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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: 1071704-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) physically and emotionally abused two vulnerable adults (VA1 and VA2) and neglected VA1, VA2, and another vulnerable adult (VA3). The concerns included: · SP1 and SP2 “screamed at” VA1 and VA2. · SP2 chased VA1 around the kitchen and “punched” VA1. · SP1 and SP2 “forced” VA2 to stay in his/her bedroom during mealtimes. · SP1 and SP2 did not always provide meals to VA1-VA3, so VA3 had to cook meals for him/herself, VA1, and VA2. · VA2 was observed to be in soiled undergarments when overnight staff persons arrived after SP1 and SP2 worked. VA2 said that SP1 and SP2 said that it was not their job to assist VA2 with personal cares or cleaning when VA2 was incontinent. Date of Incident(s): Prior to May 1, 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 2, 2023; from documentation at the facility; and through ten interviews conducted with VA1-VA3, facility staff persons (SP1, SP2, P1, P2, P4, and P5), and VA3’s guardian (G1). A facility staff person (P3) did not respond to a request for an interview. VA1 enjoyed watching football and basketball, sitting outside, and eating cereal, pizza, and Neapolitan ice cream. VA1 was diagnosed with traumatic brain injury that interfered with his/her short-term memory, dementia, and unspecified mood disorder. VA1 was not subject to guardianship. VA2’s diagnoses included traumatic brain injury and mild intellectual disabilities. VA2 used a cane to assist with ambulation and balance. VA2 enjoyed swimming and boating. VA2’s Risk Assessment Detail stated that s/he did not have consistent control regarding saying “offensive statements, making sexual comments to others, repetitive behaviors, and getting into other persons’ space.” VA2 was subject to guardianship. VA3’s diagnoses included paranoid schizophrenia. VA3 enjoyed basketball, biking, and listening to music. Some of VA3’s favorite foods included candy, lasagna, pizza, cheeseburgers, eggs, and steak. A report made to the Department of Human Services stated that SP1 and SP2 “yell and scream” and swore at VA1 and VA2. On one occasion, VA3 said that there was a “scary fight” where SP1 chased VA1 around the kitchen and “punched” VA1. It was also reported that SP1 and SP2 “forced” VA2 to eat meals in his/her bedroom, left VA2 in soiled undergarments, and refused to assist VA2 when incontinent. VA1 moved to a new/different facility approximately three weeks prior to being interviewed by this investigator. (The incidents occurred at VA1’s old/prior facility.) VA1 was not able to identify any roommates at either facility by name. VA1 said there were times that staff persons yelled at him/her; however, it was “short lived,” and s/he was only able to identify those staff persons as “middle-aged.” When asked if the staff persons s/he referred to were men or women, VA1 said there was “one of each or two of each.” VA1 denied ever being hit or punched by a staff person. VA2 said that VA1 used to live at the facility and was VA2’s “good friend.” VA2 denied arguing with VA1. VA2 denied that staff persons ever yelled at him/her or VA1. Although VA2 did not know where s/he ate his/her meals, s/he said that staff persons did a “very good job” cooking and fed VA2 double portions. VA2 had no concerns with any staff persons that worked at the facility and said that s/he was “very, very, very happy and safe.” VA3 provided the following information: · VA3 said that VA1 and VA2 “got in fights with each other” but after VA1 moved out, VA2 “doesn’t fight anymore.” Although SP1 and SP2 were “pretty nice,” they sometimes “yelled” at VA1 and VA2. VA3 believed that VA1 and VA2 “got on [SP1’s] nerves.” Sometimes there was yelling about the TV remote and despite the yelling and physical posturing, no physical injuries resulted. VA3 had no information about VA2 eating meals in his/her room. VA3 said that VA3 had no information about VA2 urinating and staff persons refusing to assist VA2. · VA3 told a facility staff person (P6) that VA3 saw a “scary fight” when SP2 chased VA1 around the kitchen island and SP2 punched VA1. VA3 did not witness SP1 “hit, slap, or shove” any clients. However, VA3 told this investigator that it was SP1 (not SP2) who chased VA1 and they “almost got in a fight” when they each had their fists in front of them like they were going to punch each other; however, no physical contact was made. The incident was “loud” and it “scared” VA3. · VA3 told P6 that staff persons cooked meals “two to three” times a week and that VA3 made meals for VA2 because staff persons will not make food for VA2. After P2’s shift ended, unidentified staff persons “will not make food” for VA2. VA3 told this investigator that SP1 and SP2 prepared the meals but sometimes, “because of their religion,” they did not touch certain foods so VA3 cooked those foods. VA3 said that occurred about “every two weeks or every so often.” P2, a supervisory staff person, and/or a facility Incident Information form provided the following information: · P3 told P2 that SP1 and SP2 “screamed” in VA2’s face, that when VA1 had “behaviors” and yelled at staff persons, SP1 and SP2 “yelled back,” that SP1 and SP2 “did not make meals” and “forced” VA2 to eat meals in his/her bedroom.” P3 did not witness these incidents but “heard it outside of work” from P4. P3 also said that P4, SP1, and SP2 were “friends.” · On an unidentified date in May 2023, P5 told P2 that when P5 arrived at the facility after SP1 and SP2 worked, the facility was not clean and VA2 was wearing the same “brief” from the morning as well as dirty clothes. · Prior to the incidents being reported, P2 had to “write up” SP1 and SP2 for performance issues related to cleaning the facility and “attitude problems.” · P2 said that VA1 had dementia and was not always accurate when reporting events. VA2 also had dementia and his/her accuracy fluctuated from day to day. P2 believed that VA3 was “able to relay things accurately,” was observant, and noticed what was going on around the facility, so P2 believed VA3 when s/he told P2 that SP2 chased VA1 and hit VA1 in his/her chest with a fist. VA3 also said that SP1 and SP2 screamed and swore at VA1 and VA2. · VA1 and VA2 “did not get along.” P2 believed SP1 and SP2 likely had VA2 eat in his/her room to avoid conflict. P1 said that although SP1 and SP2 were each counseled regarding their specific job duties, there were no specific issues regarding their treatment or interaction with clients. Staff persons were responsible for meal preparation and followed a menu; however, VA3 was capable of preparing meals for him/herself when s/he wanted to. P1 believed VA3 was “truthful” and did not “want to tell on anybody.” In the past, VA2 made allegations about staff persons that were not truthful and VA3’s truthfulness was “iffy.” According to P1, VA1 and VA2 each had dementia. P4 said that s/he never witnessed nor heard about any staff person punching any client. P4 knew nothing about VA2 having to eat in his/her room. P4 had no information that clients had to cook their own meals and said that when s/he worked with SP1, SP1 was “chill” and did not raise his/her voice. P4 said that s/he met SP1 and SP2 at the facility and denied that s/he was friends with either of them. P5 said that on one occasion s/he arrived for his/her overnight shift and VA2 appeared to be wearing an “over saturated” brief that leaked onto VA2’s bedding. P5 said that was not a “regular thing,” that s/he assisted VA2 with changing his/her clothing, and no injuries were observed. P5 did not recall who was working the shift prior to his/her arrival. SP1 stated that VA1 was challenging because s/he argued with VA2. If VA1 was asked to stop arguing, s/he got angry so SP1 usually just asked VA2 if s/he would go to his/her room and if VA2 said no, then VA1 was asked to go outside so that VA1 and VA2 were separated. SP1 denied yelling at any client, raising his/her fists towards VA1, or seeing any other staff person interact in such a manner. SP1 said that VA2 ate meals “at the table with the other clients.” If a client was incontinent and the floor needed to be cleaned, staff persons would do the clean-up. SP1 denied asking clients to cook any meals. SP2 denied yelling at VA1 or VA2, “never” saw a staff person raise their fist to a client, and denied punching VA1. SP2 said that staff persons cooked the meals and s/he “never put [VA3] in the spot” to have to cook any meals. Sometimes VA2 was incontinent so staff persons “watched” for that and provided VA2 clean or dry clothing. SP2 denied refusing to assist a client or telling a client to clean up after him/herself. The G said that VA3 “mentioned” an incident between staff persons and clients and said that VA3 was “a little bothered by what [s/he] saw but wasn’t worried.” The G said that s/he did not believe VA3 “embellished but [s/he] can have [his/her] own interpretation of events.” Facility information showed that staff persons were trained regarding VA1-VA3’s program plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Regarding emotional abuse: VA3 said that SP1 and SP2 “screamed” at VA1 and VA2; however, did not have any information about VA2 having to eat meals in his/her room. VA1 and VA2 each had memory issues related to their diagnoses and did not provide information to support the information that SP1 and SP2 screamed at them. VA2 did not remember where s/he ate his/her meals. P4 denied hearing staff persons yelling at the clients and had no information that VA2 had to eat meals in his/her room. Given there were no other witnesses and that SP1 and SP2 denied yelling at VA1 and VA2, and that SP1 said that VA2 ate his/her meals at the table, there was not a preponderance of the evidence whether SP1 and SP2 engaged in conduct which could reasonably produce emotional distress to VA1 or VA2. It was not determined whether 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). Regarding physical abuse: VA3 initially said there was a “scary fight” where SP2 chased VA1 around the kitchen and “punched” VA1. VA3 later said that it was SP1 who “almost got in a fist fight” with VA1, and that VA1 and SP1 each had their fists in front of them like they were going to punch each other; however, no physical contact was made. Given the inconsistent information from VA3, that VA1 denied being punched by a staff person, that P4 and SP2 did not witness or hear about any staff person raising their fists to a client, and that SP1 and SP2 each denied such an incident occurred, there was not a preponderance of the evidence whether SP1 or SP2 engaged in conduct which could reasonably produce physical pain. 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 or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult.) Regarding neglect: VA3 did not know anything about VA2 urinating and/or staff persons refusing to assist VA2. On one occasion in May 2023, P5 arrived at the facility and VA2’s brief was “over saturated” so P5 believed VA2 wore the same brief all day. P5 assisted VA2 with changing his/her brief and clothes and said no injuries resulted. P5 did not remember who was working prior to P5’s arrival. Although it was reported that SP1 and SP2 did not assist clients if they were incontinent and that they did not provide meals to VA1, VA2, and VA3, given that SP1 and SP2 each stated that staff persons assisted clients if they were incontinent and neither refused to do so, thatSP1 and SP2 each denied that clients were asked to cook meals, that VA3 said that s/he prepared meals periodically when items were on the menu that SP1 and SP2 did not touch due to their religion, there was not a preponderance of the evidence whether SP1 or SP2 failed to provide the VAs 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed resulting in staff persons being retrained regarding maltreatment reporting. SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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