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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: 1075970-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) twisted a bedsheet around the neck of a vulnerable adult (VA), hit the VA with a pillow, and called the VA a “fucker.” Date of Incident(s): June 17, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clauses (1) and (2): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · The use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 27, 2023; from documentation at the facility and law enforcement (LE) records; and through 13 interviews conducted with the VA, the VA’s guardian (G1) and former guardian (G2), the VA’s case manager (CM), the VA’s two family members (FM1 and FM2), two supervisory staff persons (P1 and P2), four staff persons (the SP and P3 – P5), and a facility health care professional (HCP). LE investigated this report, but at the time of distribution did not provide a final report. LE stated that due to not getting follow up contact from the SP that the case would remain open and inactive. The VA’s diagnoses included impulse disorder unspecified, pervasive developmental disorders, and mild developmental disability. The VA enjoyed listening to music, bowling, computer games, and spending time with family and friends. The VA lived alone at the facility. The facility was located in an apartment building that also had other tenants who were community persons. The facility entry door opened into a small hallway that led to a living room, a dining area, and kitchen, and to another hallway that led to a bathroom, the VA’s bedroom, and a staff office/bedroom. The VA had 1:1 staff person supervision that included an asleep overnight staff person. The VA was able to unsupervised at the facility and in the community for two hours. The VA did not have any rights restrictions regarding soda, but staff persons were to encourage him/her to make healthy choices. The VA’s Emergency Data Form stated that staff persons helped the VA with behavior management by encouraging him/her to take a break, use healthy coping skills, and actively listen to what was upsetting the VA and trying to problem solve. The VA’s Community Support Plan stated that “[the VA] should be encouraged to take deep breathes and take breaks as needed to calm [him/herself]. At times, [the VA] can get stuck in [his/her] thought process and not be willing to change [his/her] mind. Staff will process with [the VA] and offer choices or preferred items or activities.” The VA’s Coordinated Services and Support Plan Addendum stated, “If [the VA] leaves the AFC home unattended, staff will follow [the VA]. If staff loses sight of [the VA] or [s/he] is gone for more than 15 minutes, staff will call the PC [Program Coordinator] phone.” The VA said that one time there was an incident in the hallway of the facility where both s/he and the SP got “mad.” During the interview, the VA said that s/he “would rather not” talk about what happened during the incident and did not provide all details. The SP called the VA “a fucker” and told the VA to “fuck off.” The SP got a pillow from the living room and “hit” the VA with the pillow and “almost busted” the VA’s glasses. The VA said that the SP then “strangled me with sheets” and the VA “went out the door real fast” followed by the SP. The VA walked to a gas station and the SP followed the VA there and then back to the facility. The VA denied the SP did anything like this in the past. The VA then declined to provide additional information. P3 and log notes provided the following information: · On June 19, 2023, at 5 p.m., P3 started to work with the VA. At the beginning, they watched Country Music TV in the living room and the VA talked about a relative who recently passed away. P3 thought the VA looked “a little bit nervous” and “tensed up.” P3 said, “Nothing seemed to spark it, out of the blue,” the VA said the previous day the SP phoned law enforcement because the VA walked to a gas station to get a soda. · P3 did not recall the exact details of what the VA said, but the VA said the SP threw a pillow at the VA or “put a pillow on [his/her] face,” “hit” or “kicked” the VA in the back, and called the VA, “A fucker.” P3 asked what the VA did when this happened and the VA said, “I did nothing and walked out.” After talking to P3, the VA looked tense and P3 thanked the VA for telling him/her and the VA thanked P3 for listening. P3 then read the SP’s log notes from the previous day and saw that the SP documented that s/he followed the VA in a car, but there were no notes about any physical incident or