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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: 1104285-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) shoved a vulnerable adult (VA) which caused the VA to fall backwards and land on the floor. Date of Incident(s): April 29, 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 May 11, 2023; from documentation at the facility and law enforcement records; and through eight interviews conducted with the VA, the SP, the VA’s family member who was also the VA’s guardian (G), two supervisory staff persons (P1 and P2), and three staff persons (P3-P5). The VA’s diagnoses included attention deficit hyper-activity disorder, autism, depression, and post-traumatic stress disorder. The VA received one to one staffing due to his/her health and safety issues and increased complex mental health issues. The VA liked to go out to eat, exercise, watch TV, go to the lake, and spend time with staff and his/her significant other. Information obtained was consistent that the VA had a computer from the G that was for school use only. The VA was not allowed to use the computer for personal use, due to his/her previous “risky” computer behavior/interactions. The facility was a multi-level home with a living room, dining room, kitchen, and staff office on the main level. Between the living room and dining room was a staircase that led up to the VA’s other resident’s bedrooms. The kitchen and dining room were connected via a locked door that opened into the kitchen. Facility Residents were not allowed in the kitchen without staff person supervision. Through the kitchen was another locked door that led to the staff office. The VA provided the following information: · On the morning of April 29, 2023, the VA went into the kitchen where the SP and P4 were. P4 left the kitchen, went into the dining room, and sat at the table with P5 facing into the kitchen. (Note: P3 was also in the dining room.) At that time, the VA and SP were standing by the open door leading into the dining room. · The VA asked to use his/her computer and the SP said, “No,” because it was for school only. The VA became upset and stepped on the SP’s shoes. The SP asked the VA to “stop” and “please don’t do that.” The SP then “pushed” the VA and the VA “slapped” the SP’s hand. The SP said something like, “If you slap me, you wouldn’t be standing here,” which the VA took as a threat. The SP then asked P3 to came into the kitchen. When P3 did so, s/he tried to help with the situation by talking to the VA. · At some point, the SP pushed the door against the VA and then put his/her arms around the VA over the VA’s shoulder from behind. As the VA faced the dining room, s/he began to walk towards it but was “pushed down” by the SP. The SP’s hands landed on the VA’s “back and arms, like a twist around.”
· The VA said s/he “sat on the floor,” but then got up, and saw P4 and P5 sitting at the table. The VA walked over to the stairs and called the G. The VA told the G what happened and that the SP pushed him/her, but the G did not believe the VA. The G told the VA, “Go have a good day,” and exercise. · Later that day, the VA told P3 s/he wanted to talk to law enforcement so P3 took the VA and the VA told law enforcement about the incident. P3 provided the following information: · On the morning of April 29, 2023, P3 worked with the VA, who was still in bed. Because the VA was still in his/her bedroom, P3 was downstairs with another client who needed supervision. P3 heard a “commotion” from the main level, went upstairs, and saw P4 and P5 sitting at the dining room table and the door to the kitchen was closed. · P3 knocked on the kitchen door and asked if everything was okay. The kitchen door opened and P3 went in. P3 said, “I don’t remember every single detail,” but recalled s/he saw that the VA had “pinned” the SP behind the door and the kitchen counter as the VA stood in front of the SP with his/her hand on the SP’s arm. The VA said, “awful things” to the SP including, “You don’t belong in this country.” P3 believed the SP was angry about what the VA was saying because of the look on the SP’s face. · P3 attempted to talk with the VA to calm the situation. P3 said to the VA, “Come on [the VA], let’s try a reset,” and “Look at what’s going on.” At that point, the VA was “touching” the SP. The SP then told the VA his/her “breath stinks” and that s/he needed to shower. The VA then said the SP “hit” him/her and the SP told the VA s/he was a “liar” and, “If I hit you, you wouldn’t be standing here because I would knock you out.” · P3 felt his/her efforts to calm the situation were “drown[ed] out” as the SP and the VA continued to argue with each other so P3 “walked away.” P3 said “at some point” the SP asked P3 to return to the kitchen. P3 went back and asked the VA to “try a reset” but there was no change in the VA’s behaviors so P3 left the kitchen again and went into the dining room with P4 and P5 to help review a COVID-19 test instructions for another resident (R). · P3 saw the SP use the door to push the VA away so the SP was no longer pinned behind the door. The SP met the VA in the doorway and put his/her arms around the VA from behind holding the VA’s arms down. At this point, both the VA and SP faced the dining room. As the SP held the VA, the SP attempted to guide the VA toward the dining room with the force of his/her body as they moved their feet. P3 saw the VA “stumble” and the VA fell to the floor while the SP remained upright. The VA landed on his/her back and buttocks with his/her feet faced towards the kitchen door. P3 said s/he did not know how the VA turned but possibly as s/he stumbled. P3 did not know if the SP releasing the VA from the hold or pushing the VA caused the fall. P3, P4, and P5 all made eye contact after this occurred and “we were all like wow.” The R came over and asked if the VA was okay and gave the VA a hug. (Note: Due to the R’s disabilities, s/he was not interviewed for this investigation.) · The SP told P3 to shut the kitchen door, but P3 did not recall if s/he did so. The VA stood up, said s/he was “okay,” and apologized. The VA then called the G on speaker phone and said s/he was “hit” and “pushed” by the SP. The G did not believe the VA and told the VA to apologize. · The VA got ready for the day and later that morning, P3 drove the VA to work. P3 and the VA talked about what occurred with the SP and the VA was “ruminating on what happened.” P3 asked the VA if s/he lost his/her footing and fell. The VA said, “I did not slip, I was pushed.” P3 later emailed supervisory staff persons and texted P1 about the incident. · The email from P3 to supervisory staff persons said there was a “heated argument” between the SP and VA. The VA accused the SP of “hitting” him/her, and the SP responded, “If I would have hit you, you wouldn’t be standing here because I would knock you out.” The SP tried to direct the VA out of the kitchen and s/he was “pinned behind the door with [the VA] holding the door open.” P3 attempted to de-escalate the situation, but believed s/he was not heard over the comments between the VA and the SP. The SP put his/her arms around the VA in “what appeared to be a hold and shoving [the VA] out of the kitchen door and [the VA] landing on [his/her] back.” P3 said the contact lasted “around 60 seconds” and the VA’s “arms were being down” and the “force applied by [the SP] to cause [the VA] to physically move from one place to the other and [his/her] subsequent fall seemed, to me, to evidence an excess of a motion intended to redirect.” The VA was not injured, apologized for his/her behavior, and called the G who did not believe him/her when the VA said s/he was “hit” and “pushed.” P3 asked the VA if it was possible s/he lost his/her footing and fell, and the VA said, “No, I did not slip, I was pushed.” P4 provided the following information: · That morning, P4 was in the kitchen with the VA, the SP, and P3 when the VA left the kitchen and went into the staff office to review who was going to work with him/her that day. The SP directed the VA out of the office and said that information was for staff persons only. The VA saw that P3 was working with him/her and was upset about it. The SP tried to explain to the VA why it was important s/he be comfortable with P3. P4 and P3 left the kitchen and closed the door so only the VA and SP remained. · P4 left the kitchen and went into the dining room to review a COVID-19 test for the R. P3 and P5, who was also in the dining room, reviewed the test instructions together to try to understand them. P4 then heard a noise that sounded like “people scrambling” and told P3 to go see what happened. P4 then heard the SP say, "Close the door.” P4 stated s/he did not pay further attention to what occurred because s/he was involved with the COVID-19 test. · P4 heard the refrigerator door against the wall. P4 looked up and saw through the open door that P3 was closest to the dining room, then the VA, and the SP was furthest away. P4 heard P3 attempt to encourage the VA to leave the kitchen area. P4 stated that s/he did not hear the SP say, “If you push me, I am going to push you back,” or any other similar comments. · P4 saw P3 was by the dining room and the VA holding the kitchen door. P4 was did not see P3 leave the kitchen. P4 did not see how the VA got out of the kitchen or how the VA fell to the floor because s/he was focused on