|
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: 1069667-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) hit a vulnerable adult’s (VA’s) mouth and pushed him/her when the VA behaved aggressively. The VA sustained a loose tooth during the incident with the SP. Date of Incident(s): Prior to August 9, 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 28, 2023; from documentation at the facility, law enforcement records, the VA’s medical and dental records; and through interviews conducted with facility staff persons (P2 and the SP). P1 did not complete an interview with this investigator, but s/he provided information in the facility’s Internal Review that was included below. This investigator met the VA, but s/he declined to discuss the incidents. However, the VA provided information in the facility’s Incident Reports and in records from the law enforcement agency, which was included below. Facility documentation showed that the VA was diagnosed with attention deficit hyperactivity disorder, anxiety disorder, and a moderate developmental disability. The VA might have impulsive behaviors and worked on maintaining appropriate boundaries with support from staff persons and family members. When the VA was upset, s/he might destroy his/her property or the property of others, throw items, physically aggress toward staff persons, pin others against a wall, or leave the facility without supervision. Staff persons used verbal de-escalation to calm the VA and worked with him/her to understand his/her behaviors and consequences to them. The VA’s behavior might be volatile, and s/he was quick and opportunistic. Keeping busy and learning about cars was important to the VA. The VA was a hard worker who wanted to get a driver’s license. Facility documentation, the facility’s Internal Review, records from the law enforcement agency, the VA’s medical and dental records, and interviews with this investigator provided the following: · A facility Incident Report showed that shortly before 4 p.m. on August 9, 2023, the VA entered an individual’s (I’s) bedroom at the facility and might have taken some money that belonged to the I. The I became aware that the money was missing, and a law enforcement agency was called. When law enforcement officers (LEOs) arrived, the VA threw items, destroyed facility property, and attempted to leave the facility without supervision. The LEOs took the VA to a hospital for an evaluation, but no one was injured during the incident and the I’s money was located then returned to him/her. · The VA’s medical records showed that s/he was evaluated at the hospital for “aggression” but not admitted. The LEOS brought the VA back to the facility and s/he was to follow up with his/her primary care physician in a week or return to the hospital if necessary. · A second Incident Report showed that at 5:30 p.m. on August 9, 2023, the VA was upset and threw items at the facility including a remote control, a telephone, and toy cars. The VA then entered the kitchen, picked up a kitchen chair and raised it over his/her head, and ran toward P1. The SP stepped between the VA and P1, then pushed the VA to redirect his/her path away from P1. The VA fell and the SP and P1 assisted other individuals who resided at the facility outside and away from the VA. The law enforcement agency was called and LEOs soon arrived. · The SP stated that the second incident began when the VA returned from the hospital after the first incident and went to his/her bedroom to calm. The SP and the VA overheard P1 say, “Why is [the VA] back here? [The VA] should be in jail” and going “on and on” making similar statements and referring to the VA as “dangerous.” P1’s statements increased the VA’s agitation, and s/he became upset, ran past the SP into a wall outside the bedroom, and fell onto the floor, where s/he lay saying “Tell [P1] to stop saying that.” The SP went to the dining room and moved the individuals outside away from the VA, then re-entered the facility. The VA then stood, picked up a wooden dining room chair, raised it over his/her head, and ran “full force” toward P1 to hit him/her with the chair. The SP pushed the VA to the side to redirect his/her momentum, then the VA slid forward and dropped the chair without hitting P1, who quickly went outside with the individuals. The VA cried and said that s/he wanted his/her family member and did not want to go to “jail.” The law enforcement agency and the VA’s family member were called and came to the facility. According to the SP, the VA’s behavior escalated quickly and there was no time to react. · P1 declined to provide information to this investigator, but in the facility’s Internal Review, P1 denied that s/he asked why the VA returned to the facility, said that the VA should be in jail, or described the VA as dangerous. P1 knew that the VA would return to the facility after the first incident, and s/he assumed it might not go well when the VA came back based on how the VA left. Facility supervisory staff persons advised P1 to contact the supervisory team if s/he felt unsafe when working at the facility. · Records from the law enforcement agency showed that LEOs arrived at the facility at 5:32 p.m. LEOs, who were the same LEOs that transported the VA from the hospital to the facility after the first incident, observed that a dining room chair was “flipped over” in the dining room. The SP and P1 were fine, but the VA was in his/her bedroom, and his/her mouth was bleeding. The VA told an LEO that the SP pushed him/her to the ground, and s/he hit his/her head on the floor which caused his/her mouth to bleed. The VA also said that the SP hit him/her but was unable to provide additional information according to the records. The SP told LEOs that prior to attempting to hit P1 with a chair, the VA threw items, punched the wall in his/her bedroom, and hit his/her head against the bedroom wall. When the VA exited his/her bedroom, s/he obtained a chair, and ran toward P1, so the SP pushed the VA away from P1, which caused the VA to fall and hit his/her face. There were drops of blood on the floor where the incident happened. One of the VA’s teeth was loose, and s/he was transported by ambulance to the emergency department of the hospital. The law enforcement agency took no further action. · The VA’s medical records showed that s/he was evaluated at the emergency department of the hospital for a loose left front tooth but did not require immediate treatment. The VA had minor facial injuries and some dried blood on his/her lower lip but had no significant injury to the area. It