got up out of his/her chair and pinched the SP on the SP’s left arm. The SP turned around, seemed to “get very mad quickly,” and “seemed” to have “grabbed” the VA and “pinched” the VA with the SP’s “whole hand” on the VA’s arm. The VA then sat back down in the chair “as if nothing happened.” The SP went back to doing the C’s medications. · About five to ten minutes later, the VA got out of the chair and pinched the SP again on the SP’s arm. The SP “got mad” and did the same type of “pinch” to the VA again. However, there was an “appearance of more anger,” and it was a “harder pinch/grab.” After that, the VA again did not respond and went back to sitting in the chair. P1 told the SP that s/he was “out of line” and “can’t do that to [the VA].” The SP replied that if s/he wanted P1’s advice that s/he would have asked for it and that P1 was not there long enough to “earn [his/her] stripes.” P1 said that it was “not right,” and the SP said that s/he had to “reprimand” the VA and that when P1 was “older” and “wiser” s/he would understand. · The C was also in the living room at the time of the incident, but P1 was unsure of the C’s ability to provide accurate information was. P1 said that s/he did not have anything personally against the SP, but felt it was his/her job to protect the clients. P1 did not hear any staff persons at the facility yell at any of the clients and the SP did not yell at the VA during the above incident. P1 stated that s/he did not think there was any injury on the VA’s arm from the SP’s pinching/grabbing the VA and did not think the VA obtained any “bruises” or “anything.” · P1 helped the VA shower on a regular basis and did not see any “marks” on the VA after the incident. P1 said that the VA bruised “easily.” The C said that s/he did not hear any staff persons yell at any clients or pinch any clients at the facility. P2 provided the following information: · The SP told P2 that s/he, P1, the VA, and the C were in the living room and as the SP was setting up the C’s feeding tube, the VA pinched the SP. Instead of P1 helping the SP, P1 “yelled” at the SP because the SP “sternly” told the VA, “Don’t do that.” P1 did not think that was how staff persons were supposed to talk to the VA. P2 stated that the G told staff persons that when the VA pinched, staff persons were supposed to “raise their voice” at the VA but “not yell”. The SP also told P2 that the s/he told P1 s/he was the “senior” staff person and that P1 was supposed to listen to him/her when it came to the clients and if the SP wanted P1’s opinion s/he would have asked for it. · P2 was at the facility during the incident but was not in the living room and did not hear anything. P2 also said if there was yelling s/he would have been able to hear it. The SP told P2 that P1 thought the SP pinched the VA back during the incident, but the SP denied pinching the VA. P2 said there were interpersonal conflicts between P1 and the SP and that P1 was “targeting” the SP. Prior to the incident, on multiple occasions, the SP “called out” P1 for “being lazy” and P1 did not like that the SP told him/her that s/he was doing cares incorrectly. P2 had no concerns regarding the SP’s interactions. · The VA bruised easily due to his/her diagnoses and P2 noticed small bruises on the VA’s arms since s/he started working with the VA. P2 thought the bruises were from the VA bumping into things because P2 noticed that the VA got up during the night for water and did not turn on a light so could have easily run into something. P2 did not think the bruises came from staff persons. · Due to the C’s diagnoses, the C was hard to understand and P2 was unsure if the C would be able to provide accurate information because sometimes s/he got “confused.” P3 said that the VA had a tendency to pinch staff persons if they got too close to him/her and the VA had pinched multiple staff persons including the SP several times. When that happened, the SP’s general response to the VA was “stern” and s/he told the VA not to do that. P3 was told by the G that it was okay to be “stern” with the VA but in a “respectful manner.” P3 described “stern” as more like telling the VA it was not okay and “we don’t do that here.” P3 never heard any staff persons yell at the VA and had no concerns with how staff persons interacted with the VA. P3 never saw any staff persons pinch the VA but heard from P1 that the SP pinched the VA. P3 said there was no interpersonal conflict between P1 and the SP and P3 had no concerns with either of them. P3 was not aware of the VA having any self-injurious behaviors but said that the VA bruised easily and at some point, P3 saw bruises on the VA’s kneecaps and legs. P3 did not know where those bruises came from but said that when the VA went to use the bathroom s/he leaned up against a railing. P3 was not concerned that the bruises came from staff persons. P5 provided the following information: · P1 told P5 that s/he saw the SP pinch the VA the day the day prior. P5 talked to the SP about it and the SP’s description of the incident was different from P1’s with the exception of the SP and P1 arguing. The SP denied pinching the VA. P5 did not know why P1 would have said the SP pinched the VA. The G told staff persons they needed to be “stern” with the VA and tell the VA, “That’s not nice,” and were to be “direct” with the VA. P5 said the VA bruised easily but when s/he looked the day after the incident, P5 did not see any bruises. The SP and P1 had a little bit of interpersonal conflict but P5 did not have any concerns with P1 or the SP and said they were both “great” with the clients. P5 never heard any staff persons yell at clients. · The VA was diagnosed with osteoporosis and bruised easily. The VA moved into the facility the middle of March 2023, and since then, P5 noticed bruises on the VA’s arms a “few times,” but “not very often.” P5 noticed the bruises in different places on the VA’s arms and legs. The bruises were “fairly small” such as the size