that law enforcement was involved. · The remainder of P3’s shift the VA went on a walk to the gas station to get soda, walked around the community, took his/her medications, ate a snack, watched TV, and talked with P3 about other topics. That evening, P3 tried to talk with the VA again about the incident, but the VA did not want to talk about it saying s/he might get upset. The VA said s/he also told FM2 about the incident and that s/he planned to tell P2 about it the following day. · The VA did not provide any information to P3 that the SP wrapped or twisted a sheet around the VA’s neck and P3 did not see any unusual marks or bruises on the VA. P4 and log notes provided the following information: · On June 17, 2023, at 3 p.m., P4 arrived at the facility and replaced the SP. (Note: This is the shift after the alleged interaction with the SP and VA occurred.) The SP did not mention anything about the VA’s day and left the facility. The VA did not mention having any issues or incidents with the SP. P4 noted in the log notes the VA went on a walk to mall, ate dinner, and slept through the night. P4 worked the overnight shift until the next morning at 8 a.m. when s/he was replaced by the SP. P4 did not see anything unusual with the VA or at the facility. · On June 18, 2023, at 2 p.m., P4 returned to work and replaced the SP. During the shift, the VA went to the park and the mall, took medications, and ate dinner. P4’s shift ended at 11 p.m. Again, the VA did not mention any issues or incidents between him/her and the SP. · On June 19, 2023, at 7 a.m., P4 worked with the VA until 5 p.m. and there was nothing unusual. The VA went bowling, ate pizza, and went on a walk to the park across the street. The VA did not mention any issues or incidents between him/her and the SP. · On June 20, 2023, at 7 a.m., P4 arrived at work. The HCP called P4 to say s/he was on his/her way to the facility to fill medications. · That morning, the VA brushed his/her teeth and showered. When the VA got out of the shower and dressed, s/he came went into the kitchen where P4 was. The VA said s/he had “something to tell” P4 and that, “Something happened to me that I don’t like, and I have been having it on my mind.” P4 asked what happened and the VA said that the SP talked to him/her in a way the VA “didn’t appreciate” and that the VA “was abused.” P4 did not recall when the VA said the incident occurred, only that it was probably in May of 2023. · The VA told P4 that s/he tried to talk to the SP about going to get a soda, but the SP did not want to take the VA and then the SP hit the VA with a pillow across his/her face. P4 gave inconsistent information on what s/he was told by the VA that the SP said. P4 said the VA “didn’t appreciate” what the SP said to him/her, that the SP said some “foul language” towards the VA but P4 did not recall what words were used, and was “screaming” at the VA. The SP also said the VA “did not tell me that, [s/he] told me that [the SP] hit [the VA] with a pillow. The VA said s/he then left the facility and walked to the gas station to get a soda. The VA thought the SP left the facility and was “looking for [him/her] all over the place,” because the VA saw the SP at some point when the VA was at the gas station. The VA said after s/he got the soda s/he and the SP both returned to the facility. The VA did not say anything about what happened once s/he and the SP returned to the facility. · P4 thanked the VA for telling him/her what happened and told the VA that s/he should tell the HCP when s/he arrived, but the VA was “scared” to tell the HCP. P4 encouraged the VA talk to the HCP as s/he would be able to follow up on the VA’s concerns about the SP. · When the HCP arrived, the HCP and the VA went into the VA’s bedroom. P4 heard some of what was discussed, and it matched what the VA told P4. · P4 looked at the VA’s face and neck for marks, bruises, and/or injuries and did not see any. P4 also saw no signs at the facility at any time that any sort of struggle occurred. The VA did not tell P4 that the SP wrapped or twisted a sheet around the VA’s neck. The HCP and log notes provided the following information: · The HCP worked with the VA for several years and interacted with him/her about every two weeks for about 30 minutes at a time while s/he reviewed medical items for the facility. The HCP was able to identify when the VA was upset or anxious based on his/her demeanor and body language including the VA grinding his/her teeth, shutting down, not wanting to leave the facility, and declining to do tasks like showering. · On June 20, 2023, in the morning, the HCP