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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: 1073752-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson/Scott Broady 651-431-6578 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was falling out of his/her wheelchair and a staff person (SP) refused to assist the VA. Then when the SP went to assist the VA, the SP yelled and swore at the VA. Date of Incident(s): November 7, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (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: 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 December 13, 2023, from documentation at the facility; and through five interviews conducted with the VA, another resident (C) who lived at the facility, two facility staff persons (SP and P1), and a supervisory staff person (P2). The VA enjoyed motorcycles, word finds, and fishing. According to the VA’s Coordinated Service and Support Plan the VA had paraplegia and moved to the facility in 2005 after his/her health declined and the VA needed additional support to care for him/herself. According to the VA’s support plan dated February 2023, “[The VA] has been dealing with a pressure ulcer on [his/her] right buttock” and “because of this, [s/he] is encouraged to get up more and be repositioned more.” The VA’s support plan did not have any additional information regarding doctor’s orders or when s/he needed to be transferred to or from his/her wheelchair, but stated that the VA requested that the side rails on his/her bed were up while s/he was in it so s/he can reposition him/herself independently. The facility was a single-level home with four bedrooms and two bathrooms. The VA’s bedroom was in the rear of the facility across from the C’s bedroom and near a bathroom. The facility stored a Hoyer lift in the bathroom that was used to assist the VA with transfers including into and out of bed and his/her wheelchair. The Hoyer lift was controlled by a remote control that was attached by a long cord to the lift. The VA had a sling with four loops that was used to transfer him/her that attached to the Hoyer lift using four hooks. According to the facility’s Internal Review, on November 7, 2023: [The VA] went out to smoke after staff assisted [him/her] with getting up at 9:15 p.m. on November 7, 2023. When [the VA] came back in from smoking, [s/he] watched tv for about 10 minutes and then stated that [s/he] wanted to lay back down. Staff suggested to [the VA] that [s/he] just got up about 20 minutes ago and that [s/he] should try and stay up for [his/her] recommended two hours. [The VA] then proceeded to go back to [his/her] room. [The C] came out and stated that [the VA] needed assistance as [s/he] felt that [the VA] was slipping out of [his/her] wheelchair. Staff informed [the C] that they had just gotten [the VA] up and [s/he] will have to wait to lay back down. Shortly after this time, [the C] came back out and stated that [the VA] was falling out of [his/her] chair. One staff went back to [the VA] while the other staff went to the bathroom. Staff that was in the bathroom heard the staff holler out their name and they hurried up to finish up and ran back to [the VA’s] bedroom. [The VA] had the lift and remote for the lift in [his/her] hand and was lifting [him/herself] up which resulted in [the VA] starting to fall out of [his/her] wheelchair. The VA provided the following information in an interview with this investigator and in the facility’s Internal Review and: · On November 7, 2023, at 9:00 p.m., the SP assisted the VA out of his/her bed into his/her wheelchair. The VA went outside to smoke and then came back inside. The VA then asked the SP to assist him/her back into bed but the SP told the VA that s s/he needed to wait for the night staff to arrive at 11:30 p.m. The VA said that s/he was “not supposed to be up” in his/her wheelchair that long. · The VA then went to the bathroom and “drug” the Hoyer lift from the bathroom to his/her bedroom. Once in the bedroom, the VA secured two of the hooks on the lift to two of the loops on the sling that was underneath him/her in the wheelchair. The VA then took the Hoyer remote control and pulled him/herself “halfway up” before s/he dropped the remote out of reach. The VA stated that after s/he dropped the remote s/he “kept falling further down” and was “halfway in, halfway out” of his/her wheelchair. · The VA stated that s/he called out to the SP for assistance. The SP then came to the room, and s/he asked the SP to assist him/her but the SP said, “No, I’m going to leave you,” and left the room. About 15 minutes later, the SP came back into the room and assisted the VA with transferring into bed. The VA said s/he was stuck in the lift for approximately 20 minutes. The VA