the COVID-19 test. P4 saw the SP and P3 both standing in the kitchen doorway and then P3 closed the kitchen door. · The VA stood up and went to sit on the stairs where s/he called the G. P4 heard the VA tell the G that the SP pushed him/her and heard the G tell the VA that was a lie. The call then ended as the SP went back into the office. The VA walked over to P4 and apologized. P4 said there was no reason to apologize to him/her. The VA said s/he wanted to apologize to the SP, so P4 went with the VA to the office where the VA apologized to the SP. The VA asked for breakfast soP3 made the VA breakfast and s/he ate it at the dining room table. The VA finished breakfast, appeared calm, and got ready for work. P5 provided the following information: · On the day of the incident in the morning, P5 worked with the R. The R did not feel well and was in the living room. The SP came upstairs with his/her medications and went to the VA’s bedroom for the VA to take them. The VA initially declined but eventually got up and took them. · The SP came back downstairs and went into the office while the VA stayed in his/her bedroom. At some point it was decided that the R would be tested for COVID-19 so P3 got a test kit and P3-P5 were at the dining room table reviewing the test materials because they were not in English. · The VA came to the dining room, asked what staff persons were looking at, and became concerned the R had COVID-19. P5 processed with the VA that s/he would not get COVID-19 and the R was testing just to be safe. The VA asked to go into the kitchen and was let in through the door. The VA walked through the kitchen and into the staff office to talk with the SP and then the kitchen door was closed. · P5 was at the dining room table with his/her back to the kitchen. P5 heard the opening and slamming of the refrigerator door and the utensil drawers. P3 opened the kitchen door and asked if the SP was okay. The door was then slammed shut on P3. P5 said s/he was focused on the COVID-19 test and was not sure when or how P3 went into the kitchen, but the door closed behind him/her. · P5 then went to the living room to give the R the COVID-19 test. P5 did not know what happened in the kitchen, but heard the VA swearing at the SP. The VA said, “This is my house, I can do what I want.” P5 did not hear the SP make any inappropriate comments towards the VA. When P5 went back to the dining room, the VA was sitting on the floor facing the kitchen. P5 did not see how the VA got on the floor. · Later that morning, the VA later apologized to P5 for “the way I behaved,” and said s/he was upset with the SP. The VA then talked about his/her family members. P5 said s/he did not ask the VA how the VA got to the floor and the VA at no point did the VA say the SP pushed him/her. P1 provided the following information: · On April 29, 2023, around 1:45 p.m., P1 received a text message from P3 that said the VA wanted to talk about an incident that occurred with the SP earlier that day about 10 a.m. when the SP “had some sort of physical contact” with the VA that was “like a push, or a shove, or a guiding gesture.” Around 2 p.m., P1 talked the VA and the staff persons and was told different versions of what occurred. · P4 and P5 each told P1 that s/he saw parts of the incident because his/her attention was elsewhere. P4 said that the SP did not touch the VA and the VA left the area on his/her own. Either P4 or P5, P1 could not recall which, said they might have seen the VA fall, but the other did not see the incident. · P1 was told that the VA wanted to use his/her computer (not for school) and the SP did not allow the VA to have the computer. The VA stood on the SP’s feet and the SP called P3 in for help. P3 attempted to calm the situation but the VA made derogatory comments to the SP. · The VA attempted to “slam” the kitchen door closed but the SP leaned against the door preventing the VA from doing so. The VA pulled on the SP’s shoulders trying to physically move the SP out of the kitchen. The SP remained in the kitchen to prevent the VA from locking him/herself in the kitchen alone and encouraged the VA to leave the kitchen. · The VA and P3 said the SP “pivoted” with the VA. The VA said the SP pushed him/her on the back out of the kitchen and into the dining area causing the VA to fall, landing on his/her “backside.” P3 told P1 the SP pivoted with the VA and switched places before “shoving” the VA out of the kitchen and into the dining room which caused the VA to fall on his/her backside. · The VA’s story changed from the SP pushed him/her to the SP pushed the door against him/her which caused the VA to fall. P1 said the VA was an accurate reporter of incidents “like 50/50.” The