remotely reviewed some of the VA’s log notes from over the weekend. The HCP saw the VA showed increased anxiety and behaviors. The HCP did not recall specifically what those behaviors were. The notes also stated that the VA went to a gas station several times to get a soda. The HCP wanted to check on the VA and arrived at the facility around 11 a.m. and P4 was working with the VA. · The HCP made small talk with the VA and asked if something was “bothering” the VA. The VA said s/he was “stressed out” and did not want to talk about it because it might “stress me out more,” which was unusual for the VA. The HCP told the VA s/he was not in trouble and that the HCP was a “safe person” to talk to. The VA asked the HCP to come to the VA’s bedroom so they could talk. · When they got into the VA’s bedroom, the VA appeared “shaky” and “seemed like afraid.” The HCP asked the VA what stressed him/her, and the VA said, “Staff,” and “Something happened.” The VA then said s/he had a “hard time” with the SP over the weekend. The HCP asked if the VA and the SP there was “an argument” with the SP and the VA said, “Yes.” · The VA then said they were in the hallway when the SP “tried to choke me” with a “twisted up sheet” and “wrapped it around my neck.” The VA did not know where the SP got the sheet. The VA “kind of wrestled or fought away” from the SP and the SP called the VA “a fucker,” and hit the VA in the face with a pillow. The HCP also thought the VA said s/he “pushed” the SP and the VA was “taller and bigger” than the SP. The HCP said the VA does not swear so it was “uncomfortable” to repeat what the SP said. The VA said s/he went to the gas station despite the SP not wanting the VA to go. The VA left the apartment building and the SP follow in his/her car. When the VA and the SP returned, the SP grabbed his/her soda and crushed it, spilling it everywhere on the hallway carpet. The VA did not say what happened after this, but based on the medication administration log the SP gave the VA an as needed (PRN) anxiety medication. · The HCP did not see any unusual marks on the VA and asked the VA if s/he was hurt, the VA said, “No,” and the VA did not require medical care. The HCP did not recall if s/he saw any stains on the carpet from spilled soda. · The HCP left the facility, went to his/her car, and phoned his/her supervisor who asked the HCP to come to the office. The HCP did so and met with his/her supervisor who then told P1 about what the VA said occurred. The SP provided the following information: · On June 17, 2023, at 8 a.m. the SP arrived at the facility. The SP went into the living room, and said, “Hello,” to the VA. The VA appeared “antsy” and wanted to leave to get a soda. The SP reminded the VA that the day just started and asked if the VA could wait while the SP got situated at the facility and offered the VA other things to do in the meantime. The VA became “agitated” and started to yell at the SP. The SP tried to work with the VA to calm. The SP gave the VA a PRN for anxiety and the VA went into his/her bedroom for “a little bit.” · When the VA returned to the living room it appeared that the VA was not calmed by the medication. The VA again asked to go to get a soda as s/he paced around the facility. The SP said s/he was concerned what might happen if s/he were to drive the VA to get a soda because the VA was agitated. The VA “got pissed off” and wanted to go “right now.” The SP continued attempting to talk with the VA when the VA “pushed” the SP “gently out of the way,” left the facility, and slammed the door. · The SP followed the VA, got into his/her car, and then followed the VA as the VA walked. The SP was concerned because the VA was “agitated” and “walking unsafe” because the VA was “on the sidewalk, but on the edge of the street.” The SP followed the VA to a local gas station and watched from outside as the VA walked in. The SP got out of the vehicle, stood next to the gas station door, and watched the VA inside. When the VA exited, the SP offered the VA a ride back to the facility, but the VA said, “Leave me alone,” and then began walking back toward the facility. The SP again followed the VA in his/her vehicle to the facility. · The VA left the facility four different times during his/her shift and each time told the SP to not follow him/her. The SP repeated the process and followed the VA back and forth to the gas station each time. Each time, the SP offered to drive the VA, but the VA refused. · During one of the times the VA left the facility, the SP was unable to find the VA for about four to five minutes. The SP called P4 and asked for help. P4 