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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: 1069775-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: There were multiple concerns with a staff person’s (SP’s) interactions with a vulnerable adult (VA). This included that the SP yelled at the VA and attempted to hit the VA. Date of Incident(s): Ongoing and prior to August 30, 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 21, 2023; from documentation at the facility; and through eight interviews conducted with the VA, four facility staff persons (the SP, P1, P2, and P3), a supervisory staff person (P4), and the VA’s guardian’s (G1 and G2) who were also the VA’s family members. A supervisory staff person (P5) and this investigator also communicated via email and that information is below. Additionally, P3 had to leave prior to the completion of the interview and this investigator and P3 discussed finishing the interview at a later date. However, when this investigator called P3 to complete the interview, P3 did not respond to this investigators attempts. P1 also said that s/he was going to call this investigator for follow up of information but P1 did not do so. Attempts were also made via phone and U.S. mail to contact and interview the VA’s guardian (G3), who was also the VA’s family member, but the attempts were unsuccessful. The facility had three clients, including the VA. The facility was single staffed and there were two shifts. This included a staff person who worked from 8 a.m. to 6 p.m. and a staff person who worked from 6 p.m. to 8 a.m. The VA’s plans including his/her Community Support Plan, Support Plan Addendum Intensive Support Services, Self-Management Assessment, and Individual Abuse Prevention Plan provided the following information: · The VA was diagnosed with depressive disorder, anxiety disorder, and impulse control. The VA enjoyed spending time with his/her family members, playing bingo, and going out to eat. · The VA liked living at the facility and wanted to be as “independent as possible.” The VA’s family members, including G1, G2, and G3 were “very involved” in the VA’s life. · As of 2023, the VA’s mobility had “declined” over the past couple of years so the VA used a walker at the facility and a wheelchair in the community. Staff persons were “aware” that the VA may fall and were to walk next to the VA to “ensure [s/he] was safe.” · The VA had hearing aids that s/he chose not to wear at times and staff persons were to encourage the VA to wear them. · The VA had a history of “feeling” that someone had taken his/her items. The VA may yell or swear at others when upset and staff persons were to “redirect” the VA to a positive behavior, talk calmy to the VA, and redirect the VA to another activity. It was “important” that the VA have staff persons who were familiar with him/her and able to help calm the VA when upset. The VA could also call his/her family members, including G1, G2, and G3 when “upset” and staff persons were to assist the VA with this. The VA had a history of “negative talk” including “self-discipline” and a history of crying. · The VA had a history of being physically abused and at times, the VA may talk about things that happened in the past. Staff persons were to “report,” including to supervisory staff persons, if they suspected the VA was being abused. P1 and an incident report dated July 31, 2023, provided the following information: · On July 31, 2023, P1 told P5 that the VA had his/her thumb in his/her mouth and the SP “raised [his/her] hand to [the VA].” P1 then stood between the SP and the VA and stopped the SP from hitting the VA. The SP then “started laughing” and walked away. · On July 31, 2023, P1 also observed the VA stating, “Please don’t hit me.” The VA then “ducked” his/her head as if “dodging” physical assaults. P1 “believed” that the VA was talking to the SP, even though the SP was not in the room. Additionally, the VA often cried in his/her sleep “begging not to be hit.” · Additionally, when P1 came in for his/her shifts, P1 saw the SP “constantly” yell and scream at the VA, including to “grow up.” This included when the VA needed assistance in the bathroom. The SP also told the VA to “knock it off” or that the VA would not be able talk to his/her family members. The SP said that the “only reason” the VA was at the facility was for the “money” and that otherwise, the VA would be in a nursing home. The SP told the VA that s/he “did not belong” at the facility and “belonged” in a nursing home and would “ensure that happened.” When the SP did these things, the VA normally put his/her head down or started crying. The VA also told the SP that s/he would “report” him/her and that the SP was “taking away [his/her] rights.” · The SP would also not let the VA sleep in (which the VA could do) and the SP would “run” into the VA’s room and “scream and yell” at the VA and “rip” blankets off the VA. · The SP also told P1 that s/he had not changed the VA’s adult undergarment “all day” and when P1 changed the VA’s adult undergarment, it would be “soaking