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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: 1120580-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) slapped a staff person (SP) in the face and then the SP proceeded to put the VA in an “illegal” hold. Date of Incident(s): October 22, 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 (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. 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 November 15, 2023; from documentation at the facility; and through five interviews conducted with a supervisory staff person (P1), the SP, a facility staff person (P2), the VA, and the VA’s guardian (G). The VA’s diagnoses included autism, attention deficit hyperactivity disorder, disruptive mood dysregulation disorder, a mild intellectual disability, and fragile X syndrome (a disorder that affects the X chromosome and causes learning and behavioral challenges). The VA enjoyed playing video games, watching television, and listening to music. The VA’s Behavior Support Plan stated that the VA had a history of physical aggressions such as hitting or punching others, kicking, and biting. Staff persons were to try intervention and proactive strategies such as building rapport with the VA, redirecting the VA, avoiding power struggles with the VA, helping the VA with coping techniques, and maintaining a safe distance from the VA. If the VA continued to escalate, staff persons were to retreat to a safe area (i.e., staff person office), disengage, and watch the cameras on the facility cell phone or computer. An Emergency Use of Manual Restraint (EUMR) was to be used during a situation where there was imminent risk of physical harm to the VA or others and less restrictive strategies had not achieved safety. The facility was a one level home. There were three bedrooms, a laundry room, two bathrooms, an open kitchen, a dining room, and a living room area. Along one wall was one of the bathrooms, a door that led to a hallway, a door to an office, and a window looking into the office. The office had a second door that led into the hallway. The facility’s Instruction for Safe and Correct Implementation of the Allowed Manual Restraint procedure stated the following: · One Person GABLE Grip Restraint (Left Arm Lead): o The staff person was to approach the person served from slightly behind on the left side. Then, the staff person used their left arm to hook the left arm of the person served, across the front of their bicep, between their body and arm. The staff person’s left hand ended up across the back of the person served, between their shoulder blades, and their palm up. o The staff person used their right arm to hook the right arm of the person served in the same manner as was done with the left arm. The staff person then clasped their own left hand with their right hand in a GABLE grip. o GABLE grip consisted of palms together, one hand’s fingers clasping between the index finger and the thumb of the other hand and the other hand’s fingers grasping along the little finger/edge of hand. Thumbs were interlocked. o The staff person was to create a stable base with a wide stance. o The staff person must release from the restraint when the threat of harm ended. To release from the restraint, the staff person was to release their grip and remove one arm from the restraint position, supporting the outside of the arm of the person served on that side of the body with the free arm while being ready to reinitiate the procedure if necessary. The staff person was to then remove the other arm and monitor the person served in a supportive position/stance. o This was also able to be done reversed with the Right Arm Lead procedure. The VA stated that the SP and P2 were working on the night of the incident. The VA was “getting angry” so the SP “shoved” the VA into the bathroom and shut the door. The VA did not sustain any injuries but was “mad” that the SP did that. This investigator reviewed video footage from the facility for October 22, 2023, and observed the following: · The office door was closed and the door to the hallway was open. The SP and P2 were not visible through the window but were in the office. The VA approached the window to the office with a board game in his/her hands and knocked on the window. The VA walked over to the table, set the game down, walked back to the window, and knocked again. · The SP responded, “What?” and P2 said, “Can you see we’re talking?” The VA said, “Yeah,” to which P2 said, “Then you’re being rude, that needs to stop.” P2 approached the window but the VA was standing in front of the window so the view of P2 was blocked by the VA. The VA said, “[S/he] is being rude to me.” The SP asked, “How, we are talking right now.” The VA said, “Don’t do that to me,” and “[S/he] is doing this to me.” The VA put his/her hands on his/her hips. The SP was then seen through the window behind P2 going toward the door leading into the hallway. The VA walked away from the window. · P2 lowered the curtain over the window in the office, the VA stood in front of the open door leading to the hallway, and the SP appeared at that doorway. The SP asked the VA to move, and the VA asked why the SP wanted to shut the door. The SP stated