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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: 1069193-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069140-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) grabbed a vulnerable adult (VA) by the arm and shook the VA. Date of Incident(s): October 7, 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); 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 October 20, 2023; from documentation at the facility; and through four interviews conducted with a facility staff person (P1), a facility supervisor (P2), the VA’s guardian (G), and the SP. This investigator met the VA at the facility but was unable to interview the VA as s/he had limited verbal communication skills. Facility documentation showed the VA enjoyed interacting with people and valued being able to make his/her own choices. The VA liked going out to eat, watching kids, using manipulatives, and using his/her tablet. The VA did not like when other people cried or being in loud environments. The VA went to a day program multiple days a week. The VA lived at the facility for over 20 years and liked his/her bedroom as it allowed him/her to independently access a main living room. The VA was diagnosed with developmental disabilities, spastic cerebral palsy, epilepsy, and other physical health concerns. The VA utilized a wheelchair, a gait trainer, and a gait belt. This investigator completed a tour of the facility and noted there was no direct view from a living room into the VA’s bedroom. The VA’s Coordinated Services and Supports Plan (CSSP) showed the VA had seizures and was at risk of getting hurt during the seizures. The VA’s Positive Support Strategies/Outcomes and Supports showed the VA communicated in one to two word “utterances,” and staff persons were to use verbal and physical cues to assist the VA in completing tasks. The VA’s Individual Abuse Prevention Plan (IAPP) showed the VA was suspectable to physical abuse as s/he did not know what constituted physical abuse due to his/her diagnosis. The VA was unable to inform others if abuse occurred and was limited to “short phrases” in order to communicate. The VA’s Intensive Service Assessment (ISA) provided the following information: · The VA was diagnosed with epilepsy, and cooperated with taking seizure medications which controlled the seizures “relatively well.” The VA “startle[d] easily” which could “trigger a seizure.” Staff persons may hear sounds such as the VA “banging on [his/her] headboard or wall” which could indicate the VA was having a seizure. · The VA was able to redirect his/her behavior “most of the time,” but would be verbally and physically aggressive when s/he needed attention, or to communicate when s/he did not feel well. Staff persons were to redirect the VA with other activities such as using manipulatives, listening to music, or watching movies. If the redirection did not work, staff persons were to give the VA “space to calm down.” The facility's Incident Report, the VA's progress notes written by P1, and an interview with P1 provided the following information: · On October 7, 2023, around 7 p.m., P1 was in the facility living room while the SP was assisting the VA in his/her bedroom. P1 heard the VA become verbally aggressive and started yelling at the SP, and the SP responded by yelling back at the VA, "Stop it, stop it!" and requested the VA stand up “several times.” P1 noted the SP said, “We have to [do] things [the] hard way,” and it seemed to make the VA “fearful,” and “scream” louder. P1 left the living room and walked to the VA’s room, and observed the SP holding the VA’s arms and “shaking” the VA. P1 said the shaking s/he witnessed including the bed frame moving and the VA being shaken to the point his/her butt was moved off the bed. · After observing the incident P1 did not witness any “adverse reaction” from the VA thereafter, and P1 was unsure if the VA was injured during the interaction. P1 said after the alleged incident occurred the SP told P1 the VA was the reason staff persons did not want to work at the facility. · On October 8, 2023, P2 observed light bruising on the VA’s arm. It was unknown if the bruising was related to the incident with the SP, or a result of the VA’s seizure disorder. P2 said the VA had a history of “moving/flailing” his/her arms around and “hitting them on walls, chairs etc.” There was no documentation of the VA having an observed seizure within the previous week of the incident. P2 provided the following information: · P2 said P1 informed him/her of the incident on the evening of October 7, 2023. Thereafter P2 contacted another staff person (P3) regarding the incident. P3 went into the facility on October 7, 2023, and observed the VA. P3 informed P2 s/he did not see any injuries to the VA. · P2 observed the VA the following day and did not observe any injuries such as a handprint or bruising in the form of fingers. However, P2 observed a bruise on the VA’s arm, but it was uncertain if the bruise could be attributed to the incident. P2 said the VA did not have a change in his/her behavior. · P2 had worked with the SP on multiple occasions and did not observe the type of behavior that was reported. P2 added there were no concerns P1 would provide inaccurate information. The G said the facility informed him/her of the alleged incident, and the G did not have any prior concerns with the facility. The SP provided the following information: · The SP said s/he was assisting the VA with his/her bedtime routine, at which time the VA tried to bite him/her. The SP said the attempted biting occurred when the SP was transferring the VA. The SP said s/he told the VA to “stop it, stop it,” and s/he “probably yelled too loud.” The SP said s/he changed how s/he was attempting to transfer/assist the VA and stood behind the VA during the transfer. The SP then attempted to change the VA’s clothing. The SP said it may have appeared like s/he was shaking the VA while changing the VA’s clothing, but the SP denied grabbing the VA by the arm(s) and shaking him/her. · The SP said P1 did not assist with the VA’s bedtime routine and was not in the VA’s bedroom during the alleged incident. The SP said P1 was in the living room with another person receiving services. · The SP did not believe s/he abused or neglected the VA during the interaction. The facility completed an Internal Review which provided consistent information to the information which this investigator obtained. The P, SP1, and SP2 were trained on the facility’s policy and procedures, client specific programming, and the Reporting of Maltreatment of Vulnerable Adults. Conclusion: It was reported that on October 7, 2023, the SP grabbed the VA and shook him/her. P1 said s/he was in the facility living room while the SP was assisting the VA in his/her bedroom. P1 heard the VA become verbally aggressive and started yelling at the SP, and the SP responded by yelling back at the VA, "Stop it, stop it!" and requested the VA stand up “several times.” P1 observed the SP holding the VA’s arms and “shaking.” P1 said due to the shaking the VA’s bed frame was moving and the VA’s butt was moved off the bed. P1 contacted P3, who went to the facility and observed the VA. P3 informed P2 the VA did not have any injuries. P2 observed the VA the next day, October 8, 2023, and although the VA had a bruise, it could not be attributed to the alleged incident. The VA was unable to provide information to this investigator. The SP said s/he was assisting the VA with his/her bedtime routine and the SP yelled “too loud,” when the VA attempted to bite him/her, but denied grabbing and/or shaking the VA. The SP stated that s/he shook the VA while the SP changed the VA’s clothes. P2 said s/he had worked with the SP on multiple occasions and did not observe the type of behavior that was reported, but also stated there were no concerns P1 would provide inaccurate information. Although P1 had no incentive to provide inaccurate information and the SP had reason to minimize his/her actions, the information each provided conflicted regarding whether the SP grabbed and shook the VA. Additionally, a bruise the VA had on his/her arm could not be determined as to have occurred during the incident, during seizure activity, or from a other unknown cause. Given there was no further information to confirm or dispute P1’s or the SP’s account, that the SP was assisting the VA with his/her bedtime routine while having physical contact with the VA, and that the SP reacted to the VA attempting to bite when the SP yelled “too loud,” 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, but not followed. The facility completed re-training with the SP on multiple policy and procedures related to the alleged incident. There were no previous similar events, and the facility decided to not have the SP provide care and services to the VA but remained an employee. There was no additional corrective action completed by the facility to protect the persons that received services. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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