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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: 1070988-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at a vulnerable adult (VA), threatened to throw his/her cell phone at the VA, and threatened to move the VA to a nursing home. Date of Incident(s): December 15, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on January 26, 2024; from documentation at the facility; and through six interviews conducted with a facility staff person (P1), a supervisory staff person (P2), the VA, a resident (R), the SP, and the VA’s case manager (CM). A staff person (P3) declined an interview. The VA enjoyed drinking coffee, watching television, going shopping, travelling, and spending time with his/her friends and family members. The VA’s diagnoses included a traumatic brain injury, osteoporosis, and right-side paralysis. The VA used a wheelchair for mobility. The VA was not subject to guardianship. According to the VA’s Risk Assessment Detail, the VA might not be able to defend him/herself against verbal abuse. The VA would report verbal or emotional abuse s/he experienced. In the past, the VA provided inaccurate information about others taking his/her possessions. The VA sometimes became verbally or physically abusive to others. At those times, the staff persons were to distract or redirect the VA. The VA stated that the SP “had to be in control all the time.” On one occasion, the SP threatened the VA by telling that VA that s/he “better shut your mouth before I throw this phone at you.” The SP raised his/her arm in the air while s/he held his/her cell phone in his/her hand. At the time of the incident, the VA was in his/her bed while the SP stood at the door of the VA’s bedroom. The VA asked the SP to assist him/her with getting out of bed, but the SP refused. The VA believed the SP would throw his/her telephone. The VA called for another staff person (P3) to assist the VA to get out of his/her bed. On one occasion, the SP told the VA that s/he should live in a nursing home. The VA did not provide additional information about the incident. According to the facility’s Internal Review, P3 was present when the SP told the VA to “shut up or I’m going to throw my phone at you.” The SP also made a motion with his/her arm as s/he made the comment to the VA. On “many” occasions, the SP told the VA and other residents to shut up and was “always” arguing and screaming at the VA. P1, P2, and the SP provided the following information: · P2 stated that on the day of the incident, at approximately 8 a.m., s/he arrived at the facility at the same time the SP finished his/her work shift. The SP told P2 that s/he was “sick” of the VA and left the facility. The SP denied telling P2 that s/he was sick of the VA. The VA then told P2 that the SP “threatened” the VA while P3 was assisting the VA with getting out of bed. The SP yelled at P3 because s/he wanted P3 to assist another resident with getting out of bed, even though the other resident was still sleeping. The VA yelled that s/he wanted to get out of bed first and the SP then told the VA that s/he would throw his/her cell phone at the VA if the VA did not “shut the fuck up.” P2 stated that the VA was “mad” when s/he told P2 about the incident. · P2 then talked to P3 about the incident and P3 told P2 that s/he did not hear the SP tell the VA s/he was going to throw his/her cell phone at the VA, but s/he saw the SP waving his/her arm in the air while holding the cell phone. P2 telephoned his/her supervisor (P4) and told him/her about the incident. P1 was not present during the incident, but P3 later told P1 that the SP was holding his/her cell phone in the air and waving it around as s/he talked to the VA. · The SP stated that s/he never told the VA to shut up, threaten to slap the VA, or threaten to throw his/her cell phone at the VA. Prior to leaving the facility on the day of the incident, the SP asked P3 if s/he needed assistance getting the VA out of bed and P3 told the SP s/he did not need assistance, so the SP left the facility. The SP stated that the VA sometimes yelled at the staff persons, but then apologized for doing so. The SP also stated that s/he never told the VA to “shut the fuck up.” The SP did not “have a problem” with the VA and did not get frustrated when the VA was difficult. The SP stated that P2 told him/her to document when the VA attempted to hit the SP or swore at the SP. · P1 believed that the VA liked the SP, but the VA and the SP sometimes “argued back and forth.” P1 was uncertain if the SP and the VA were “actually fighting” because they would eventually stop arguing and “be fine at the end of it.” P1 stated that one of the VA’s “biggest fears” was having to move back to a nursing home. On one occasion, the SP told the VA that s/he would have to move back to a nursing home, which upset the VA. P1 believed the SP made the comment to the VA in December 2023, and believed that the SP made the comment because s/he knew the VA was afraid of moving to a