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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: 1101129-H_CRS (Home and Community-Based Services-Community Residential Setting)-(Closed August 31, 2023) Investigator(s): Christine Henne 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled “loudly” and swore at a vulnerable adult (VA), “grabbed” the VA by his/her shoulders and cheeks, and kicked the VA. Date of Incident(s): Multiple dates between April 22, 2023, and May 22, 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); 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 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. 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 June 22, 2023; from documentation at the facility and law enforcement records; and through five interviews conducted with two supervisory staff persons (P1 and P2), an administrative facility person (P3), and the VA’s guardians (G1 and G2). This investigator met the VA, but s/he was unable to provide information due to his/her diagnoses. This investigator met the SP for an interview on June 22, 2023, but when the SP arrived, the SP declined to interview, and the SP did not respond to subsequent attempts. The VA’s Coordinated Services and Supports Plan (CSSP) stated the VA loved to shop, swim, go on walks, fly on airplanes, watch movies, read stories, and color. The VA was non-verbal and diagnosed with moderate intellectual disability and autism spectrum disorder. The VA’s Intensive Support Self-Management Assessment stated the VA used non-verbal cues such as eye gaze, body language, and sounds to communicate as well as one- or two-word phrases to get his/her needs “partially met.” The CSSP stated the facility was responsible for all of the VA’s personal, health and safety, home management, personal safety, communication, and cognitive support needs. The VA required 24-hour plan of care that included 24-hour supervision with 1:1 or 1:2 support. A “good day” for the VA included a routine that the VA expected with engaging activities to participate in. When the VA was engaged in a preferred activity, s/he exhibited a happy and wonderful sense of humor. When the VA was frustrated, s/he exhibited a variety of behaviors such as screaming, hitting him/herself in the head and groin area and may destroy property and physically attack others. The VA had a PRN protocol that needed to be followed if s/he was not able to calm through less intrusive means. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA was susceptible to abuse due lack of community orientation skills and an inability to identify potentially dangerous situations and deal with verbally/physically aggressive persons. The VA was “very trusting” of people and did not understand enough about physical abuse to be able to protect him/herself. The VA would likely cooperate or not resist in a situation of potential danger and would not know what to do in response to others being verbally or physically abusive towards him/her. The facility was a split-level home. On the main/upper level there was an open kitchen/dining/living room area. Down a hallway from the main area was the VA’s bedroom, a bathroom, and a staff office. According to the facility’s Internal Review (IR) and General Events Report (GER), on May 18, 2023, P2 noted an “increase in behaviors” with the VA at a shift change and told P3. P3 instructed P2 to “watch” the “interactions” during the shift changes moving forward to determine if there was something “notable.” On May 19, 2023, P1 saw bruising on the back of the VA’s left arm and pictures were sent to P2. At some point on May 20, 2023, G1 expressed concerns about the SP to P2 and P2 notified P3 about it. P3 then reviewed video footage from the SP’s shifts from April 20 to May 20, 2023. The facility’s IR, General Events Report (GER), and facility camera footage provided the following consistent information regarding the interactions between the SP and the VA: · On April 22, 2023, the VA was eating supper and watching a movie in the main area at the facility. The VA walked back and forth between a table where s/he was eating and the TV. During that time, the SP walked out of the office and went to the refrigerator. The VA walked up to the SP and the SP turned the VA around and physically escorted the VA to the table. The SP escorted the VA with his/her hands placed on the VA’s left shoulder and upper back, and then placed the VA in a chair at the table. While the VA sat in the chair, the SP leaned over to the VA, inches from the VA’s face, and “yell[ed]”, “Eat your food. Eat it. Eat your food.” The VA started eating and the SP walked back to the office. · On May 16, 2023, video clips showed the following incidents: o The VA was standing in the living room and the SP repeatedly walked in a circles around the VA. Following that, the SP appeared to “squeeze” the VA’s cheeks, telling the VA that s/he was “handsome.” The VA led the SP to a calendar and asked about staff