because the VA was being “rude.” The VA said s/he was not going to move, and the SP stated, “Yeah, you are.” · The VA told the SP to, “Go away,” as the VA took his/her left hand and slapped the SP on his/her left cheek. The SP then put his/her hands on the VA, and it appeared the SP tried to get the VA’s left arm behind the VA’s back. The VA stumbled and then fell to the ground hitting a chair on his/her way down (this investigator was not able to determine what part of the VA hit the chair) and stated, “Ow.” The VA landed on his/her right side. The VA was on the floor behind the table, and the SP was standing over the VA with his/her right hand on the VA’s left bicep. The SP told the VA, “Do not put your hands on me anymore, do you understand me?” At this time P2 came out of the hallway door and stood with his/her right hand on the door handle. · The VA rolled to his/her back with his/her left arm up by his/her chest/throat area and the SP had his/her right hand on the VA’s left bicep while the SP’s left hand was on the back of a chair. The SP applied pressure to the VA’s arm with the SP’s right arm straightened while the SP’s left hand maintained grasped to the chair. The VA made a “chocking sound.” The VA attempted to hit the SP and then rolled onto his/her stomach keeping his/her head up. The SP placed his/her right hand between the VA’s shoulder blades. The VA lifted his/her head moving it side to side and then turned onto his/her left side while asking. “Where is the knife.” The SP told the VA to think about the consequences. · The VA attempted to kick, hit, and bite the SP as the SP was holding the VA’s wrist and moving back. The SP let go of the VA after 40 seconds of contact and the VA got up on his/her own, grabbed at the SP’s shirt, kneeled back down, and then attempted to grab the SP again as they both got into a standing position near the wall. The SP moved the VA to the wall and “held” the VA against the wall while holding the VA’s right arm behind the VA’s back. At this point the VA was facing the wall and the SP was behind the VA. The VA said, “I’m going to kill you, I’m actually going to kill [him/her].” The VA slapped the SP in the face with his/her left hand, the SP grabbed a hold of the VA’s left wrist, and the VA bit the SP’s hand. · The SP then maneuvered the VA toward the bathroom door and the VA leaned against a counter right outside of the bathroom and said, “Ow.” The VA told the SP to “let go.” The SP then put his/her hands on the VA’s back and front and moved the VA into the bathroom and shut the door. The SP ran back toward the hallway door and s/he and P2 went through the door as the VA came out of the bathroom. · The VA then came out and yelled at the office window, went to the kitchen, turned on the stove, took the silverware tray out of the drawer, and threw it at the office window. At that point P2 said s/he was calling 9-1-1. The VA then grabbed a broom and proceeded to hit the office window with the broom handle. The VA walked outside of the facility about three and a half minutes after coming out of the bathroom. · The time from when the VA initially slapped the SP to the SP closing the bathroom door on the VA was less than a minute and a half. The time the VA was on his/her stomach was approximately four seconds. P2 stayed by the doorway leading into the hallway the entire time during the incident. P2 provided the following information to this investigator and during the facility’s internal review: · On the day of the incident, around 8:30 p.m., P2 was in the office working on the computer, and the SP was at the other desk, but P2 was not sure what the SP was working on. The VA came to the window to ask P2 and the SP something, but P2 was not able to recall what it was about. The VA became agitated and was showing signs of a behavior beginning. · The SP went to shut the hallway door, which was protocol, when the VA “punched” the SP in the face. P2 heard a “ruckus” so s/he left the office and went out to see what it was. The VA was on his/her stomach and the SP had his/her arm on the VA’s back. The VA rolled over onto his/her back and tried to kick the SP. P2 stood by the door watching in “disbelief.” P2 did not do anything to intervene. · P2 was not able to recall how the SP and the VA got into a standing position, but the SP had his/her arm across the VA’s chest and the VA tried to bite the SP. The SP “pushed” the VA against the wall and told the VA s/he needed to “calm down.” The SP then led the VA to the bathroom, and the VA braced against the wall, so the SP “pushed” the VA into the bathroom and shut the door. · The SP ran, grabbed P2, “pushed” him/her into the hallway to shut the door behind them. P2 said the SP looked “angry.” The VA came out of the bathroom and left the facility. P2 told the SP they had to go after the VA. P2 and the SP followed the VA in a vehicle to make sure the VA was safe. The SP called law enforcement at that time. · Law enforcement arrived and spoke with the VA for a few minutes. P2 asked the VA if s/he was “calm” and the VA said, “Yes,” and they went back to the facility. · Once back in the facility, P2 asked the VA if s/he was okay, and the VA said s/he was, “fine,” but refused to show P2 and the SP his/her arms. The