wet” and have fecal matter on it. · The VA also only fell on the SP’s shifts. The VA had a history of falling but it was “almost every day” with the SP. The SP told P1 that the VA fell when trying to get out of his/her recliner. The SP also said that the VA fell trying to walk from his/her chair to the dining room or trying to lay in bed. Staff persons typically followed the VA so s/he did not fall. P1 had “no idea” if the VA required medical attention for the falls. However, the VA wanted to go to the hospital but the SP would not let him/her go. The SP thought it was “funny” that the VA fell. · The SP had also taken the facility medication keys and the keys to the client’s bedrooms “home by accident.” Another staff person told P1 that the SP was starting to get “Alzheimer’s.” The SP had recently begun “forgetting [things] a lot.” · The SP also did not provide food choices for the clients, including the VA. The SP worked the day shift and when P1 came in for the overnight shift, the SP told P1 that s/he “forgot” to feed the client’s lunch and did not give them snacks. P1 did not know if the SP did this due to being “mad” at the clients or forgetting due to Alzheimer’s. P1 had “no idea” if there was any impact to the clients not eating, such as weight loss. · At some point, the VA also got new clothes and the VA realized they were missing. Later, the SP told P1 that s/he “got a free pair of leggings.” P1 asked the SP where s/he got them from and the SP told P1 that s/he “could not tell [P1] that information.” However, P1 said that the SP did not typically wear leggings and “only wore jeans.” · The VA said that at some point, a family member also “abused” him/her (Note: G1 and G2 said that was “false” regarding the family member and that the concern had been previously investigated) which P1 said was why the VA “attached” to the SP. Because of this, P1 thought that the VA may not provide information about the SP as the VA was trying to “protect” the SP. · P1 said that s/he saw the concerns around May 2023, when P1 began working at the facility. P1 did not know specific dates of the concerns but said that it was “constantly.” P1 was initially “scared” to say anything as the SP said that s/he would “make sure” P1 got “fired.” P3 had also observed some of the concerns. · At some point, the SP wanted to “sue” the facility and the SP “wrote everything down” about staff persons, including P1. The SP said s/he wanted to “sue” because s/he was “forced” to work including when s/he was sick. · Around August 2023, the SP stopped working at the facility. After the SP stopped working, “everyone in the office” began “targeting” P1 and treating P1 “badly” due to P1 making them aware of the concerns. Additionally, around this time, P2 also began yelling at the VA including to “close [his/her] mouth” and to “shut up.” P2 told the VA that s/he was the “reason” that the clients could not go on outings. (Note: There was no additional information that P2 did these things). · Staff persons were trained to treat the clients with “respect.” The VA said that s/he “liked” staff persons including the SP and that the SP was “funny.” The SP no longer worked at the facility and the VA “missed” the SP. The VA said that no staff person hit him/her. The VA said that if s/he wanted to call his/her family members, that s/he was able to do so. No staff person ever said that s/he could not talk to his/her family members. The VA said that no staff person yelled at him/her. The VA then said that there was a “tunnel underground” and began talking to this investigator about cartoon characters. P2 provided the following information: · P2 did not typically work with the SP. However, in approximately August 2022, when the SP was training P2, the SP was “very loud,” including “screaming,” at the VA. The SP was a “little hard of hearing” but was “yelling” which was “uncalled for. When this investigator asked how loud the SP was on a scale of one to ten, with ten being the loudest, P2 said that the SP was “way beyond a ten.” This included that the SP told the VA that the VA “had to do [certain things]” on his/her own, although P2 said that the VA typically needed a “little hands on” assistance with those things. The VA put his/her “head down” when the SP yelled at him/her. Additionally, at some point, the VA was talking and the SP told the VA, “That’s naughty talk” and to “shut up.” The VA was “minding [his/her] own business” and P2 told the SP that the VA “did not ask anything wrong.” P2 was “scared” when s/he heard the SP speak in that manner. P2 also said that s/he was “getting a headache” and became “physically sick” and wanted to quit. However, P4 then began training P2 who was the “total opposite” of the SP. Staff persons were not trained to yell at the VA. · P2 was not aware of the SP yelling at the other clients but said that they were not typically at the facility when P2 worked. · Another time, P2 was working but the SP came in on his/her day off. P2 told the SP that s/he had “something special” for the clients, including a snack but the SP told P2 that they could