offered suggestions to the SP on what to do. The SP believed the VA went to a neighbor’s place for a bit, because the SP found the VA back in the facility. · The SP tried talking with the VA about what happened, but the VA became agitated, played with the microwave, and stood in the kitchen and did not want to talk. The SP offered the VA another PRN which the VA took. As the time passed, the VA appeared calmer and spent time in the living room where s/he watched TV and relaxed on the couch. At 3 p.m., the SP’s shift ended and P4 came to replace him/her. The SP updated P4 on what occurred with the VA while on shift. · The SP said, “There was never a physical altercation between me and [the VA].” The SP denied hitting the VA with a pillow, swearing at the VA, crushing the VA’s soda, and/or putting a sheet around the VA’s neck. · On June 18, 2023, at 8 a.m., the SP arrived at the facility and the VA was in the living room watching TV. The VA then ate breakfast, spent time in his/her room, and took his/her 10 a.m. scheduled medications. The VA apologized for what happened the previous day and said s/he planned to listen to the SP from now on. At noon, the VA and SP went on a walk and stopped at the gas station where the VA purchased a soda. The SP and VA walked back to the facility where the VA watched TV. Later, the VA wanted to go back to the gas station for another soda and the SP talked with the VA about how much soda s/he already drank, but the VA still wanted to get more. Then the SP and VA went back to the gas station, the VA purchased another soda, and they returned to the facility. P2 provided the following information: · On June 20, 2023, P1 received an email from P2 about the incident and P2 called the SP. The SP told P2 that the VA went to the gas station twice to get a soda and on the third time the SP said, “That is enough.” The VA got “angry” and walked away from the SP, left the facility, and went to the gas station. The SP followed the VA, and the VA called the SP “a fucker.” P2 was unsure if this was true because s/he never heard the VA swear before this. The SP denied to P2 that s/he threw the VA’s cup in the garbage and/or that there was any physical altercation between him/her and the VA. · That same day, in late morning or early afternoon, P2 went to see the VA. The VA seemed “good, [s/he] was fine.” P2 asked if the VA’s throat hurt, or if any other body part hurt and the VA said nothing was hurt. P2 saw no bruises or marks on the VA’s neck or face. The VA was initially hesitant to talk about what happened with the SP. But then the VA told P2 information that was consistent with the information the VA told the HCP. The VA said s/he wanted to get a soda, the SP refused, and that the SP got “so mad.” The SP “hit [the VA] with a pillow on [his/her] face, and then [the SP] got the sheet and strangled [the VA] with the sheet.” The VA said the SP then took the VA’s cup and threw it in the garbage. The VA denied hitting the SP.
· P2 said the VA was truthful “most of the time.” The VA occasionally said things that were “not true” such as when s/he did not want to do a task, s/he might say s/he felt ill or if s/he already took a medication when s/he did not. The VA had no history of providing inaccurate information about staff persons who were physically aggressive with him/her. The VA had not previously mentioned concerns with the SP. · P2 stated there was a prior concern with the SP in the past about the manner s/he talked with another vulnerable adult, but P2 saw no “red flags” or other concerns with the SP. P5 and log notes provided the following information: · On June 18, 2023, P5 worked the overnight shift and arrived at the facility at 11 p.m. P5 and the VA talked about the VA’s day, and the VA did not mention any issues with the SP. The VA said that s/he went to the gas station and the SP followed in his/her car. P5 did not see anything unusual around the facility that showed any situation may have occurred. P5 saw no marks on the VA’s neck and the bedding was in the usual place in the VA’s bedroom on the floor. · The VA’s “reality at times can get skewed.” There were times when the VA made inaccurate statements but when asked the VA said s/he was “kidding.” · P5’s shift was often prior to the SP’s and P5 did not have concerns regarding the SP’s interactions with the VA. The VA was usually “happy” to see the SP. The VA never told P5 about any concerns with the SP. P1 provided the following information: · On June 20, 2023, P1 received an email from the HCP about what the VA told him/her regarding the incident. The HCP provided information in the