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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: 1103760-H_CRS (Home and Community-Based Services-Community Residential Setting) Closed August 31, 2023 Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that a staff person (SP) attempted a physical altercation with a vulnerable adult (VA). It was also reported that the SP left the VA in the community unsupervised and called the VA a racial slur. Date of Incident(s): June 24, 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 August 4, 2023; from documentation at the facility, law enforcement records, and medical records; and through seven interviews conducted with a facility supervisor (P3), three facility staff persons (SP, P1, and P2), the VA, the VA’s case manager (CM), and the VA’s guardian (G). This investigator reached out to P4 and P5 by telephone and mail to request an interview, but neither P4 nor P5 responded. The facility was a split level. On the upper level there were three bedrooms, a bathroom, a living room, a dining room, and a kitchen. Off of the dining room there was a sliding door that led to a porch. The lower level had an additional three bedrooms, another bathroom, another living room, and another dining room. The VA’s diagnoses included a mild intellectual disorder, unspecified sexual disorder, borderline personality disorder, and attention deficit hyperactivity disorder. The VA enjoyed going to movies, spending time with his/her significant other, and fishing. The VA’s Coordinated Services and Supports Plan (CSSP) stated that the VA did not have unsupervised time in the community per the Department of Correction conditions of release. The VA “need[ed] 24-hour supervision to ensure [his/her] health and safety needs are adequately met as well as to meet [his/her] probation requirements.” The VA’s safety plan included one to one staffing. P1 provided the following information to this investigator and for the facility’s Internal Review: · On June 24, 2023, P1 received a telephone call from the SP that s/he did not feel safe at the facility with the VA. P1 arrived about 10-15 minutes after that telephone call and saw the VA talking on a telephone so P1 talked to staff persons and was told 9-1-1 was also called. P1 was told that the VA was upstairs cooking and there was smoke, so staff persons tried to open up a door. The VA went and “slammed” the door and threatened staff persons to not open it again. The VA got angry and grabbed a chair and threatened to hit staff persons. · P1 then talked to the VA and a law enforcement officer. They realized the VA had a cut on his/her finger, so they cleaned it up and took the VA to urgent care. P1 asked the SP to follow them to urgent care. · The VA was treated at urgent care and seemed to “calm down.” The VA told P1 s/he was “fine.” P1 received another call to assist at another facility, so s/he left the VA and the SP at urgent care. · While assisting at the other facility, P1 received a telephone call from the SP stating that the VA walked out from the hospital and wanted the SP to follow him/her. The SP did not feel comfortable following the VA as there was traffic. P1 told the SP to put on the hazard lights and if s/he was stopped by law enforcement to explain that s/he was following the VA. They hung up and then the SP called again and said s/he was not able to follow the VA and that the SP was going back to the facility. · The client at the other facility was “good” so P1 left to find the VA. P1 said s/he found the VA on a walking bridge over a highway. The VA got into P1’s vehicle to go back to the facility. It was determined that where P1 found the VA was just over two miles from the last known location provided by the SP to P1. Given that distance it was approximately a 45-minute walk. · P1 and the VA arrived back at the facility approximately 11:30 p.m. and P1 noticed another vehicle in the driveway, so P1 stayed in the road to let that vehicle back out. The SP approached P1’s vehicle and the VA was agitated so P1 told the SP to leave. The SP started swearing and using racial slurs toward the VA and P1. The occupants of the other vehicle exited and pulled the SP back from P1’s vehicle. P1 said the other staff persons in the facility saw too. There was no physical behavior, just “abuse words” came from the SP. P1 said it lasted about five minutes. The VA provided the following information: · On the day of the incident, the VA was cooking and an unknown staff person (the VA did not remember who it was but stated it was not the SP) opened the sliding door so the VA went over to shut the door. The staff person opened the door again and the VA shut the door again stating that bugs were getting in. The VA held the door from the inside and the staff person “ripped” it open from the outside, then the VA said the staff person “pushed me, shoved me, grabbed me by my throat.” The VA said the staff person called the VA “trash” and “the ‘R’ word.” The VA said s/he “snapped” and grabbed a wooden chair to go sit out back. · The VA said that staff person ran around the yard because s/he thought the VA was going to hit him/her with the chair. The VA said s/he noticed the cut on his/her pinkie finger. The VA stated that the staff person kept coming over and asking, “Are you okay? Tell me if you are okay?” and saying, “I do not want to get in trouble.” · The VA said a law enforcement officer arrived and the VA stated s/he wanted to press charges against the staff person. The VA went to the hospital with P1 to get stitches in his/her finger. The VA said P1 stayed until the SP arrived at the hospital, but then P1 had to leave to answer another call. · The VA stated s/he did not want to return to the facility and that s/he did not