of a penny or smaller. P5 said they did not look like fingerprints and had no concerns that they came from staff persons. The bruises could have been accidentally caused from the VA “plopp[ing] down” on a recliner or when s/he walked would “swaying back and forth” and hit a doorway wall going from the bathroom or to his/her bedroom. · P5 said that staff persons did not need to physically assist the VA when getting into a shower chair. P5 did not think there was ever a time that staff persons needed to have physical contact or hold the VA’s arms when helping him/her shower except for helping wash the VA’s arms with a washcloth. P5 never saw staff persons be rough with the VA and P5 denied being rough with the VA. P6 said that when s/he talked to P5 about P1 saying s/he saw the SP pinch the VA, P5 told P6 that s/he “fully” believed the incident did not occur because P5 had no concerns with the SP and was “really confidant” in the SP. P6 talked to the SP, and the SP told P6 about the interpersonal conflicts between him/her and P1. The SP denied pinching the VA and said that s/he would never pinch or harm any clients. P6 was at the facility two different times after being told what P1 saw and P6 did not see any bruises on the VA. P6 said that sometime in March 2023, the VA had an intake meeting, and it was brought up that the VA bruised easily. At that time, the VA was also recovering from an ankle injury and the VA’s balance was not “perfect” and s/he used a walker. The G said that the VA moved into the facility around March 2023, and s/he had no concerns with the facility and was “thrilled” that the VA was living there. The VA bruised easily, had severe osteoporosis, and was recovering from a previous injury. The VA had a history of pinching persons and could be “overstimulated” if the environment was too loud or persons stood too close to the VA. The G said that if the VA pinched a staff person, the staff person should respond in a “firm, but gentle” way because the VA did not respond well to “frustration,” “irritation,” or “impatience.” The G also said a stern voice could be used but that did not mean to be “loud” or “disrespectful.” However, the main way to address the VA potentially pinching someone was “prevention” by decreasing the stimulation. The SP said that on August 14, 2023, s/he was at a staff meeting and became aware of “maltreatment complaints” and that it was “apparent” some of the complaints were “made against” the SP. The SP heard that P1 said s/he saw the SP pinch the VA on an unknown date, three to four weeks prior to August 16, 2023. The SP stated that during the time of the alleged incident, s/he was in the living room with the C, the VA and P1, working on the C’s food bag for ten to fifteen minutes. While the SP was working on the C’s feeding, the VA was sitting behind the SP in a chair and the SP’s back was to the VA. The VA did not like the noise the C’s bag/pump made and at some point, the VA got out of his/her chair and pinched the SP’s arm. The SP turned and said to the VA, “Don’t do that.” The SP “raised” his/her voice “a little bit” but had been told by the G to give the VA an “oral reprimand” when the VA pinched staff persons. P1 “snapped” at the SP and said, “Don’t respond like that.” The SP then “snapped back” at P1 and said that the G said to respond that way to the VA. The SP said there was some tension and interpersonal conflicts between him/her and P1 because the SP “reprimanded” P1 for his/her job performance and P1 did not like to hear that from the SP. The SP denied any physical contact with the VA including pinching the VA and denied yelling at the VA. The SP said the C was hard to understand and would answer yes or no questions but was not able to accurately report information. P1-P3, P5, and the SP were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Although P4 had concerns that the VA had unexplained bruising and thought that maybe the bruises were caused by P5 or a staff person, given that no other staff persons had concerns that the VA’s infrequent, unexplained bruises came from staff persons; that the VA bruised easily and may have accidently bumped into something that caused the bruises; and that P5 denied being “rough” with the VA or having physical contact with the VA unless helping him/her wash his/her arms with a washcloth when showering, there was not a preponderance of the evidence whether the VA’s bruises caused by any staff persons by any means other than accidental. It was not determined whether physical abuse occurred (Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult.) Although P1 said that on July 20, 2023, s/he saw the SP pinch/grab the VA two different times as the SP was working with the C’s feeding, given that there was no information provided that the VA sustained any injury or bruises, that no other staff persons had concerns with the SP or saw the SP pinch/grab the VA, that P1 and the SP had interpersonal conflict, that the SP denied pinching or yelling at the VA, and that according to P1 the VA had no reaction, there was not a preponderance of the evidence whether the SP pinched the VA . In addition, although there was a concern that the SP yelled at the VA, information from all sources was consistent that staff persons needed to speak “firmly” to the VA and there was no information provided that the SP or any other staff person spoke to the VA in a manner that could reasonably be expected to produce emotional distress. It was not determined whether emotional or physical abuse occurred (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.) Action Taken by Facility: The facility completed an Internal Review and determined that their policies and procedures were adequate and followed, but there was a need for additional staff training to review the VA’s behavior support plan and company policies for reporting incidents. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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