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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: 1073087-H_CRS (Home and Community-Based Services-Community Residential Setting) 1073083-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that there were concerns about a vulnerable adult’s (VA) treatment at the facility included that the VA was not allowed to go on activities, that two staff persons slapped the VA on his/her head, that a staff person hit the VA on the back with a spoon, and that the VA had bruises on both hands. Date of Incident(s): Unspecified dates prior to December 2022. 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); 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 28, 2022; from documentation at the facility; and through ten interviews conducted with the VA’s day program staff persons (P1-P2), facility staff persons (P3-P7), the VA’s case managers (CM1-CM2), and the VA. Facility documentation showed the VA enjoyed socializing with peers and in the community. The VA had a good sense of humor and was able to articulate his/her wants and needs. The VA had a history of confrontations with staff persons and peers, and the VA would verbally aggress using offensive or racial slurs. The VA’s outburst could come out of nowhere, and staff persons should allow the VA to have time to calm down. The VA’s physical health was declining. The VA was unable to complete most hygiene tasks independently, and the VA used a manual wheelchair. The VA had six hours of unsupervised time while at the facility, and two hours of unsupervised time while in the community. The VA was diagnosed with borderline personality disorder, depression, and bipolar disorder. The VA had a history of “making false accusations.” The VA was not subject to guardianship. The VA provided the following information: · The VA said staff persons would “slap” him/her, but they would “lie” to the investigator about any incident occurring. The VA did not identify the staff persons but said two staff persons slapped him/her. The VA said one staff person slapped him/her in the head with a spoon, and the other staff persons used a spoon to slap the VA on the back “all the time.” · The VA said s/he had bruising on his/her hand and knee and showed this investigator his/her hands and knee. The VA’s hand appeared to have multiple scabs, and abrasions, but no identifiable bruising. The VA’s knee had an adhesive-bandage, and the VA said the injury was a result of a staff person pushing the VA’s wheelchair in a hallway, and the VA hit his/her knee. · The VA said that staff persons were “mean” to him/her and s/he could not take it anymore. The VA continued to say that staff persons wanted him/her to move, and that s/he had not “done” anything “wrong.” The VA said s/he spent most of his/her time in his/her bedroom and wanted to move out of the facility “real bad.” The VA denied using any racial statements, and said staff persons would use racial slurs directed towards the VA. P1 provided the following information: · P1 said the VA was not at the day program from November 14 to November 17, 2022. A phone call was made to the VA on November 14, 2022, and the VA said s/he had a “cold” and was not “feeling well.” However, on November 18, 2022, the VA returned to the day program and said s/he had “lied” about being sick. · The VA told P1 that a staff person had caused bruising to his/her hands and showed P1 his/her hands. P1 observed two dark circles of bruising on both of the VA’s hands. The bruises were dime-sized and located below the middle of one the VA’s knuckles on both hands. The VA demonstrated to P1 that a staff person (the VA was unable to identify the staff person) blocked his/her wheelchair, and pinched the VA’s hands, while the VA was in his/her wheelchair. P1 said there were “some scratches” and “scrabs,” on the VA’s hands, however P1 did not take pictures of the VA’s hand.
· P1 said there was a “strained” relationship between the VA and facility staff persons, and the staff persons allegedly did not like the VA. P1 was aware the VA had behaviors such as using racial slurs, or throwing items at staff persons, and the VA told P1 that staff persons at the facility did not allow the VA past certain areas within the facility. · P1 said the VA’s ability to provide accurate information was “case by case” and the VA was “pretty impulsive.”