persons. The SP took both of his/her open hands and placed them “firmly” on the VA’s shoulders and said multiple staff persons names in response. As the SP did/said this, the SP’s hands hit the VA’s shoulders three times and once on the VA’s upper arms. The sound of the contact increased with each “tap.” After that, the SP placed his/her open hands on the VA’s shoulders and said “shoulder shake” while shaking the VA’s shoulders and continued by saying, “Let’s do shoulder shake. Shake your shoulder.” The SP and VA then high-fived. o Later, the VA appeared “agitated,” and the SP “physically escorted” the VA to his/her room and said, “Stay in your room,” and “seclude[ed]” the VA to his/her bedroom. (Note: Video footage also showed the SP’s right hand contacted the VA’s left upper arm as the SP guided the VA to his/her room). o At some point later, the VA “calmly” entered the office room and looked at the SP who was sitting in a chair behind a desk looking at a cellphone. Less than 10 seconds after the VA entered the office, the SP looked at the VA and “yell[ed],” “What do you want? What the hell do you want?” There was a short pause and then the SP “yell[ed]” again, “What do you want?” At that point, the VA makes “noise[s]” in response and all that can be heard on camera was the SP responding back “in the same tone” as the previous yells, “na na na na na na” in a “mimicking and antagonizing fashion.” The SP then told the VA to go to his/her room, but the VA remained standing in the office. The SP told the VA, “Go to bed,” “Get out of here,” and “Go to your room.” The VA left the office for a short time but then walked back into the office. The SP told the VA, “Go to your room,” Don’t touch me” and “Go eat,” and “Get out of here.” The VA left the office again as the SP continued to sit at the desk and made a phone call. The VA walked back into the office while the SP was on a phone call. The VA walked near the SP and the SP used his/her left hand and “pushe[d]” the VA back away from him/her making contact with the VA’s right wrist. The VA moved back and stood still. The SP then stood up and physically guided the VA out of the office. Once the VA was out of the office, the SP moved a “printer cart” in front of the door, causing a “barrier” preventing the VA from getting back into the office. The VA then went to his/her bedroom while the SP went back to sitting at the desk and talking on the phone. · On May 18, 2023, the VA walked into the office with the SP behind him/her. The SP “grab[bed]” the VA by the hand, pulled the VA, and turned the VA around saying, “You don’t go in there. Remember that.” · On May 20, 2023, the SP was heard on camera trying to wake the VA who was in his/her bedroom. The SP said, “Get up, God Damnit [sic].” The VA got up, let his/her bedroom, and made his/her way to the kitchen as the SP physically guided the VA. The SP put his/her hands on the VA’s cheeks and said, “Hi, handsome,” and told the VA what kind of food was on his/her plate and then said, “Eat your food.” The SP raised his/her voice and said, “Eat it,” and it appeared the VA started laughing. The VA sat at the table as the SP walked into the kitchen. The SP again said, “Eat your food,” and told the VA that the VA was going to G1’s house. The VA sat at the table but then stood up and started walking toward the hall, but the SP intervened and physically redirected the VA back to the table. The SP again “yelled” that the VA needed to eat his/her food. The VA expressed s/he needed to go to the bathroom did so. Another instance, the VA was on the couch with his/her weighted blanket watching a movie and the SP asked the VA if s/he wanted to go to “[a family member’s] house” and repeated it over and over in an “antagonizing fashion.” · On May 23, 2023, P3 talked to the SP regarding the SP’s interactions with the VA in the aforementioned video footage. The SP stated that his/her interactions were a “joke” and that was how the SP and the VA interacted with each other. Law enforcement (LE) also investigated the allegations and reviewed approximately 130 hours of video footage of the SP’s shifts with the VA. The LE report provided the following information regarding the videos: · On June 6, 2023, P2 told LEO s/he was downloading video footage from the facility’s WiFi camera system, but due to poor quality of internet service, some video was not captured. · Camera footage reviewed was between April 24 and May 18, 2023, and some of the SP’s shifts had a large amount of video and some days had less than one hour. It was noted that during a majority of the days, the SP spent his/her time on a cell phone or computer in the office leaving the VA alone in the living room/kitchen area. P2 also said that staff persons were supposed to be interacting with the VA and that the VA should not be left alone for any significant period of time. · LE documented the following concerns while reviewing video footage: o On April 22, 2023, the SP repeatedly yelled to the VA to “eat