VA often mixed-up details of events or information was not consistent with what happened. · The SP told P1 that after the VA attempted to pull the SP’s shoulders but was unable to the move the SP the VA left the kitchen on his/her own. The SP then closed to the kitchen door and did not see the VA fall. The SP provided the following information: · On the day of the incident the SP was in the office when the VA got out of bed and came downstairs and into the office. The VA asked which staff person worked with him/her that day. The SP said P3 was the VA’s staff person, and the VA became upset. The SP told the VA that P3 would “only take you to work” and explained how it was important that the VA worked with a variety of staff persons. The VA slammed the office door multiple times as the SP tried to verbally calm the VA. The SP was trained to leave the situation when the VA was this upset, but because the VA was by the office door the SP was not able to leave. · The VA left the office and went into the kitchen where s/he started slamming open and closed the refrigerator door. The SP followed the VA into the kitchen locking the office door behind him/her. The VA continued slamming the refrigerator door when P3 opened the door from the living room to the kitchen to see what was causing the noise. The VA went to the kitchen door and closed it on P3 and slammed it open and closed several times. · The VA then grabbed the various cooking items and the SP attempted to get the items away from the VA because the VA had a history of property destruction and self-injurious behavior. The SP asked the VA to come with the SP into the basement to talk but the VA said s/he would not leave the kitchen because the R had COVID-19 and the VA did not want to get sick. The SP said the R did not have COVID-19 and P3 to P5 were just making sure. The SP offered other spaces where s/he and the VA could go to talk, but the VA refused to leave the kitchen. · The VA told the SP, “Shut up. You don’t belong here, I belong here.” and made a derogatory statement to the SP. The VA then told the R, “Get out of here.” The SP leaned against the kitchen door and called for P3 to come into the kitchen. At this point, the VA tried to spit on the SP, stood on the SP’s feet, and reached behind the SP trying to pull the kitchen door closed. The VA pushed and pulled on the SP’s shoulder trying to move the SP out of the way. · The SP told the VA, “You have been doing so well. You don’t want me to call [the G] and tell (him/her) you had a behavior problem?” The VA got upset and said, “I’m going to tell [the G] you hit me.” P3 then said to the VA, “You are the one that is hitting [the SP].” The VA then said to the SP, “You don’t belong here. You are always snitching on me telling [the G]. I am going to tell [the G] you pushed me.” · The VA then left the kitchen followed by the SP, and the SP closed the door, but realized it was unlocked. When the VA saw the door closed, the SP turned to lock the door and the VA got behind the SP and reached to take the SP’s hands away from the knob. The VA used his/her body to try to force the SP out of the way. The SP called for P3 and asked him/her to lock the door. As the SP continued trying to block the VA with his/her body, s/he opened the door slightly to allow P3 to reach in and lock the knob from the kitchen side. The VA said, “I am going to tell [the G] you pushed me.” The SP turned around and the VA was on the floor scooting backwards through the dining room towards the staircase. · The VA sat on the stairs and called the G on speakerphone and said the SP pushed him/her. The G said s/he did not believe the VA and the SP said, “If I push you [P3-P5] would see that,” and “If I push you, you fall on the table.” The VA hung up on the G and the SP walked away from the situation to let the VA calm. · After five to ten minutes, the VA came to the SP and apologized. The VA then ate breakfast and the SP returned into the office. Around 11:45 a.m. and 12 p.m., the SP came out of the office to pass medications and the VA and P3 were gone. · The SP denied s/he told the VA that s/he “stinks,” but had directed the VA to brush his/her teeth because the VA needed reminders to brush along with other hygiene items. The SP said that with his/her accent and how s/he speaks with his/her hands sometimes the VA interpreted the SP as “being mean.” The SP denied restraining the VA, wrapping his/her arms around the VA, or pushing the VA to the floor. P2 was not on shift the day of the incident. On Monday, May 1, 2023, s/he talked with the VA about what occurred. The VA told P2 that s/he did not want to work with P3 and talked to the SP about that in the kitchen. When the SP did not