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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: 1070650-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP) walked in front of a vulnerable adult (VA1) and pulled VA1’s walker too fast, making it difficult for VA1 to walk. The SP later grabbed VA1’s arm and pulled VA1 to a standing position in an “aggressive” manner. The SP spoke to VA1 in a sharp tone, poked VA1 in the stomach, and told VA1 that s/he was fat. Allegation two: It was reported that the SP told a vulnerable (VA2) to look in the mirror and ask him/herself if anyone would date VA2’s “ugly self.” The SP also told VA2 that s/he did not need privacy to talk to another staff person and that there were “no secrets” at the facility. Date of Incident(s): Ongoing, prior to November 3, 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 November 20, 2023; from documentation at the facility; and through eleven interviews conducted with four facility staff persons (P1 – P4), an administrative staff person (P5), the SP, VA1, VA2, VA2’s case managers (CM1 and CM2), and VA1’s and VA2’s guardian (G). VA1 enjoyed watching sporting events, spending time with his/her family members, going shopping, going to car shows, and watching television. VA1’s diagnoses included mild developmental disability, Fuch’s dystrophy (eye disease), glaucoma, schizophrenia, and a mood disorder. According to VA1’s Individual Abuse Prevention Plan (IAPP), VA1 sometimes made rude, insulting, and derogatory comments to others. The staff were to coach VA1 to use appropriate interactions and comments with others. Allegation one: It was reported that the SP walked in front of VA1 and pulled VA1’s walker too fast, making it difficult for VA1 to walk. The SP later grabbed VA1’s arm and pulled VA1 to a standing position in an “aggressive” manner. The SP spoke to VA1 in a sharp tone, poked VA1 in the stomach, and told VA1 that s/he was fat. VA1 stated that s/he liked living at the facility and that the staff persons treated him/her well. Sometimes the staff persons, including the SP, did not like VA1’s music, which upset VA1. VA1 believed the staff persons were “doing what they were supposed to do.” P1, P2, P3, P4, P5, and the SP provided the following information: · P1 stated that VA1 recently began to use a walker because s/he was having mobility issues and was afraid s/he would fall. VA1 had some difficulty using the walker and was worried that s/he would trip. P2 stated that VA1 sometimes moved too fast when using the walker so P2 would stand in front of him/her and remind him/her to walk more slowly. VA1 also sometimes had difficulty moving from a chair to a standing position. At those times, the staff persons would assist VA1 with standing. P2 stated that sometimes it helped to place a hand on VA1’s back so that VA1 believed s/he could stand. The SP stated that VA1 began to have more mobility problems when his/her physician recently made a change to VA1’s medications. The SP stated that VA1 sometimes pushed his/her walker too far in front of him/herself and the staff persons had to hold the walker so VA1 did not walk too fast and fall over. · P1 stated that on October 9, 2023, P1, P2, P5, and the SP worked at the facility. That afternoon, the staff persons decided to move an unused lift chair from another bedroom so VA1 could use it in his/her bedroom. While P5 was in the other bedroom taking the chair apart so they could move it to VA1’s bedroom, P2 and the SP helped VA1 get out of the chair in his/her bedroom so that s/he could wait in the living room for the new chair to be placed in his/her bedroom. P1 stated that VA1 did not want to leave his/her bedroom and the SP began to yell at VA1 to “knock it off, you can do it yourself.” The SP grabbed VA1’s walker and “walked” VA1 to the living room while VA1 held onto his/her walker. VA1 “screamed” because the SP was making VA1 walk fast and VA1 was concerned s/he was going to fall. VA1 “mumbled” and told the SP to “stop it.” The SP told VA1 to “shut up” and “get your ass going.” The SP stated that s/he did not yell at VA1 or grab his/her arm, but encouraged VA1 to stand and move to the living room. The SP also stated that s/he did not make VA1 walk faster. · P1 stated that the SP and VA1 went approximately 20 to 30 steps from the VA’s bedroom to the living room, where VA1 sat in another chair. VA1 continued to ask to return to his/her bedroom, but the SP told VA1 that s/he had to wait until the other chair was moved to his/her bedroom. P5 stated that s/he did not observe the interactions between the SP and VA1, but heard the conversation between them. P5 stated that the SP spoke to VA1 in a “sharp tone” and was “more aggressive” than was necessary. The SP did not yell at VA1, but spoke in a “loud, sharp, firm tone.” P5 did not remember the specific words the SP used when speaking to VA1. · P1 stated that while VA1 continued to ask to return to his/her bedroom, the SP called VA1 “stupid and dumbass” in a very loud voice. After the chair was moved to VA1’s bedroom, VA1 was unable to stand without assistance, so the SP grabbed VA1’s right arm and pulled VA1 up “so fast [s/he] screamed.” P2 stated that the SP “kind of yelled” at VA1, told him/her to stand, and “yanked” VA1 by the arm so that VA1 stood and was “shaking and scared.” The SP stated that s/he held VA1’s arm and assisted him/her with standing, but did not “yank” VA1 to his/her feet. P1 stated that the SP then moved VA1 back to his/her bedroom by pulling on his/her walker “faster than [s/he] brought [VA1] out” to the living room and yelled at VA1 to “hurry up and knock it off.” VA1 told the SP to “stop it.” P5 saw the SP walk in front of VA1 to VA1’s bedroom, but did not see if the SP was pulling VA1’s walker. P5 did not hear VA1 say anything during the incident. The SP stated that s/he did not yell at VA1 to move faster or pull VA1’s walker to make VA1 move faster. The SP typically told VA1 to keep his/her walker closer to his/her body so that s/he did not move too quickly and fall. · Later that afternoon, P1 told the SP that VA1 was bloated, which was a concern because VA1 had a history of bowel obstruction. The SP went to VA1’s bedroom to check on VA1, poked VA1 in the stomach, and said, “[VA1] is just a fucking fat ass.” P1 told the facility’s health care professional (HCP) about VA1’s feeling bloated and the HCP recommended that VA1’s physician be consulted, which resulted in VA1 being taken off one of his/her medications. P2 stated that the staff persons sometimes touched VA1’s stomach to see if it was distended. P2 never saw the SP “poke” VA1 in the stomach or say that VA1 was a fat ass. The SP stated that s/he never told VA1 that s/he was “fucking fat.” When VA1 appeared to be constipated, the SP sometimes touched VA1’s stomach to see if it was hard or “jiggly” and to determine if s/he needed medication for the constipation. · Later that day, P1 texted P5 and asked to talk to him/her about the incident between the SP and VA1. Two days later, P1 and P5 met and discussed the incident. The next time P1 worked at the facility, VA1 asked P1 several times if the SP was at the facility and told P1 that s/he was scared and did not like the SP. · P2 stated that the SP was “loud and very demanding.” P4 stated that the SP had a “louder voice.” VA1 told P2 that the SP was “rough,” but P2 believed VA1 seemed to like the SP. VA1 did not tell P2 that s/he was scared of the SP. P3 believed VA1 was afraid of the SP because the SP was “an authority figure” and acted like “a drill sergeant” around the residents. P4 stated that s/he never heard the SP make unkind comments to VA1 or handle him/her roughly. P4 stated that some of the other staff persons “targeted” the SP, making it difficult to work as a team. P4 stated that the SP sometimes told VA1 that s/he could do things on his/her own so that VA1 would continue to do things for him/herself rather than rely on the staff persons. The SP stated that s/he was a “loud” person, but s/he did not “yell” at the residents. · P5 stated that s/he talked to the SP several times about the “tone of voice” the SP sometimes used when speaking to the residents and other staff persons. P5 stated that the SP sometimes made “sharp snide remarks” and could be in a “foul” mood, but P5 did not hear the SP make derogatory or humiliating remarks to the residents and did not hear the SP swear at the residents. The SP stated that there were interpersonal conflicts between him/her and some of the other staff persons. The G stated that if VA1 felt something was wrong, s/he would report it. The G was not aware of VA1 having any concerns about the staff persons who worked with VA1. VA1 seemed very happy at the facility and got along with the staff persons. VA1 usually told the G about anything that upset VA1 and had not brought up any concerns about the staff persons. Facility documentation showed that the SP and P1-P5 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion for allegation one: P1 stated that the SP forced VA1 to walk too fast while using his/her walker, “yanked” VA1’s arm to force VA1 to stand, poked VA1’s stomach with his/her finger while calling VA1 fat, and “yelled” at VA1. None of the other staff persons provided information about the incidents. Consistent information was provided that the SP was a “loud” person, but the SP stated that s/he did not yell or swear at VA1. The SP stated that s/he did not make VA1 walk too fast when using his/her walker or yank VA1’s arm to make him/her stand. The SP stated that s/he touched VA1’s stomach to determine if it was hard because VA1 was constipated, but did not “poke” VA1 in the stomach or call him/her fat. In addition, information was provided that there were interpersonal conflicts between the SP and other staff persons. Inconsistent information was provided by the staff persons about the SP’s interactions with VA1. However, given that only P1 provided information that the SP forced VA1 to walk too fast and yanked VA1 to his/her feet, that the SP denied that the incidents occurred, and that VA1 did not have any complaints about his/her interactions with the SP, there was not a preponderance of the evidence as to whether the SP’s actions could reasonably be expected to produce physical pain or injury or emotional distress to VA1. It was not determined whether emotional and 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 and/or 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). Allegation two: It was reported that the SP told VA2 to look in the mirror and ask him/herself if anyone would date VA2’s “ugly self.” The SP also told VA2 that s/he did not need privacy to talk to another staff person and that there were “no secrets” at the facility. VA2 enjoyed playing music on his/her instruments, creating art, going on