P2 provided the following information: · The VA said on the morning of November 18, 2022, that a staff person hit him/her in the upper back with a spoon while s/he was waiting for transportation to the day program. The VA was unable to identify the staff person, but the VA identified the gender of the staff person who caused an injury to his/her back. · According to the facility schedule P3 worked at the facility from 12 to 7 a.m. on November 18, 2022, and was the same gender that the VA identified. · P2 observed the VA’s back and saw three “faint reddened and faint bruised areas” on the VA’s her upper back which were approximately the size of a half dollar coin. P2 also observed scratches on the VA’s lower back, however the VA did not know how s/he got the scratches. The VA denied the injuries were scratches to his/her back, and P2 took a photo of the VA’s back. The photo showed numerous thin small scratches (approximately one inch or smaller in length), scabs, skin abrasions, and potential bruises. · P2 said the bruising could have been from a “larger spoon,” and the VA said, this was not the first time something like that had happened. P3 denied ever hitting the VA with a spoon and was not aware of any other staff persons hitting the VA with a spoon. P3, P4, and P5 provided consistent information within their interviews with this investigator. P3-P5 each denied hitting the VA at any time and were not aware of the VA being hit by any staff person. P3-P5 each said the VA was not an accurate reporter of information, and the VA engaged in verbal aggression, including derogatory comments towards staff persons. P3-P5 each stated they did not believe the VA was being abused or neglected by any staff persons. P6 said the VA had a history of providing inaccurate information, but the VA would insult staff persons and the VA could be at risk of "possible" retaliation. However, P6 could not "see" any staff persons physically harming the VA. The VA was “very vocal” and did not like it when people touched him/her. The VA wanted to move out of the facility as the VA wanted “more” staff persons the same “race” as him/her. P7 provided the following information: · P7 said all staff persons at the facility were interviewed and there was no information which showed the VA had been “abused.” P7 added that the VA did not provide any names of staff persons who the VA said had hit him/her. · P7 said the VA was not an accurate reporter and had made “a lot” of previous allegations, but there was no information the allegations occurred. · P7 said there was no information in daily progress notes which showed the VA had bruising on the VA’s hands during November 2022. · The VA had previously said a staff person hit him/her in the head on July 11, 2023. However, the VA did not provide the staff person’s name, and the VA did not have any injuries. CM2 provided the following information: · The VA told CM2 that staff persons had hit him/her, and CM2 spoke with P3, who denied there was any incidents of physical harm to the VA. CM2 had no additional information regarding which staff person(s) or when the incident occurred. · CM2 said the VA would “stretch the truth,” and did not have a good relationship with staff persons, to the point the VA had thrown objects at staff persons. CM2 said s/he was unable to tell when the VA “told the truth or not.” · CM2 said the VA had moved around multiple facilities and did not have the “best social awareness.” CM2 said there was “tension” between the VA and staff persons at the facility, and it worsened over the last few months. CM2 believed the VA needed to move out of the facility, as it was not a good situation for the VA. CM2 added that most of the staff persons at the facility were a different race than the VA, and the VA called staff person degratory names. CM2 said the VA wanted to live at a different facility and had recently taken a tour. The VA planned to move out of the facility at the beginning of 2023. CM1 said the VA told CM1 a staff person had hit him/her, but the VA did not provide a name for the staff person. CM1’s conversations with the VA ended with the VA “breaking down crying.” The VA “indicated” s/he had issues with two staff persons, but the VA only identified the genders of the staff persons and not their names. CM1 did not have any concerns with the facility and had not witnessed any “maltreatment” or “abuse.” Although there was an allegation that the VA was not allowed to go on activities, there was no information which showed the VA was not allowed to go on activities in the community. P3-P6 received training on the VA’s client specific plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on November 18, 2022, the VA told P1 that s/he had bruises on his/her hands because a staff person blocked his/her wheelchair. The VA did not identify the staff person but demonstrated that staff persons pinched the VA’s hands on his/her wheelchair. The VA had dime sized bruises on both hands below the middle knuckle. The VA also said that s/he “lied” about being sick the past three days and missing day program. Then, the VA told P2 that a staff person hit him/her with a spoon in the back. The VA did not identify the staff person but identified his/her gender. The photo of the VA’s back showed numerous thin small scratches (approximately one inch or smaller in length), scabs, skin abrasions, and potential bruises including two faint reddened areas the size of a half dollar coin. The facility determined that P3 was working that morning and was the same gender as the VA identified. P3 denied hitting the VA with a spoon. The VA also stated that in July 2023, two staff persons hit the VA in the head. The VA was unable to provide the staff persons’ names and did not have any injuries. There were multiple persons interviewed who stated the VA was not an accurate reporter of information, and there were racial issues and tensions within the facility. P3-P5 each denied hitting the VA, and did not have any knowledge of any other staff person harming the VA. P7 said all staff persons at the facility were interviewed and there was no information which showed the VA had been hit. Although the VA said that staff persons hit him/her with a spoon, and pinched his/her fingers causing bruises, given that the VA did not provide staff person names for any of the incidents, that it was not able to be determined how the VA’s bruises and marks were sustained, that P3, P4, and P5 each denied hitting the VA and denied seeing any staff person hit the VA, that P7 interviewed facility staff persons and no information showed the VA was hit, and that the VA had a history of not providing accurate information, there was not a preponderance of the evidence whether staff persons engaged in conduct that would cause the VA pain or injury. It was not determined whether abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult.) Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate and were followed. The facility did not complete additional staff training, but created a de-escalation plan to better support and protect the persons that received services. The report was not similar to past events. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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