not have a snack. P2 then reminded the SP that it was P2’s shift and that the SP trained P2 that the clients were to have a snack. · The VA also said that staff persons, including P1 and P2, did not give him/her water but P2 said that s/he “did not know what [the VA] was talking about as [staff persons] gave [the VA] water all day long.” The VA also said that staff persons did not give him/her food but P2 said that staff persons gave the VA food. · At times when the SP was not at the facility, the VA said “[name of SP] stop it.” The VA also “acted like [s/he] was [the SP]” and the VA would tell him/herself to “knock it off” and to “stop that.” When the VA was “agitated,” s/he had a history of talking to him/herself. · P2 was not aware of the SP hitting the VA. However, the VA said “random” things such as that someone “just hit me” but when P2 asked who did that, the VA “did not answer.” · P1 and P3 each told P2 that the SP would not let the VA call his/her family but P2 had not seen that. P1 and P3 would each provide accurate information and there was no reason not to believe what they said. · The VA also asked if s/he were “going to a home?” P2 asked the VA who said that to him/her but the VA “would never say.” P2 was not aware of the SP calling the VA any names. · The VA walked independently on his/her own but used a walker. The SP told P2 that the VA fell often but P2 “did not understand how.” P2 was only aware of the VA “sliding” off a recliner chair. When that occurred, P2 had to call someone to help pick the VA up. P2 was not aware of the SP refusing medical attention for the VA. · Because of these concerns, the SP no longer worked at the facility. The VA talked about how s/he “missed” the SP and that the SP was his/her “favorite.” Because of this, P2 did not know if the VA would provide accurate information about the SP. According to P2, since the SP stopped working at the facility, it was “calm.” P3 provided the following information: · P3 began working at the facility in approximately May 2023. The SP trained P1 and P3 at the same time and the SP was “all over the place.” This included that there were “pills” “all over the place” and the SP’s training was “confusing.” The SP also “lost” facility keys. · The SP also “yelled” at the VA, including “screaming” from the kitchen to the living room to “knock it off” or “turn off the TV.” When the SP did this, the VA put his/her head “down.” The SP told the VA to “keep it up” and that the VA would be “switched to a nursing home” which “shocked” P3. The VA said that s/he would “change” and that s/he “did not want to go.” · The SP also used to “hurry up” to get the clients to bed and woke them at 5 a.m. The SP went into the VA’s bedroom and “ripped” off his/her blankets when the VA did want to get up. P3 said that the VA did not need to get out of bed but the SP said the VA needed to so s/he did not get bed sores. However, the VA’s family member said if the VA wanted to sleep in, to let the VA sleep in as long as the VA did not have any appointments. · P3 had not seen the SP hit the VA. However, when the VA was “dreaming” at night, s/he said, “don’t hit me” but when P3 went into the VA’s bedroom to check on the VA, the VA was asleep and “snoring.” · On one occasion in June 2023, the VA was “screaming” and P3 asked the SP “what was going on.” The SP said that the VA needed to “calm down” before s/he “called anyone.” Staff persons were not trained to do that. P4 and an untitled document from P4 provided the following information: · On July 31, 2023, P1 and P3 told P4 about “issues” at the facility. This included that the SP was “yelling” and “screaming” at the clients. Additionally, at some point P1 told P4 that s/he had to “intervene” because s/he “thought” that the SP was going to “hit” the VA but P1 “stepped in” prior to the SP doing so. P1 also told P4 that the SP was “upset” that the clients were still in bed when s/he came in the mornings and wanted the clients to get “up and ready for the day.” The SP would “pull” or “yank” their blankets off and “tell them to get up.” The SP also “banged” on the client’s bedroom doors when it was time to get up. P1 also said that when the SP was not at the facility, the VA stated that s/he would “be good [name of SP] tomorrow. Please don’t hit me.” The clients also typically had snack before bed and the SP told the clients that they did not need a snack as they “just ate supper.” · Additionally, P1 told P4 that the SP was “forgetting things” such as “losing” facility keys which were later found in the refrigerator or taking them home with him/her and “forgetting” to feed the client’s lunch. The SP also made the “same meal [burgers]” for “four days straight.” The SP was also “forgetting” who P1 was. At some point, the SP also “blocked the door” so P1 could not leave after his/her shift until one of the clients was awake and showered. · P4 had worked with the SP for approximately seven and a half years and “never saw [the SP] abuse” any clients, including hitting the VA. The SP was typically “pretty calm.” However, the SP would “encourage” the clients by reminding them that their “doctors” wanted them to do something. Additionally, P4 had “never” seen the SP “upset” that the clients were in bed. P4 heard the SP “raise” his/her voice but said that the SP was “hard of hearing” and wore a hearing aid so “talked louder.” However, P4 did not hear the SP “scream.” · P4 was not aware of the SP refusing to seek medical attention for the VA. At some point, the VA fell twice in the same day but that was due to the VA having Ativan prior to a dental appointment, which made the VA “tired and weak” and which staff persons no longer gave to the VA. · Although P4 did not have any concerns with the SP’s interactions with the clients, recently, the SP began to “struggle” with documentation and logging in to enter his/her time entry. The SP was not able to find his/her “password” to login and was “getting upset” including needing his/her “shoebox” that contained his/her “passwords.” The SP also showed P4 a sheet of paper with the “same password scribbled out roughly 20 times.” Additionally, the SP stayed at the facility later than scheduled to complete documentation. The SP was acting “a little odd.” P4 was not aware of the SP having any medical diagnoses including dementia or Alzheimer’s. · The VA “cared” about the SP and after the SP stopped working at the facility due to the investigation, the VA asked about the SP and stated that s/he wanted the SP to continue working there. The VA would tell P4 if s/he did not like a staff person and the VA had not done so. · P4 had not heard the VA talking in his/her sleep. However, there was one occasion where the VA awoke at 2 a.m. and thought it was time to get up but then went back to bed when P4 told him/her it was 2 a.m. Additionally, the VA had a bear from a family member and if s/he could not find that during the night, the VA would ask. · P4 said that P1 had a history of providing inaccurate information. This included that on August 21, 2023, P1 called P4 stating that the VA was “screaming” and refusing to get out of bed, which the VA had a history of doing, and wanted to sleep in. P4 asked to talk to the VA and when P1 went to get the VA, there was “silence” on the phone and P4 did not hear the VA “screaming.” Additionally, when P4 spoke to the VA, the VA was “chipper.” · P1 also discussed recent financial concerns such as “losing” his/her home and needing as “many hours” as s/he could. · The facility was typically single staffed. P2 and the SP worked the “opposite schedule” so did not “really cross paths.” However, P4 was not aware of any reason why P2 or P3 would provide inaccurate information. P4 was not aware of staff persons being afraid to report anything and said that staff persons, including P1 and P3, told him/her a “lot of things.” · Staff persons were trained to talk to the VA in a “calm voice” and “reassure” the VA that they were there to help the VA. It would not be appropriate to yell at a client, including the VA. Staff persons were not trained to withhold food from clients or phone calls. P5 and the Internal Review completed by P5 provided the following information: · On July 31, 2023, P1 told P5 about the concerns with the SP. On August 30, 2023, P1 also made the “exact same report” regarding concerns about P2. However, when P5 asked P1 for additional information regarding P2, P1 said that s/he “guessed [s/he] did not know exactly what happened.” P5 said that P2 did not work when P1 said the concerns happened. P1 then “quit.” P5 “found it very interesting that [P1] said the exact same things [about P2] yet could not elaborate or clarify.” Additionally, P1 and P2 “never” worked at the same time and no other staff person had concerns with P2. · The VA said that at some point, the SP told him/her to “get out of bed before I call your [family members].” The VA also told P5 that the SP yelled at the VA a “little bit.” That made the VA feel “not very happy.” The VA denied that any staff person tried to hit him/her. The VA ate snacks and his/her meals each day. · One of the clients (who was not named) denied that any staff person yelled at the clients and said that s/he “did not know” if any staff person was “mean” to the VA. When another client was asked if anyone ever yelled at him/her, s/he said, “yes,” but was “unable” to say who. · The VA had a history of being abused at a prior facility and would “mix up” information from the “past and present.” · The SP did not typically work with P1, P2, or P3 as the facility was typically single staffed. · P4 knew the clients, including the VA, “way longer” than any other staff persons. The SP provided the following information: · The SP described his/her interactions with the VA as “pretty good” and said that s/he was a “seasoned staff.” The SP worked at the facility for “over” 20 years and was not aware of any prior concerns with his/her interactions with the clients. · The VA had a history of “screaming a lot” and wanting “all the attention” from staff persons. The VA had “declined over the years” and was starting to become “confused.” This included that the VA had a