nursing home. The SP denied that s/he told the VA that s/he would have to move to a nursing home and stated that s/he did not have the authority to make the VA move to a nursing home. · On one occasion, the SP told P1 that s/he was going to “rile up” the VA, but P1 did not know if the SP meant s/he was going to make the VA mad “on purpose” or if s/he was joking. P1 did not hear what the VA and the SP said to each other at that time. The SP stated that s/he never made a comment about trying to “rile up” the VA or “push [his/her] buttons.” P1 stated that the SP was “generally pretty loud” when s/he spoke. P2 stated that the SP “talked loud” and “wanted things done” the way s/he wanted. P1 did not hear the SP insult the VA or swear at him/her, but sometimes the SP’s tone had a “bite” to it. · P1 stated that the VA was not always an accurate reporter of events. The VA sometimes said that the staff persons took the VA’s personal items even though the VA misplaced the items. The VA sometimes got times and dates mixed up. P1 believed the VA was “75%” accurate when describing events. P2 stated that the VA was sometimes forgetful. In the past, the VA told P2 that P2 said s/he was going to send the VA to a nursing home even though P2 was discussing a “hypothetical” situation that might happen if the facility were to close. The SP stated that the VA sometimes made comments that were not accurate about the staff not doing their jobs.
· P2 stated that s/he had no previous concerns about the SP’s interactions with the residents. The SP typically worked the overnight work shift and the residents were usually sleeping for most of the SP’s work shift. P2 stated that s/he trained new staff persons at the facility. When the VA became verbally aggressive and the staff persons were unable to redirect the VA, the staff persons were to remove themselves from the situation and have the VA let them know when s/he wanted to talk to them. The R stated that s/he “got along” with the SP, but the SP “rushed people.” At times, the SP was loud and “got mad” at others. The R did not recall the SP making hurtful or insulting comments. On one occasion, the R was in his/her bedroom, but s/he heard the SP become angry with the VA. The R heard the SP tell the VA that s/he was acting “naughty.” After the SP made the comment, the VA was “quiet.” The R was unable to provide any additional information about the incident. The CM stated that the VA’s memory was not always very accurate and might require prompts to recall events. When the VA became angry or aggressive, the staff persons needed to calmly speak to the VA and provide information to the VA. According to the facility’s Recipient Rights, the residents had the right to be treated with courtesy and respect and to be free from maltreatment. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: On December 15, 2023, the VA told P2 that the SP “threatened” the VA while P3 was assisting the VA with getting out of bed and that the SP told the VA that s/he would throw his/her cell phone at the VA if the VA did not “shut the fuck up.” The VA provided consistent information to this investigator. P3 told P2 that s/he did not hear the SP tell the VA s/he was going to throw his/her cell phone at the VA, but s/he saw the SP waving his/her arm in the air while holding the cell phone. The SP stated that s/he did not swear at the VA, tell the VA to shut up, or threaten to throw his/her cell phone at the VA. P1 and the VA each stated that on one occasion, the SP told the VA that s/he would have to move to a nursing home, but no additional information was provided about the incident. The SP denied that s/he told the VA that s/he would have to move to a nursing home and stated that s/he did not have the authority to make the VA move to a nursing home. Consistent information was provided that the VA was not always an accurate reporter of events. P1 stated that the SP was “generally pretty loud” when s/he spoke. P1 did not hear the SP insult the VA or swear at him/her, but sometimes the SP’s tone had a “bite” to it. P2 stated that the SP “talked loud” and “wanted things done” the way s/he wanted. The R stated that the SP was loud and “got mad” at others, but the R did not recall the SP making hurtful or insulting comments. Consistent information was provided that the SP spoke in a loud voice. P3, the VA, and the SP provided inconsistent information about what occurred during the incident with the SP’s cell phone. Inconsistent information was also provided about whether the SP told the VA that s/he would have to move to a nursing home and no information was provided about the context of any such comment. Given that inconsistent information was provided about the incidents and that the SP denied that either of the incidents occurred, there was not a preponderance of the evidence as to whether the SP’s actions could reasonably be expected to produce emotional distress to VA1. 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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