SP filled out a General Events Report (GER) for the incident and P2 called the on-call supervisor (P3) to report a restraint, but P2 did not tell the supervisor everything about the restraint. · P2 said staff persons were trained to “get away from the situation” with the VA when the VA became “aggressive.” If staff persons were not able to get away, they were to perform a Gable “hold” on the VA. If the VA went to the ground, staff persons were to let the VA go. Staff persons were to remove themselves so the VA could “deescalate” on his/her own. If the VA left the facility, staff persons were to leave with him/her to monitor and call law enforcement in needed. P2 stated the SP did not perform the correct Gable “hold” on the VA. · P2 said the SP was “stern” with the VA, but the VA liked the SP because the SP played video games with the VA. The SP provided the following information to this investigator and during the facility’s internal review: · On October 22, 2023, around 7 p.m., the SP and P2 were working in the office on paperwork when the VA approached the window and wanted their attention. The VA was told they would be right with him/her, but the VA started banging on the office window “really hard.” The VA was asked to stop but continued banging on the window. · The VA was “having a behavior” and the SP stated the facility policy was to close the hallway door in between the two offices if the VA was “having a behavior.” The SP got up to shut the hallway door. The VA was standing by the door, so the SP asked him/her politely to move. The VA did not respond and that was when the VA “attacked” the SP by striking the SP in the face. · The SP tried to put the VA in a “trained” hold, but the VA was “flailing around” and the SP “accidently” tripped, and both the VA and the SP fell on the dining room floor. The SP stated s/he was in a crouched position with a hand on the VA’s back. The SP said it was “illegal” to have the VA on his/her stomach (prone position), so the SP tried to turn the VA over. The VA was “flailing, biting, and kicking” at the SP when s/he tried to turn the VA over. · During the altercation, the SP stated the VA punched the SP, hit the SP in the face, kicked the SP, and bit the SP on the arm and ankle. The SP stated s/he did not know where P2 was at the time. The SP stated s/he was trying to defend him/herself. The SP stated the VA was in a prone position “less than two seconds.” · The SP tried getting away while trying to keep him/herself, the VA, and P2 safe. The SP saw the bathroom door was open, so the SP guided the VA in, and closed the door. The SP stated s/he did not push the VA. The SP stated that s/he then went to the hallway door and closed it behind him/her and P2. The SP said the entire interaction from when s/he came out of the office to putting the VA in the bathroom lasted “a minute and a half, maybe two [minutes].” · The SP did not remember what happened after that but stated that s/he checked on the VA about 45-60 minutes later to see if the VA was “okay” and if the VA had any bruises. The VA did not have any bruises, so the SP and P2 completed paperwork, and called P3. The SP stated that s/he filled out a GER form. · The SP knew s/he was to verbally try to deescalate a situation with the VA but did not feel s/he was properly trained on holds. The SP also stated that s/he did not know the facility policy for implementing holds when a person served was on the ground. The facility’s Internal Report and Summary provided the following information: · On October 22, 2023, around 9:15 p.m., P3 received a telephone call from P2 and the SP. P2 stated that the VA was at the window and “seemed frustrated” with P2 and called him/her “rude.” P2 could tell the VA was escalating and asked the SP to go close the hallway door. · The SP went to close the hallway door and the VA hit the SP. The SP then went to put the VA in an EUMR and P2 stated that the VA went down to the ground. P3 understood that to mean that the VA put him/herself on the ground to avoid a hold. P3 was told the VA was kicking, hitting, and biting. · The SP told P3 s/he was “concerned” because there was a hold where the SP put his/her hands on the VA’s back while the VA was on the ground. The SP applied pressure to the VA’s back while the VA was on his/her stomach and then the SP helped the VA turn on to his/her back. The VA was coming after the SP, so the SP used another EUMR once the VA was in standing position. · The SP described that hold as a “one arm bear hug” and the SP walked the VA into the bathroom and then the SP went back into the office. P3 stated that s/he believed the accuracy of the incident P2 and the SP described because they called in together. When P3 was able to review video footage, s/he did not feel that P2 and the SP accurately described the incident with the VA.