history of yelling and screaming in his/her sleep. The VA also talked in his/her sleep and was “confused.” · The VA hit staff persons, but the SP denied hitting the VA. When the VA hit the SP, the SP asked the VA why s/he did so. · The VA had a history of falling and being “checked out” by medical staff with no issues. Two of the times the VA fell, s/he was taking Ativan due to the dentist. Because of the VA’s history of falling, the SP requested two staff persons at the facility as the clients were “getting older” and the SP “did not want any accidents” if only one staff person was working. However, the SP “did not hear anything” from the facility. · The SP did not hear any staff person yell at the VA and the SP denied doing so. However, the VA and the SP both wore hearing aids and there was “one time,” the SP arrived for his/her shift and the VA was in his/her bedroom “screaming.” The SP “talked loud” to ask the VA not to scream, so that the VA could hear him/her. There were also times the VA did not wear his/her hearing aids and the SP needed to “talk loud.” The SP did not know why someone said s/he yelled at the VA. · The SP said that the time the VA awoke “varied.” However, the VA was given his/her medication and then the SP let the VA sleep and got the other clients ready first. When the VA’s family member came to pick up the VA, there were times where if the VA was still asleep and was not getting up, the SP would pull back the VA’s covers. The SP pulled back the VA’s covers so that the VA’s feet would not get “caught” in the covers. · The SP denied telling the VA s/he were to go to a nursing home but heard the VA’s family member and psychiatrist say that. The SP said that s/he “did not call anyone names.” · The VA called his/her family member “all the time.” The SP denied refusing to have the VA make a call and said that would not be appropriate. The SP denied withholding snacks or food from clients and said that clients got snacks after work and prior to bed. · There were no personal conflicts between him/her and staff persons and said that s/he “gets along with everyone.” G1 had not “witnessed” anything concerning regarding staff persons interactions but said that s/he was not at the facility a “ton.” However, G2 was often at the facility. The VA had “dementia” and had dreams that s/he thought may be “real.” The VA had a history of providing inaccurate information including regarding sexual abuse and also regarding cartoon characters. However, the facility was single staffed so G1 “did not want to discount” the concerns. The VA would make it “obvious” if s/he did not like a staff person by “making their time very difficult together.” The VA had not told G1 about any staff persons that s/he had concerns with. However, the VA saw G2 more often so may have told G2 any concerns. The VA had a history of falling and staff persons were to call an ambulance if the VA was unable to get up on his/her own. G1 was not aware of any times that the VA did not get medical care after falling. G1 was not aware of any times that the VA could not call him/her or other family members and staff persons knew they could call G1, G2, and G3 if the VA was “upset” to assist the VA to “calm.” G2 said that s/he went to the facility often and at times, unannounced. G2 did not have any concerns with staff persons, including the SP. G2 described the SP as “very courteous” towards the VA and the SP never had “short patience” with the VA. The SP also ensured that G2 was able to visit with the VA. G2 never heard any staff persons yelling, including when s/he went unannounced and was outside the facility. G2 was not aware of any staff person hitting the VA but said that the VA may hit staff persons. The VA never said s/he was hit. Additionally, the VA called G2 “quite often.” The VA would have told G2 if there were concerns and the VA never did so. G2 was not aware of any staff persons withholding food from the VA but said that at times, the VA may choose not to eat. G2 was not aware of any times that the VA did not get required medical attention. The Code of Ethics said that staff persons were to “respect the dignity” of each client. The Rights of Persons served said that the clients had the right to be free from maltreatment and treated with courtesy and respect. Clients were to have the right to have “access” to three nutritionally balance meals and nutritious snacks between meals. Clients were to also have access to the house phone for making “private” conversations. Facility documentation showed that staff persons, including the SP, P1, P2, P3, P4, and P5 were trained on the VA’s plans, the facility policies and procedures, including the Code of Ethics, Rights of Persons Served, and the Reporting of Maltreatment of Vulnerable Adult’s Act. Relevant Rules and Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), state that a person’s protection-related rights include the right to be treated with courtesy and respect. Conclusion: Regarding emotional abuse: There was inconsistent information regarding the SP’s interactions with the VA. P1, P2, and