community outings, and spending time with his/her family members. VA2’s diagnoses included paranoid schizophrenia, depressive disorder, major neurocognitive disorder, memory loss, seizure disorder, bursitis, arthrodesis, and cognitive deficits. VA2 wore a brace/boot combination on his/her right leg and a patellar knee brace. According to VA2’s Coordinated Services and Supports Plan (CSSP), VA2 sometimes experienced “minor forgetfulness.” The staff persons provided support to maintain VA2’s health and personal safety. According to VA2’s Individual Abuse Prevention Plan (IAPP), VA2 sometimes made false statements about staff persons. VA2 sometimes shared extremely personal information with others and did not always maintain personal boundaries with others. The staff persons were trained to remind VA2 not to make inappropriate remarks to others. VA2 frequently made comments about the staff persons being gang members and wanting to harm VA2. VA2 sometimes criticized others regarding their weight. VA2 stated that s/he liked living at the facility. VA2 believed that the SP understood what VA2 was going through. However, sometimes VA2 was “mean” to the SP, which VA2 “didn’t like.” The staff persons were not mean to VA2, did not say hurtful or mean things to VA2, and did not yell at VA2. None of the staff persons told VA2 that s/he would never have a girl/boyfriend. P1, P2, P3, P4, P5, and the SP provided the following information: · P1 stated that on one occasion, VA2 asked the staff persons if they thought s/he would ever have a boy/girlfriend. The SP then told VA2 to “go into the bathroom and fucking look at yourself and ask would you ever date your ugly self?” P3 stated that s/he did not hear the SP’s comment to VA2, but was told by the SP that s/he told VA2 to look “in the fucking mirror” when VA2 asked about having a boy/girlfriend. P3 stated that s/he heard the SP make derogatory comments about VA2 to the other staff persons, but did not hear the SP make those comments to VA2. P4 stated that VA2 did not want to have a boy/girlfriend and did not want to date. The SP stated that s/he did not swear at VA2 and never told VA2 to look in the “fucking mirror” or ask VA2 who would date VA2. The SP stated that s/he did not use “hurtful” language when talking to VA2. P1 stated that on another occasion, VA2 wanted to speak to P1 privately and asked the SP for privacy, but the SP told VA2 that s/he could “fucking tell all of us, there are no secrets.” VA2 then went to his/her bedroom. · P4 stated that s/he never heard the SP make unkind comments to VA2 and that VA2 and the SP had a “good relationship.” P4 stated that the SP “took care” of VA1 and VA2. P4 did not hear the SP call VA2 ugly. P3 stated that the SP was a loud person and often “screamed” at the residents and other staff persons. The SP often told VA2 that s/he “was capable of doing this fucking task” when VA2 was showering or doing other tasks. The SP stated that while s/he was a “loud” person, s/he did not “yell” at VA2. P5 believed that VA2 “got along pretty good” with the SP and the SP helped VA2 with making appointments and filling out paperwork. P5 stated that the SP’s “tone” of voice was sometimes sharp when speaking to the residents and the SP sometimes lacked interpersonal skills when working with the residents and other staff persons. CM1 stated that the G recently became VA2’s guardian. Prior to that, VA2 was not subject to guardianship. VA2 was “generally” an accurate reporter of events, but might sometimes not understand what occurred. CM1 believed that the staff persons were supportive of VA2 and VA2 had never expressed concerns about the staff persons to CM1. CM1 believed the SP was “more strict” than some of the other staff persons. CM2 stated that in the past, the SP had been a “good advocate” for VA2. VA2 had not voiced any complaints about the SP to CM2 and the SP was “professional” around CM2. The G stated that s/he recently became VA2’s guardian and did not yet have much information about VA2. Conclusion for allegation two: P1 stated that when VA2 asked the staff persons if they thought s/he would ever have a boy/girlfriend, the SP told VA2 to “go into the bathroom and fucking look at yourself and ask would you ever date your ugly self?” None of the other staff persons heard the SP make the comments to VA2. While consistent information was provided that the SP frequently spoke in a “loud” voice to the residents, the SP stated that s/he did not “yell” at VA2. Inconsistent information was provided by the staff persons about the SP’s interactions with VA2. However, given that only one staff person reported that the SP made the comment to VA2 that s/he was ugly and would never have a boy/girlfriend, that the SP denied making the comment, and that VA2 stated that none of the staff persons, including the SP, told him/her that s/he would never have a boy/girlfriend, there was not a preponderance of the evidence as to whether the SP’s actions could reasonably be expected to produce emotional distress to VA2. It was not determined whether emotional abuse occurred (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 the facility’s policies were adequate and were followed by the staff persons. After the incident, the staff persons received additional training on the facility’s policies. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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