your food.” o On May 10, 2023, the VA walked into the office and the SP “shov[ed]” the VA back and said something unintelligible followed by calling the VA “nosey.” o On May 16, 2023, the SP “scream[ed],” What do you want, what the hell do you want?” “What do you want na na na na;” “Go to your room;” and then told the VA, “Get outta [sic] here.” The SP then escorted the VA out of the office and put a small shelving unit in front of the door blocking the entrance. The VA later entered the office by moving the shelving unit and the SP “chase[d]” him/her out of the office into the VA’s bedroom. Later, the VA came back to the office and the SP “yell[ed]” repeatedly, which was unintelligible and the VA “[ran]” back to his/her room. o On May 17, 2023, the VA and the SP were sitting at the dining room table. The VA was eating, and the SP was on a laptop. The VA stood up and walked around the table but did not say anything. The SP told the VA, “Not today, don’t start, knock it off, you better knock it off, not today, do you hear me?” The SP then told the VA to “eat” and the VA sat back down at the table. The VA then “made a noise” and the SP moved his/her body as if s/he was “kicking/nudging” the VA under the table and did that three times while stating, “knock it off” each time. The VA’s body moved as if the SP made contact with him/her under the table. The VA then made louder noises and “pound[ed]” his/her hand on the table a few times. The SP then appeared to kick at the VA from under the table and the SP “fully extend[ed]” his/her leg toward the VA in an “aggressive manner.” The VA then “hit” the SP’s phone, which was sitting on the table and the SP appeared to “kick” at the VA three more times under the table and it appeared the fabric on the VA’s pants moved. The SP stood up and “escort[ed]” the VA to his/her room. (Note: This investigator also reviewed this video footage and approximately five minutes later, the VA returned to the table where the SP was sitting. The VA said, “Sorry,” and the SP responded, “I don’t care.” The VA asked the SP for a “high five” and the SP continued to look at the cellphone and not respond to the VA. P1-P3, G1, G2, and facility documentation provided the following consistent information (Note: This investigator and a law enforcement officer (LEO) were both present for P2 and P3 interviews): · Staff persons were at the facility, their time was to be spent with the VA and there was no reason for the SP to be in the office. The VA was “very interactive” and liked staff to engage with him/her. · On May 20, 2023, sometime in the evening, P1 helped the VA with a shower and saw three “dot”-like bruises that looked like finger marks and like someone “grabbed” the VA on the back of the VA’s forearm. The bruises were “faded” yellow and purple and P1 thought they looked a couple days old. (Note: Photos of the VA showed bruises on his/her left upper back arm. The entire bruised area appeared to be one to two inches high up and down the arm and a half inch to one-inch wide. The larger bruised area appeared to be yellow and within the larger bruised area were two to three darker red/purple bruises/marks.) P1 asked the VA about it, the VA became “wound up” and started “mimicking” the following words: “Get over here; Stay by me; Eat your food.” The VA then reacted with physical aggression towards objects and P1. According to the facility’s daily logs, when P1 saw and asked the VA about the bruises, the VA responded by saying, “Get over here. I don’t like that. You stay right here.” The VA then punched the walls, TV, TV stand, counters, and began hitting him/herself and crying. The VA said, “Owe” so staff offered and administered Tylenol and then staff noticed the VA cut his/her right pinky knuckle, so staff administered first aid. P1 sent a photo of the bruises to P2 and documented the VA’s reactions in an Incident Report. P3 heard about the incident and due to the VA’s reactions to P1, s/he reviewed past video footage from the facility. P1 did not see the video footage, but P3 told him/her that P3 was “upset” by what s/he saw. · P1 said that s/he did not think the VA bruised easily and that the VA “punch[ed]” walls and never sustained bruises from that. At times, the VA punched the side of his/her head or groin area but did not have any self-injurious behaviors to his/her arms. The VA also “mimick[ed]” what persons said to him/her. The VA was able to ambulate on his/her own. However, at times, P1 assisted the VA by putting his/her hands on the VA’s arm such as in the wintertime if it was icy outside or getting in and out of a vehicle. Other times, the VA held P1’s hand. P1 did not work with the SP but saw him/her during shift changes/overlaps. A few days prior to P1 seeing the bruises on the VA, during a shift change, the SP was “upset” and told P1 that it was a “rough shift” but P1 never saw documentation of it. P1 and the SP were in the staff office and the VA came to the office and the SP told the VA to, “Go