P1 provided the following information: · P1 reviewed video footage on October 23, 2023, and saw the VA approach the office window and ask P2 and the SP to come out of the office. The VA looked as if s/he was “offended.” The VA saw the SP going toward the office door, so the VA went to the hallway door to block it so that the SP was not able to shut the door. The VA “struck” the SP and the SP “took” the VA to the ground in an “illegal” hold. P1 stated that the VA’s hands were up, the SP’s hands were pushing down, and P1 heard a “chocking sound.” The VA started hitting and biting. They stood up and the SP “pushed” the VA up against the wall and put the VA in the bathroom and the SP and P2 ran into the office. · P1 said that after the incident, the VA was “super angry” and started throwing things and swearing at P2 and the SP. The VA left the facility and law enforcement was called. Law enforcement came and brought the VA back to the facility. · When P1 spoke with the VA and asked what happened, the VA told P1 that s/he was “mad” and the SP “took me down.” The VA told P1 that s/he was not hurt. · P1 said staff persons were trained to deescalate with words first. P1 said staff persons were only approved to use Gable holds and that was a last resort. If a client went to the ground, staff persons were to release the client. P1 said that when the VA struck the SP, the SP should have backed up and went into the office. The G was aware of the incident but had not spoken with the VA about it. The G said the VA may “embellish” things, but thought the VA was a reliable reporter. The G stated that the staff persons did not do “holds” very often and that they were trained to lock themselves in a safe room. The G had no prior concerns regarding the facility. The facility’s policy for Positive Supports and the Emergency Use of Manual Restraints stated: · Staff persons were allowed to use an EUMR if a person served’s conduct posed an imminent risk of physical harm to self or others and less restrictive strategies had not achieved safety-this included the use of one-person and two-person GABLE grip restraints. · An EUMR must not use a prone restraint. “Prone restraint” meant the use of manual restraint that placed a person in a face-down position. Prone restraint did not include brief physical holding of a person, who during an EUMR, rolled into a prone position, and the person was restored to a standing, sitting, or side-lying position as quickly as possible. · An EUMR must not apply back or chest pressure while a person was in a prone or supine (meaning face-up) position. The facility’s Policy and Procedure Regarding Employee Professionalism stated that, “All [staff persons] are expected to conduct themselves in a professional manner at all times…this includes treat[ing] persons served with dignity and respect.” Facility records showed the SP, P1, and P2 were each trained on the facility’s Positive Supports and Emergency Use of Manual Restraints and the Reporting of Vulnerable Adults Act. A Behavior Intervention Reporting Form (BIRF) was submitted on October 23, 2023. Conclusion: Consistent information was provided that on October 22, 2023, the VA became upset with the SP and P2 who were in the office. The SP went to close the hallway door as per protocol. At that time the VA slapped the SP in the face. P1 said the SP “took” the VA to the ground, P3 heard the VA went to the ground, and the SP stated that s/he tried performing a “trained” hold but the VA was “flailing” around, so the SP tripped and s/he and the VA fell to the ground. While on the ground, the SP kept a hand on the VA’s arms when the VA was on his/her back. The VA made a “chocking sound” and then rolled onto his/her stomach. The SP had a hand between the VA’s shoulder blades for approximately four seconds, and then the VA rolled onto his/her left side. The VA continued to kick, hit, and bite the SP. The VA and the SP were able to get into a standing position and then the SP moved the VA to the wall facing against the wall, led the VA along the wall to the bathroom door, moved the VA into the bathroom, shut the door, and ran back to the hallway door shutting it behind him/her and P2. The SP stated s/he was defending him/herself. Although the SP could have backed away from the VA into the office, the VA was blocking the door so the SP could not shut it. The VA was verbally aggressive, so the SP was verbally engaging with the VA and then when the VA slapped the SP, the SP began physical intervention. For four seconds, the VA was on his/her stomach, but it was when the VA rolled onto his/her stomach and during that time the VA had his/her head raised and was moving it from side to side. In addition, the SP stated that s/he tried to roll the VA over. Given that the SP attempted to restrain the VA as trained when the VA physically aggressed, that the SP attempted to end physical contact but the VA continued to make verbal threats and tried to hit and bite the SP, that when the SP could get away from the VA as the VA’s plans directed the SP did, and that the VA was not injured, there was not a preponderance of the evidence whether the SP failed to provide the VA with reasonable and necessary care and services or whether any of the SP’s actions could reasonably be expected to produce physical pain or injury. It was not determined whether neglect or physical abuse 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; 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 found their policies and procedures adequate, but not followed by the SP. The SP 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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