change the VA’s staff person from P3, the VA got upset and started to hit the refrigerator door against the wall. The SP told the VA to stop because if the refrigerator broke, the food would spoil. The VA stopped and walked out of the kitchen and then tried to go back in to cause more damage. The SP tried to close the kitchen door to stop the VA and the VA pushed back against it. The SP closed the kitchen door which pushed the VA to the floor. The VA later went with P3 to the LEO to file a report. The G provided the following information: · The VA called the G “screaming” to be picked up. The G heard in the SP in the background asking the VA to step away from the kitchen, but the VA would not. The VA said the SP “pushed [him/her] from behind” and the VA fell. The G said the version the VA told changed. The next day P1 told the G that P3 took the VA to the police station and the VA made a report. · The VA was not an accurate reporter and took advantage of new staff persons such as P3. The VA had a history of misstating what others said. · The G had no concerns with the facility and felt the staff persons were “great” and “very supportive.” The G said the SP was “wonderful.” The law enforcement report provided the following information: · P3 told the law enforcement officer (LEO) that the SP and VA were in the kitchen and P3 saw the SP put the VA in a “trained hold or technique.” The SP used “an extra shove while this technique was used and [the VA] fell” to the floor. The SP “was saying things like, ‘I’d knock you out!’” P3 said s/he calmed the VA and later drove the VA to work. The VA continued to be upset about the situation and s/he wanted to report it to the LEO. · On May 5, 2023, the LEO talked with the SP. The SP said s/he was in the kitchen with the VA who slammed the door to the kitchen several times and stood or stomped on the SP’s feet. The SP called for P3 to come help because it was “standard to have a witness in these cases.” The SP said this continued for “about 20 minutes.” The SP tried to calm the VA and said s/he would phone the G which increased the VA’s behavior. The VA grabbed the SP’s hands as they were “pushing the door open and shut.” The SP denied restraining the VA, putting his/her hands on the VA, or pushing the VA to the floor. At some point, the SP saw the VA on the floor “scootering or scootching” to the steps. The VA told the SP that s/he was going to tell the G that the SP pushed him/her, and the SP replied, “If it gets to the point of pushing and shoving, I’ll probably knock you out.” · The LEO closed the case without further action. Facility documentation showed that P2-P5 and the SP were each trained on the VA’s plan and Reporting of Maltreatment of Vulnerable Adults Act. P1 was trained in the Reporting of Maltreatment of Vulnerable Adults Act, but did not provide direct care to the VA and therefore did not require training on the VA’s care plan. Conclusion: Information was consistent that on April 29, 2023, the VA and the SP were in the office and the kitchen when the VA became upset with the SP after s/he was told P3 would work with him/her that day or when the SP would not give the VA his/her computer. The VA became verbally and physically aggressive. At some point, after the VA moved out of the kitchen, the VA fell to the floor. The VA said that the SP pushed him/her causing him/her to fall but the SP denied pushing the VA. P3, P4, and P5 were in the dining room immediately next to the incident as it was occurring. P3 provided consistent information that there was physical interaction between the SP and the VA but provided different accounts. P3 told this investigator that the VA “stumbled” and fell to the floor but then said s/he did not know if the SP releasing the VA from the hold or pushing the VA caused the fall; told supervisor staff persons via email and P1 that the SP “shoved” the VA either while holding the VA or not, causing the VA to fall; and told the LEO that the SP used “an extra shove which caused the VA to fall to the floor. P4 and P5 each told this investigator that s/he did not see how the VA fell. P4 also told P1 that the SP did not touch the VA. Given the different accounts of what occurred, and that at the time of the incident, the VA required some type of redirection given his/her physically aggressive behavior, there was not a preponderance of the evidence whether all of the SP’s interactions were therapeutic conduct or caused the VA to fall producing physical pain. 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 allegation and determined that their policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No additional action taken.
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