P3 each said that the SP “constantly” “yelled,” “screamed,” or was “loud” with the VA. P3 said that the SP did so when s/he was in another room, including for the VA to “turn off the TV.” P2 also said that the SP told the VA to “shut up.” P1 and P3 each said that SP told the VA that s/he “belonged” in a nursing home or would get “switched” to a nursing home. According to P2, the VA asked if s/he were “going to a home” but when P2 asked the VA who said that to him/her, the VA “would never say.” When the SP did these things, P1, P2, and P3 said that the VA put his/her head down, cried, or talked about his/her “rights.” P4 described the VA as “pretty calm” and had not heard the SP scream. P2 and P4 each said that the SP was hard of hearing so “talked louder” and “raised” his/her voice. The VA told this investigator that no staff person yelled at him/her but told P5 that the SP yelled at him/her a “little bit.” The Internal Review showed that one of the clients (who was not named) denied that any staff person yelled at the clients. When another client was asked if anyone ever yelled at him/her, s/he said, “yes,” but was “unable” to say who. The SP denied yelling but said s/he and the VA wore hearing aids so the SP “talked loud.” Although P1 said that the SP would not let the VA call his/her family members, the VA said that s/he was able to talk to his/her family members and G1 and G2 each said that the VA called him/her and other family members. P2 also said that s/he had not seen the SP restrict the VA from calling his/her family members. The SP denied telling the VA that s/he could not call his/her family members and said that the VA did so “all the time.” P1 had concerns that the VA fell more frequently on the SP’s shifts. P2 was not aware of this and P4 said that there was a time the VA fell twice on a shift but it was due to a medication. The VA’s plans and G1 each said that the VA had a history of falling and G1 said that if the VA was not able to get up on his/her own, staff persons were to call an ambulance. P1 also had concerns the SP was starting to get Alzheimer’s and had been forgetting things, such as snacks. P1 also said that the SP may have withheld things because s/he was “mad.” P2 said that at some point, the SP came in on his/her day off and told P2 that the clients could not have a snack. However, P2 said that the SP trained him/her to give the clients a snack. The SP denied withholding snacks or food from the clients. On and after August 30, 2023, P1 also told this investigator and P5 that P2 did the “exact same” things as the SP but could not “elaborate” which P5 found “interesting [Note: There was no additional information that there were any concerns with P2’s interactions with any clients, including the VA].” P4 said that P1 had a history of providing inaccurate information and needing as “many hours” as s/he could. P4, G1, and G2 each said that the VA would have told him/her or indicated if s/he did not like a staff person and the VA had not done so. The VA told this investigator that s/he liked the SP and the VA asked multiple staff persons when the SP was returning to the facility. The SP had worked at the facility for approximately 20 years with no prior concerns. Additionally, the facility was single staffed and P1, P2, and P3 did not typically work together. While not all of the SP’s interactions with the clients, including the VA, might be considered therapeutic conduct, given the aforementioned, there was not a preponderance of the evidence as to whether the SP’s actions could reasonably be expected to produce emotional distress to the VA. It was not determined whether 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: 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). Regarding physical abuse:
P1 also said that at some point, the SP “raised” his/her hand “to” the VA and that P1 stepped in between the VA and the SP to intervene. P2 and P3 were not aware of the SP hitting the VA. However, P2 said that the VA said “random” things such as that someone “just hit me” but when P2 asked who did that, the VA “did not answer.” P3 said that when the VA was “dreaming” at night, s/he said, “don’t hit me.” However, when P3 went into the VA’s bedroom to check on the VA, the VA was asleep and “snoring.” P4 had worked with the SP for approximately seven and a half years and “never saw [the SP] abuse” any clients, including hitting the VA. The VA told this investigator that no staff person hit him/her. The SP denied hitting the VA. Given the aforementioned, there was not a preponderance of the evidence whether the SP hit or attempted to hit the VA. 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 and determined that policies and procedures were adequate but not followed. There were no similar prior incidents, including with the SP. Staff persons were retrained on the maltreatment of vulnerable adult act. The SP was also removed from working at the facility until the investigation was completed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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