away,” and not to touch him/her and the VA became “really upset.” That day the internet was down so the cameras were not working. · P2 trained the SP and regularly overlapped shifts with the SP. P2 had no concerns about the SP until May 17 or 18, 2023, around 3 p.m. when P2 was in the VA’s bedroom with the VA and the SP came in for his/her shift. “Out of nowhere” the VA had a “big behavior” and was “mad,” “angry,” was “yelling/screaming.” P2 had not seen that happen before and told P3 s/he was concerned. P3 told P2 to be more mindful of how the VA reacted when the SP was talked about. At some point, P2 saw the video footage of the SP’s interactions with the VA and said that what s/he saw in person was “completely different” than what she saw of the SP on video and that the “whole thing just blew [his/her] mind.” P2 was “sicken[ed]” by what s/he saw in the video footage. In the video footage, P2 saw the SP “pushing” the VA, “screaming” at the VA, and watched the SP “barricade” the VA away from the SP by moving a shelf to block the doorway while the SP was in the office. The SP also putt one hand on the back of the VA’s chair while the VA was eating and one hand on a table and leaned down in front of the VA’s face and told the VA, “Eat your food. Eat your food.” The VA did not “randomly bruise” but sometimes hit or kicked objects, but staff persons could usually “pinpoint” the cause if the VA had bruise. The VA had self-injurious behavior, but P2 never saw that the VA had bruises from it. The VA was “unstable at times” but P2 never saw him/her fall and staff persons did not need to assist the VA with walking. Staff persons only had physical contact with the VA when holding hands or linking arms or doing a “high-five.” · P3 said that the bruising was on the VA’s left arm. P3 said that G1 told him/her about concerns G1 had on May 20, 2023, regarding the SP’s interactions with the VA while they were on an outing when G1 was present. Due to P2’s and G1’s concerns, on May 22, 2023, P3 obtained camera footage from the facility for the previous 30. P3 said s/he saw a verbal interaction between the SP and the VA that concerned him/her. The SP was making dinner for the VA and the VA walked over to the refrigerator where the SP was, the SP physically turned the VA around and “escorted” the VA to the dining table. The SP had the VA sit down and put one arm on the back of the chair and one arm on the back of the table and the SP put his/her face “six inches” from the VA’s face and was “screaming” for the VA to eat his/her food. P3 had saw concerns about the SP’s interactions in multiple video clips. P3 reviewed the video footage to try to determine what might explain the bruises on the VA and found one incident where the VA threw something down the stairs by the front door. The SP “grabbed” the VA by his/her arm and “escorted” the VA to his/her room. The SP told the VA to stay in his/her room and then closed the door. · After reviewing the video, P3 met with the SP. The SP told P3 that things were “great” and that s/he really enjoyed working with the VA. At that point, P3 showed the SP video footage of the SP screaming in the VA’s face to eat his/her food and asked the SP to explain the interaction. The SP said it was a “joke,” that was how s/he “joke[d]” with the VA, and that the VA laughed and then ate. P3 told the SP that it did not look like the VA was laughing. P3 then showed the SP another video clip. In that video clip, the VA walked into the office and the SP “screamed,” “What do you want? What the hell do you want?” P3 asked the SP if that was a joke too and the SP said it was how s/he “joke[d]” with the VA. P3 told the SP that was “completely inappropriate.” The SP apologized and said it would not happen again. · G1 said that s/he was present for several hours during an outing, on a Saturday in May, with the SP and the VA. (Note: According to the facility GER, this outing occurred on May 20, 2023). G1 had some concerns with the SP’s interactions with the VA and said that the SP was not really acknowledging or interacting with the VA. At one point, the SP seemed “reluctant” to help G1 get the VA out of a vehicle. G1 told P3 about his/her concerns and asked P3 to pull camera footage from the facility. G1 also told P2 about his/her concerns and heard that another staff person saw bruising on the VA’s arm the same evening of the outing G1 was present for. During the outing, the VA’s shirt covered the upper portion of his/her arms, so G1 did not see any bruising at that time. P3 reviewed the camera footage and a couple days later told G1 that prior to the outing s/he found multiple instances that concerned P3 regarding the SP and once incident appeared to relate to the bruising on the VA’s arm. A couple of days prior to the outing with G1, the VA was at the top of the stairs and appeared “agitated” with the SP. The VA “swiped” his/her hats off a shelf and knocked them onto the floor. The SP then “aggressively” “grabbed” the VA by the