stated that during the incident, the SP was “cussing and swearing” at the VA and calling the VA’ names, and that the interaction made the VA “pissed off.” · The VA stated that the SP was the only staff person working at the time of the incident and that no other residents saw what happened. The C stated that on November 7, 2023, the VA “hollered” at the C to get someone to assist the VA because s/he was falling out of his/her wheelchair. The C then went and told the SP that the VA was falling out of his/her chair, but the SP did not go assist the VA. The C then went outside for “maybe 5 minutes or so,” and when s/he went back to his/her bedroom s/he saw the VA hanging from the lift in his/her bedroom. The C went back to the SP and stated, “[The VA] needs your help,” and the SP went to assist the VA. The C could not remember if anyone else was working at the time of the incident, and only remembered talking to the SP. P1 provided the following information: · On November 7, 2023, P1 and the SP were working at the facility when around 9:00 p.m., the SP and P1 assisted the VA out of bed and into his/her wheelchair. The VA went outside to smoke, came back inside to have a snack, and asked to lay back down. P1 told the VA that s/he had only been up for 10 minutes, and the VA again asked to lay back down. The SP told the VA, “You’re gonna be up for an hour and a half and [the night staff] will put you to bed.” The SP and P1 then began doing inventory of facility supplies and the VA left the room. P1 stated that it was a doctor’s order that the VA needed to be up out of his/her bed for two hours at a time. · An unknown amount of time later, the C approached the SP and P1 and told them that the VA said s/he was falling out of his/her chair. P1 “assumed” the VA was “saying something for attention” so s/he and the SP did not go assist the VA and continued what they were doing and then they were going to go check on the VA. · Approximately 10 minutes later, the C came back and told the SP and P1 that the VA needed assistance. The SP then went to the VA’s room, and P1 went to use the bathroom. While P1 was in the bathroom, s/he heard the SP yell out to him/her so when P1 was done, s/he went to the VA’s bedroom. · When P1 arrived in the VA’s bedroom, s/he saw two of the four sides of the sling connected to the lift. Both P1 and the SP “raised [their] voices out of concern and surprise.” The SP and P1 then transferred the VA into his/her bed. When asked if the SP swore at the VA, P1 stated, “not really, I was caught up in the moment.” P1 stated that s/he had a conversation with the VA afterwards and apologized for raising his/her voice at the VA. P1 stated that the VA was not injured in the incident. The SP provided the following information: · On November 7, 2023, at an unknown time during the evening, the SP and P1 assisted the VA out of bed into his/her chair and told him/her that the night shift worker would put him/her back to bed because the VA needed to stay out of bed for two hours. The SP stated that s/he believed the VA had a doctor’s order that s/he was to be up out of bed for two hours at a time. The VA then went outside to smoke for about 20 minutes. · When the VA came back inside, s/he told the SP and P1 that s/he was going to his/her room, which “a lot of times meant [the VA] was ready to lay down.” The SP and P1 told the VA that s/he had just gotten up and they would not be putting him/her to bed. The VA then left the room. · An unknown amount of time later, the C then came to the SP and P1 and told them that the VA “wanted or needed help,” and that the SP “assumed” that meant the VA was ready to lay down. The C then left the room and went outside. · Then after “a couple [of] minutes” the C returned and told the SP and P1 that the VA was falling out of his/her wheelchair. The SP immediately went to the VA’s room and found the VA “halfway hooked up on the lift” on his/her left side. It appeared that the VA had hooked him/herself up using two of the four hooks and lifted him/herself up out of his/her wheelchair using the attached remote. The SP stated that the VA’s sling was kept underneath him/her when s/he was up in his/her wheelchair at the facility. The SP described the VA as “on top of where [s/he] had been sitting” and “hanging out of [his/her] chair.” After the SP saw the VA, the SP yelled for P1’s assistance and said, “What the fuck are you doing?” but did not say any other swear words or yell at the VA. When P1 arrived, P1 and the SP assisted the VA to bed. The SP checked the VA for injuries and found none. P2 provided the following information: · P2 was not working the night of November 7, 2023, but when P2 arrived at the facility on November 8, 2023, the VA told P2 that the SP yelled at him/her the night