feel safe there because of another client. The VA stated that the SP was at the hospital to drive the VA home, but first the VA wanted to walk around the parking ramp and have a cigarette to “calm down.” The VA stated s/he was not on a bridge, and that the SP was able to see the VA the whole time in the parking ramp. · When the SP and the VA returned to the facility, the VA had a cigarette, went downstairs, and watched television in the recliner. · The VA said that another client in the house called him/her racial slurs, not staff persons. Law Enforcement Records showed that on June 24, 2023, at 5:34 p.m., a call came in from the VA stating that staff persons “dragged [him/her], pushed [him/her], and verbally assaulted [him/her].” Law enforcement officers arrived on scene and made contact with the VA and staff persons. “There was a disagreement about cooking and smoke/heat in the house. [The VA] became upset. [The VA] cut [his/her] finger on a chair from the house. [A facility] crisis team was on the scene and mediated. No[thing] further to report.” Medical Records showed that on June 24, 2023, at 7:15 p.m., the VA presented to the urgent care department with a cut on his/her right fifth finger. The VA stated s/he “got in a scuffle” with a staff person and the VA picked up a metal chair and it cut his/her right pinky finger. The VA received three sutures, antibiotic ointment, and a non-adhesive packing strip and splint. The VA left urgent care in “no acute distress.” The SP provided the following information: · The SP said that the VA was upstairs cooking and P4 did not like the smell, so P4 went to open the door to outside. The VA closed the door and P4 opened it again and this went back and forth. The VA started shouting so the SP stepped in to “deescalate the situation.” · The VA told the SP that P4 called the VA a racial slur and the VA went after P4. The SP tried to get in between them and got pushed around by their chests. The VA and P4 argued. The VA grabbed a chair and started chasing P4. The SP said that was when the VA cut his/her hand. · The SP called law enforcement and P1. Law enforcement and P1 arrived at the facility, and the SP told them what happened. P1 took the VA to the hospital and had the SP follow them. The VA was “stitched up” and in “good spirits.” P1 left. · The SP went to take the VA back to the facility and the VA got into the car and was upset about things in the past and stated, “I am leaving this house, and I am suing all of you.” The VA told the SP s/he was going to walk so the VA got out of the car. · The SP called P1 and told P1 that the VA did not want to get in the car. P1 told the SP that s/he needed to follow the VA. The SP lost the VA in a traffic circle. The SP stopped and got out, the SP was anxious because there were cars behind him/her, and the SP did not want to get pulled over. The SP called P1 back and told P1 that s/he was not able to see the VA anymore. P1 said s/he was on his/her way and the SP gave P1 his/her location. The SP waited five minutes and then left. The SP said P1 did not tell him/her to wait. · The SP said his/her ride was waiting outside when the VA and P1 arrived back at the facility. The SP wanted to talk to P1 because P1 made it sound like the SP was going to get in trouble, so the SP went to P1’s vehicle to talk. The SP was nervous, anxious, and felt like it was an “honest mistake.” The VA and P1 kept closing the vehicle window and the VA told the SP to, “Get out of here,” so the SP went home. · The SP normally worked overnight with the VA and the VA was not out in the community during that time. · The SP denied calling the VA a racial slur. The SP stated during the altercation with the VA cooking the SP did say something like, “This is your house.” The SP did not mean it in a harmful way but realized it could have been worded better. P2 stated that s/he was not working the morning of the incident in which the VA got hurt but P2 came in to work the overnight that evening. P2 heard that the VA and the SP were “mad” at each other. P2 said the VA and P1 arrived back at the facility and the SP went out to the vehicle and “pushed on the car.” P2 said that s/he, P4, and P5 were in the facility at that time and heard the SP, P1, and the VA arguing so they ran out to “deescalate the situation” and tell the SP to go home. P3 provided the following information: · P3 was not working at the time but reviewed the video and saw the VA cooking upstairs and P4 opened the patio door. The VA yelled at P4 and they “fought back and forth.” The SP arrived upstairs and asked what was going on and “a power struggle” between the SP and the VA ensued. P3 heard, “You have to live here for a reason,” on the video. The SP stated P4 said that to the VA. P3 saw the VA grab a chair and then the SP and P4 went outside. · P3 stated there was no video footage of what happened once everyone got outside, but he heard that the VA was chasing staff persons with a chair and when the VA put it down the VA had a cut on his/her pinkie. One of the staff persons called 9-1-1 to help with the situation. · P3 did not remember if the VA received stitches at urgent care or if his/her injury was just bandaged. P3 heard that the VA did not want to get in the vehicle with the SP so s/he walked away and the SP followed in the vehicle. The VA went toward a traffic circle and walked in a ditch next to it. The SP followed in the traffic circle and had other vehicles honking at the SP and the SP was no longer able to see the VA so the SP requested help from P1. · P3 heard that P1 found the VA about two- and one-half miles away about 20-35 minutes after the SP left the VA. P1 drove the VA back to the facility and the SP “yelled” at P1. P3 heard that the SP was “more upset” that