bicep, “forcefully” escorted the VA to his/her room and told the VA s/he had to stay in his/her room. There were other instances of the SP verbally “taunting” the VA and causing the VA to become “agitated,” including an incident in the office when the VA approached the SP and the SP said, “What the fuck do you want?” and another incident where the SP told the VA to “eat [his/her] fucking breakfast.” · G1 said that the VA had a “good sense of humor” and was “gentle” until s/he encountered frustration in communication his/her needs. The VA was able to understand “a great deal” but his/her “expressive communication” was more “delayed” and would sometimes echo what a person asks of him/her. G1 had no previous concerns with the facility, or the care provided to the VA. · G2 said that s/he was aware of the incidents and had no previous concerns with the facility. The LE forwarded the case to the Wright County Attorney’s office for charges of 5th degree assault. All staff persons including the SP were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rule and/or Statute: Minnesota Statutes 245D.04, subdivision 3, paragraph (a), clauses (4), (6), and (8), state that the servant recipient has the right to: · Be free from restraint, time out, seclusion, restrictive intervention, or other prohibited procedure identified in section 245D.06, subdivision5,or successor provisions, except for: (i) emergency use of manual restraint to protect the person from imminent danger to self or others according to the requirements in section 245D.061 or successor provisions; or (ii) the use of safety interventions as part of a positive support transition plan under section 245D.06, subdivision8,or successor provisions; · Be treated with courtesy and respect and receive respectful treatment of the person’s property; and · Be free from bias and harassment regarding race, gender, age, disability, spirituality, and sexual orientation. Conclusion: A. Maltreatment: According to the facility’s IR and GER, on May 18, 2023, P2 noted an “increase in behaviors” with the VA at a shift change and told P3. P3 instructed P2 to “watch” the “interactions” during the shift changes moving forward to determine if there was something “notable.” On May 19, 2023, P1 saw bruising on the back of the VA’s left arm and pictures were sent to P2. At some point on May 20, 2023, G1 expressed concerns to P2 regarding the SP’s interactions with the VA and P2 notified P3 about it. P3 then reviewed video footage from the SP’s shifts from April 20 to May 20, 2023, and shared the video footage files with LEO and this investigator. Video footage from the facility showed the SP had several concerning interactions with the VA that included repeatedly yelling at the VA, mimicking the VA, two instances of swearing at the VA, escorting the VA to his/her room with unnecessary physical contact which was likely to have caused the bruising on the VA’s upper left arm at times when the VA was not a danger to him/herself or others, what appeared to be kicking/nudging the VA from under the dining room table, and spending unnecessary time in the office when the VA was elsewhere at the facility and required supervision, which was inconsistent with standards of a professional caregiver in a facility licensed by the Minnesota Department of Human Services and violations of Minnesota Statutes 245D.04, subdivision 3, paragraph (a), clauses (4), (6), and (8). Although the SP told P3 that was how s/he “joke[d]” with the VA, yelling and swearing at a vulnerable adult and causing injury to them was likely not considered joking to any reasonable person. The SP’s actions were not accidental or therapeutic conduct and produced injury to the VA. Therefore, there was a preponderance of the evidence that the SP engaged in actions towards the VA that produced and could reasonably be expected to produce pain or injury; could reasonably be expected to produce emotional distress; and were a failure to supply the VA with reasonable and necessary care or services. It was determined that physical and emotional 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 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.) It was determined that neglect 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.) B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the VA’s plans and the reporting of Maltreatment of Vulnerable Adult’s Act. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated physical and emotional abuse and neglect for which the SP was responsible was “recurring and serious” maltreatment because of the repeated nature of the SP’s physical interactions with the VA and given that the VA sustained a bruise on his/her arm. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were adequate but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Given that the facility took immediate corrective action, a correction order was not issued for the violations outlined in this report.
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