before but did not say anything about the lift at that time. P2 then asked P1 and the SP about what occurred on November 7, 2023, and requested that both P1 and the SP fill out incident reports. · P2 said the VA did not have a doctor’s order that stated s/he was required to be out of bed for any amount of time but it was a suggestion from the VA’s doctor. The VA’s team had discussed the possibility of a rights restriction, but it had not been implemented and at the time of the incident there was no rights restriction in place preventing the VA from going back to bed. At the time, P1 and the SP believed that it was a requirement, not a suggestion, that the VA be out of bed in his/her wheelchair for 2-hour periods of time. P2 retrained P1 and the SP on the VA’s plans. · P2 stated that s/he never heard the SP yell or swear at the VA. The VA was “not fond of” the SP, and did not tell P2 that the SP yell or swore at him/her during the incident. According to the facility’s “Rights Handout,” residents have the right to: · Have services and supports provided in a way that respects them and considers their preferences · Be free from restraint, time out, seclusion, restrictive intervention, or “other prohibited procedures” · Be treated with courtesy and respect Relevant Rule and/or Statute: Minnesota Statutes, section 245D.04 subdivision 3, paragraph (a), clauses (4), (6), and (15) states in part a person’s protection-related rights include: to be free from restraint, time out, seclusion, restrictive intervention or other prohibited procedure; to be treated with courtesy and respect; and to engage in chosen activities. Conclusion: Information was consistent that on November 7, 2023, when the VA returned inside s/he wanted to go back to bed but P1 and the SP told the VA that s/he needed to wait until the night staff person arrived approximately one and a half hours later. At the time, P1 and the SP believed that the VA had a doctor’s order that required him/her to be out of bed two hours. However, there was not a doctor’s order, and it was solely a recommendation. P1’s and the SP’s actions were a violation of Minnesota Statutes, section 245D.04 subdivision 3, paragraph (a), clauses (4) and (15). When P1 and the SP did not help the VA, the VA went to the bathroom, pulled the Hoyer into his/her bedroom and when s/he tried to transfer him/herself, the VA got stuck halfway out of his/her wheelchair. Consistent information provided by the C, P1, and the SP that the C told P1 and the SP that the VA needed assistance, but P1 and the SP did not check on the VA at that time because they were not aware it was an emergency. Sometime later, about five minutes according to the C, the C told P1 and the SP that the VA was falling out of his/her chair, at which time the SP went into the VA’s bedroom and found him/her hanging halfway on the sling out of his/her wheelchair. The SP then called for P1, who came to the VA’s bedroom, and they transferred the VA into bed. While P1 and the SP were delayed in assisting the VA out of his/her chair and into his/her bed, given that they were engaged in work related activities and initially did not know the VA was halfway about of his/her chair, and that the VA did not sustain an injury, there was not a preponderance of the evidence whether there was a failure to supply the VA with care and services that were reasonable and necessary.
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.) In addition, although P1 did not hear the SP swear, the VA said that the SP swore at him/her and the SP acknowledged that s/he asked the VA, “What the fuck are you doing?” when s/he saw the VA falling out of his/her chair. The SP swearing at the VA was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04 subdivision 3, paragraph (a), clause (6). However, it was a single word during a single incident. Therefore, there was a preponderance of the evidence that the SP’s actions were not repeated and could not reasonably be expected to produce emotional distress. It was determined that emotional abuse did not occur (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.) Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed, and there was a need for additional staff training. On November 14, 2023, all facility staff were retrained in the following areas: how to properly fill out an observation report and when, employee handbook and job description, proper policies and procedures, person served rights and rights restrictions, chain of command, lift storage when not in use, and speaking to persons served and co-workers in a respectful manner. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action, a Correction Order was not issued for the violations outlined above.
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