P1 told the SP s/he should not have left the VA. P3 did not recall hearing any racial slurs from the SP or P4. The G stated that the VA had one to one supervision requirements, “always within earshot or eyesight.” The G was not aware of the VA being left without supervision in the community. When the G talked to the VA, the VA did not want to talk about the incident or his/her finger but wanted to talk about moving out because of another client in the facility. The G said the VA will “play a story to [his/her] advantage” by telling one thing to someone and something else to another person. The CM said that the VA told him/her that an unknown staff person came downstairs and called the VA a racial slur and the “R word.” The unknown staff person then went toward the VA, so the VA grabbed the unknown staff person by the neck and moved him/her toward the door to upstairs. The unknown staff person then went upstairs. The CM stated that the VA will tell a story, but it will be one sided, and if the VA was angry it might be exaggerated, but the VA was not known to “flat out lie.”
This investigator reviewed two video clips. The first video showed the VA at the stove cooking and P4 walked by and opened the sliding door and went outside. The VA said, “Close the fucking door.” The VA walked over to the sliding door and closed it. P4 opened the door and asked the VA, “Can you keep the door open, the [facility] is smoky, and to get the scent out.” The VA stated the facility was not smoky and s/he and P4 continued to argue about this. After about one minute, the VA shut the door again and the SP came from the hallway and asked the VA, “What are you doing?” and then asked P4 what the VA was doing. P4 explained to the SP about the door and the SP tried to explain to the VA. The VA became upset and swiped a roll of paper towels off of the counter and yelled at the SP, “Don’t fucking yell at me you son of a bitch.” The SP and P4 continued to try to tell the VA that they were having the door open to get the smell out. The VA continued to yell at the SP and P4, so the SP said, “You’re the one that is supposed to be here, remember that. It’s your fault that you’re here, do not complain to nobody.” The VA came toward the SP and aggressively moved a bar stool and got in the SP’s face. At this time P4 came back through the sliding door from outside and got in between the SP and the VA. At no point did the VA or the SP put hands on one another. P4 walked the SP out the sliding door and that was where the video ended. This investigator did not hear the SP or P4 call the VA the “r” word or use racial slurs. The second video clip was from when the VA returned to the facility from urgent care. There was a vehicle (V1) parked in the driveway and another vehicle (V2) approached and parked in the street (information showed that the VA and P1 were in V2). The SP came out of the facility and went around V1 in the driveway and said to the occupants, “I’m about to beat somebody down.” The occupants said, “[The SP] no,” to which the SP responded to the occupants of V1, “Shut the fuck up.” The SP approached the driver’s side of V2 parked in the street and while raised voices were heard, it was not always audible. After 20 seconds V1 backed out of the driveway onto the street facing V2 and the occupants got out and tried to get the SP in V1. At this point you can hear the SP say a racial slur and “I will fuck you up,” to the occupants of V2 as the occupants of V1 pushed at the SP and got between the SP and the door of V2. P2, P4, and P5 came out of the facility and one of them stated, “Yo [The SP, the SP, the SP], chill [man/woman].” The SP can be heard yelling, “You old ass [racial slur].” One of the occupants of V1 said, “I think [s/he] is just frustrated with what happened today.” P2, P4, and P5 went over to help the situation and there were some more inaudible exchanges and then the SP said, “You bitch ass [racial slur].” The SP and the occupants of V1 left and V2 pulled into the driveway. While this investigator could hear some of the racial slurs used by the SP, including the “n” word, it was not clear if they were used at the VA or at P1 but the SP was near V2 in audible range of the VA and P1. The facility’s Program Abuse Prevention Plan stated that, “Staff [persons] will travel with the individuals in the community and help them each to monitor for traffic and other hazards. Individuals do not currently have time alone.” The facility’s policy on Person-Centered Planning and Service Delivery stated that, “Services respect each person’s history, dignity, and cultural background.” Facility records showed that the SP, P1, P2, P3, P4, and P5 were all trained on the Reporting of Vulnerable Adults Act, the facility’s policies, and the VA’s plan. Relevant Rule and/or Statute: Minnesota Statutes, 245D.07, subdivision 1a, paragraph (a) states the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum, and in compliance with the requirements of this chapter. Conclusion: A. Maltreatment On June 24, 2023, an incident occurred but information from the VA and the SP differed. However, there was video footage that showed the VA was cooking upstairs and P4 opened the patio door to let some air in. The VA was upset and closed the door. P4 opened the door again and the VA yelled at P4. The SP came into the area at this time and asked what was wrong. At that time the VA and the SP yelled at one another. The VA picked up a bar stool and slammed it on the ground. The VA got into the SP’s face and P4 got in the middle and moved the SP outside. The SP stated that P4 called the VA a racial slur but that was not heard on the video and the VA stated no staff persons called him/her a racial slur. The SP stated that the VA chased staff persons with