email that was consistent with the information the HCP provided in his/her interview. · P1 then reviewed the log notes and read an entry dated June 19, 2023, from P3 that said, “[The VA] reported that [s/he] got in to [sic] a fight with staff yesterday. [The VA] initially reported that staff hit [him/her] in the back and hit [him/her] with a pillow on [his/her] face.” · P1 later spoke with the VA and asked the VA if the SP put a sheet around his/her neck, hit the VA in the face with a pillow, and called the VA a “fucker.” The VA said, “Yes.” P1 then met with the SP and asked about what occurred with the VA over the weekend. The SP said the VA was “obsessing” about going to the gas station to get a soda and the SP told the VA s/he “should wait.” The VA did not want to wait, “shoved” the SP, and then left the facility. The SP said s/he did not document the interaction because, “It wasn’t a big deal.” The SP denied putting a sheet around the VA’s neck, denied hitting the VA with a pillow, and denied calling the VA a “fucker.” · The VA did not knowingly provide incorrect information but might interpret incidents “differently” and “inaccurately” due to his/her anxiety. The VA might state a staff person at the facility who asked the VA questions was “mad” at him/her, but the VA misinterpreted the conversation. P1 had “never known [the VA] to just make up an outright lie.” P1 said the VA would “never say that [a staff person] hit [him/her] if [the staff person] didn’t.” G1 recently became the guardian for the VA and had limited communication with the facility. G1 had no concerns with the facility apart from not being informed there was the reported interaction between the VA and the SP. G2 provided the following information: · G2 did not have any concerns about the facility apart from when the VA appeared “disheveled” at times. · G2 said s/he did not know about the incident between the VA and the SP. (Note: On June 21, 2023, P2 emailed G2 about the incident.) G2 did not believe the VA was an accurate reporter because the VA “says things that don’t make sense.” For example, in the past, the VA made allegations about staff persons that were later determined not to have happened, including that a staff person hit the VA. The VA later said s/he was “just upset” and recanted what s/he said. The CM was new to working with the VA and the VA did not express any concerns to the CM about the facility. The CM did not have any concerns about the facility and did not know if the VA was an accurate reporter. On June 21, 2023, the CM received an email from P2 about the allegation. FM1 and FM2 were aware of the allegations and did not have further information. Facility documentation stated that P2, P3, P4, P5, and the SP received training on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On June 17, 2023, the SP worked at the facility and the VA wanted to leave to get a soda. The SP tried to talk with the VA about making healthy choices and the VA left the facility to the gas station to get a soda. The VA provided similar information to P1, P2, P3, P4, the HCP, and this investigator that the SP hit him/her in the face with a pillow, wrapped a twisted sheet around his/her neck, and crushed a soda onto the hallway floor and/or swore at the VA. The VA also told P3 that the SP t called law enforcement. The VA told P5 s/he left to get a pop at the gas station and the SP followed in his/her car, but there was no mention of any physical incident. Although the VA provided similar information to multiple persons at different times, no staff person who interacted with the VA between June 17 and 20, 2023, saw any marks, bruises, or injury on the VA; and P4, who worked the shift after the alleged incident, did not see any signs that a physical struggle occurred, misplaced pillows or sheets, or that soda was spilled on the hallway carpet. In addition, information regarding the VA’s ability to provide accurate information varied and the SP denied the allegations. Therefore, there was not a preponderance of the evidence whether the SP engaged in the actions as described by the VA. It was not determined whether physical and/or 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/or the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: Facility Internal Review showed that company policies and procedures were adequate, but not followed by P3 for not reporting the maltreatment and an incident report. P3 will be retrained on incident response and reporting. The SP no longer worked with the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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