was recommended that the VA be evaluated by a dentist the next day and s/he was instructed to eat soft foods to prevent further disruption of the tooth. The VA was discharged to a family member’s residence, and s/he planned to spend a few days there with the family member who agreed to take the VA to a dentist. · The VA’s dental records showed that on August 25, 2023, an “attendant” accompanied the VA to a dental clinic. X-rays were taken of the VA’s teeth and showed they were “within normal limits” with no issues were noted. A cleaning for the VA’s teeth was scheduled for September of 2023, and the VA was advised to watch for changes over time in the color of his/her front teeth then to return to the clinic if necessary. · P2, who was a supervisory staff person, said that when s/he initially became aware of the incident, no concerns were raised that a staff person hit the VA. Later P2 learned that the VA’s mouth was injured, and s/he asked more questions about the incidents. The SP and P1 provided mostly consistent accounts of the incidents with the VA to P2, and s/he thought they were honest with him/her about the incidents. The VA was a “bigger” individual and the SP and P1 were scared that the VA might hit P1 with the chair and seriously injure or kill him/her. When the VA ran at P1, P1 froze, shook, and cried. The SP wanted to change the VA’s path, so s/he pushed the VA to redirect his/her course and P1 was traumatized by the second incident. P2 thought that the VA was likely injured when s/he fell and did not think that the SP hit the VA’s face. It was not uncommon for the VA to have explosive aggressive behaviors that escalated quickly, but for the VA, when the behavior was over, it was “done,” and s/he returned to his/her baseline behavior with no issues carrying over from the behavior. P2 had no concerns regarding the SP’s work at the facility. The facility’s Emergency Use of Manual Restraints Policy stated that staff persons could use manual restraints when a person posed an imminent risk of physical harm to him/herself, or others and it was the least restrictive intervention to achieve safety. Physical contact could be used to block or redirect a person’s limbs or body without holding the person or limiting the person’s movement to interrupt the person’s behavior that might result in an injury to him/herself or others with less than 60 seconds of physical contact by staff persons or to redirect a person’s behavior when the behavior does not pose a serious threat to the person or others and the behavior was effectively redirected with less than 60 seconds of physical contact from staff persons. Personnel files showed that the facility trained its staff persons on the Reporting of Maltreatment of Vulnerable Adults Act, and the facility’s policies and procedures, prior to August of 2023. Relevant Statues: Minnesota Statutes, chapter 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s rights included the right be treated with courtesy and respect. Conclusion: Information was consistent from P1, P2, the SP, and records from a law enforcement agency that on August 9, 2023, there were two incidents that involved the VA. During the first incident, the VA was taken by LEOs to the emergency department of a hospital for an evaluation but was not admitted and the LEOs brought the VA back to the facility. According to the SP, the second incident began when P1 was overheard questioning why the VA was permitted to return to the facility after the first incident and referring to the VA as “dangerous.” The VA’s agitation increased, s/he became upset, ran past the SP into a wall, and fell. The VA asked the SP to “Tell [P1] to stop saying that.” The SP assisted two individuals outside, then re-entered the facility where s/he saw the VA pick up a dining room chair, raise it over his/her head, and run with force toward P1. The SP pushed the VA and redirected him/her to the side, causing the VA to slide forward and drop the chair. The VA cried, asked for a family member, and said that s/he did not want to go to “jail.” The law enforcement agency and one of the VA’s family members were called to come to the facility. P2 said that the SP and P1 gave mostly consistent accounts of the incidents to him/her, and s/he did not think that the SP hit the VA but pushed the VA to redirect his/her path. P2 thought that the VA was probably injured when s/he fell and there had been no previous concerns regarding the SP’s work at the facility. Medical records showed that the VA had a loose left front tooth, minor facial injuries, and dried blood on his/her lower lip, but no injuries required immediate treatment. The VA was evaluated by a dentist and his/her teeth were within normal limits. The facility’s Emergency Use of Manual Restraints Policy stated that staff persons were permitted to use less than 60 seconds of physical contact to block/redirect a person’s limbs or body without holding the person or limiting the person’s movement to interrupt the person’s behavior. P1 denied that s/he was vocal about the VA returning to the facility or said that the VA was dangerous, but the SP said that s/he and the VA heard P1 make these statements, which caused the VA to become more upset and agitated. Having a staff person question whether the VA should be at the facility and say that the VA should be in jail was not consistent with the role of a professional caregiver in a DHS licensed facility and was a violation of the facility’s policies and procedures and of Minnesota Statutes, chapter 245D.04, but did not meet the criteria to be determined as maltreatment. Although the VA’s tooth was temporarily loosened during an incident at the facility, given that the VA was agitated when the incident occurred, was actively engaged in physically aggressive behavior, had fallen on his/her own prior to the incident, and that information was consistent that the SP used brief physical contact to redirect the VA’s path, there was not a preponderance of the evidence whether the VA’s injury was sustained by any other means than accidental. 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 for each incident which determined that its policies and procedures were adequate and were followed when staff persons worked with the VA. On September 12, 2023, P2 retrained the SP and P1 on the Reporting of Maltreatment of Vulnerable Adults Act, De-escalation techniques, and the Positive Supports Rule Core training. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action, the facility was not issued a correction order for the violation outlined in this report.
|