the chair outside, while the VA stated that s/he did not and took the chair outside to smoke. The SP called law enforcement and P1 for assistance. When P1 and law enforcement arrived, it was noted that the VA had a cut on his/her finger and needed medical attention. P1 took the VA to the hospital and asked the SP to follow them. While at the hospital the VA “calmed down” and P1 received a call from another facility and left to assist there. The VA received three stitches and then s/he and the SP left. The VA stated that s/he never left the parking ramp and just walked around the ramp while s/he had a cigarette. The SP stated that the VA got into the vehicle and was “upset” so the VA exited and stated s/he wanted to walk. The SP tried to follow but lost the VA in a traffic circle. The SP was “nervous and anxious” as there were cars in the traffic circle and the VA did not want to get pulled over. The SP called P1 and told P1 what had happened and where s/he was. P1 told the SP s/he was on his/her way, so the SP left and returned to the facility. P1 found the VA over two miles away from his/her last known location (about a 45-minute walk). P1 and the VA returned to the facility. When P1 and the VA returned to the facility, the SP stated that s/he approached the vehicle to talk to P1 because s/he was concerned about what was going to happen to him/her for leaving the VA as P1 made it seem like the SP would get in trouble. P1 stated that the SP was yelling and using racial slurs at P1 and the VA. P2, P4, and P5 exited the facility to help and P2 stated they were trying to “deescalate” the situation. This investigator heard the SP use racial slurs including the “n” word in the video, but was not able to determine if they were used toward P1 or the VA. The SP denied using racial slurs and the VA stated that staff persons did not use them toward him/her, but another client in the facility used them at the VA. Regarding Physical Abuse: The VA stated that an unknown staff person (not the SP) “pushed me, shoved me, grabbed me by my throat” during the altercation at the facility, and called the VA derogatory names. Although video showed the VA arguing with the SP and P4, the video did not show that any staff person laid a hand on the VA. The SP stated that the VA chased staff persons with a chair, so the SP called law enforcement and P1 to help the situation, and it was during this that the VA cut his/her finger on the chair. Given the video did not show the SP or P4 pushing, shoving, or grabbing the VA’s throat, that the VA could be unreliable when providing information, and that the VA’s finger injury was caused by a chair, there was not a preponderance of the evidence whether the SP or any staff persons engaged in actions that would cause the VA pain or injury. 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 including, but not limited to: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Regarding neglect: After the VA was discharged from urgent care, the VA did not get in the car with the SP who was going to take the VA back to the facility. The VA and the SP provided different information. The VA stated s/he was not out of the SP’s sight and was in a parking ramp to smoke before going back to the facility. The SP stated that the VA started walking away and the SP followed the VA as long as s/he could but then lost sight. The SP called P1 for assistance and P1 found the VA and brought him/her back to the facility. Although the VA did not have any unsupervised time in the community and that the VA was unsupervised for approximately 45 minutes, which was a violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a), given that the VA would not get into the SP’s car, that the SP attempted to follow the VA, that once the VA was out of the SP’s sight, s/he contacted P1 who found the VA, and that the VA was not harmed when s/he was unsupervised, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether 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). Regarding emotional abuse: Although the SP stated that P4 called the VA a racial slur, the VA said no staff persons called him/her a racial slur. In addition, P4 was not heard doing so on the video. Later, P1 stated that the SP was yelling racial slurs, including the “n” word, at the VA and P1 through the car window. Although the SP denied doing so, this could be heard on video footage. The “n” word and racial slurs the SP used could have been directed toward P1, the VA, or both, however regardless, given that the SP was next to the vehicle the VA was in, that the “n” word was particularly egregious in nature and considered malicious, that the VA heard the SP use racial slurs multiple times, that the SP had reason to minimize his/her actions for fear of consequences, there was a preponderance of the evidence that the SP used repeated malicious language that could be reasonable expected to produce emotional distress. It was determined that 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: 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). 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 Reporting of Vulnerable Adults 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 emotional abuse for which the SP was responsible did not meet the statutory criteria to be determined serious and was not recurring maltreatment as it was a single incident. Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures adequate, but not followed by the SP. The SP was retrained. Action Taken by Department of Human Services, Office of Inspector General: A Correction Order was not issued for the violation outlined in this report because the facility closed on August 31, 2023, and changed ownership.
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