MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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.”

1115738-H_CRS (Home and Community-Based Services-Community Residential Setting)
1071456-HCBS (Home and Community-Based Services)

Investigator(s):

Beth Virden
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6572

beth.virden@state.mn.us

Suspected Maltreatment Reported:

Allegation One: It was reported that a staff person (SP) struck a vulnerable adult (VA) with a fly swatter more than once leaving marks on the VA’s face.

Allegation Two: It was reported that more than once, staff declined to assist the VA out of bed, which left him/her in bed longer than s/he wanted.

Allegation Three: It was reported that throughout the day, staff put the VA in his/her bedroom as punishment for behaviors.

Allegation Four: It was reported that the VA had a pressure sore on his/her buttock that was infected.

Allegation One Date of Incident: October 15, 2023

Allegations Two, Three, and Four Date(s) of Incident(s): Unknown, Ongoing

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b); and Minnesota Statutes, section 626.5572, subdivision 15; subdivision 2, paragraph (b), clauses (1), (3), and (4); 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.

· Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and

· Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825.

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 law enforcement records; and through interviews conducted with the VA, the VA’s guardian (G) who was also the VA’s family member, the VA’s other family members (FM1 and FM2), facility staff persons (the SP, P1, P2, and P3), and supervisory staff persons (P4 and P5).

[Note: At the time of the site visit, this investigator met the VA’s housemates (H1 and H2). H1 had a weighted blanket pulled over his/her head and did not acknowledge this investigator. H2 was sitting in the sunroom and did not acknowledge this investigator. H1 and H2 were each described to this investigator as being “nonverbal,” which was consistent with this investigator’s observations at the site visit. The VA’s other housemate (H3) was not home at the time of the site visit. H1-H3 were not interviewed for this investigation.]

The VA’s support plan and support plan addendum provided the following information:

· In September 2022, the VA moved into the facility seeking supports and services relating to his/her diagnoses, which included, moderate intellectual disability, cerebral palsy, quadriplegia, and major depressive disorder.

· The VA relied on staff to complete all of his/her activities of daily living. [Note: At the time of the site visit, this investigator observed that the VA’s arms were contracted, held against his/her body with limited movements. The VA’s neck or shoulders were also contracted. The VA had limited movement of his/her head. This investigator did not see the VA use his/her arms or hands and/or turn his/her head in a typical manner at any point during the visit. This investigator offered the VA a business card and the VA did not reach out for it but asked that it be placed on a bedside table. The VA’s speech was difficult to understand.]

· The VA used an electric wheelchair and might need help from staff to maneuver the wheelchair. Staff used a mechanical lift to transfer the VA into and out of his/her wheelchair, bed, etc. Staff also helped reposition the VA’s body as needed. [Note: At the time of the site visit, the VA was in the living room in his/her electric wheelchair. A staff person used the wheelchair’s steering device to drive/maneuver into the VA’s bedroom to meet with this investigator. When the interview was over, the staff person returned and steered/drove the VA’s wheelchair back to the living room. This investigator did not see the VA touch the steering device or operate his/her own wheelchair.]

· The VA had a history of providing inaccurate information. “For [the VA], this looks like reporting that staff did not assist [him/her] when requested even though staff did. [The VA] will also say that staff are calling [him/her] names or refusing to provide [his/her] essential cares, despite additional witnesses and documentation showing otherwise. [The VA] will also claim that [s/he] is being abused or neglected. This does not include instances where [the VA] reports abuse and neglect that is under investigation or substantiated by formal investigation.”

The VA lived at the facility with H1-H3. The facility provided at least one staff person 24 hours a day for the housemates’ care and supervision.

The facility was a single-family, one-story house. There was a large open-concept room that consisted of a kitchen, a living room, and a dining room. The VA’s bedroom was at the end of a longer hallway that wrapped around to the front of the house; the VA’s was the lone bedroom in this hallway.

Facility documentation stated that the SP and P1-P5 received training on the Reporting of Maltreatment of Vulnerable Adults Act. In addition, the SP and P1-P4 received training on the VA’s support plan and support plan addendum; P5 was not required to receive this training based on his/her position.

Allegation One: It was reported that the SP struck the VA with a fly swatter more than once leaving marks on the VA’s face.

The VA’s support plan and support plan addendum provided the following information:

· “Because [the VA] is in a wheelchair, [s/he] would most likely not physically defend [him/herself] from physical abuse. [The VA] has a history of using profanity towards staff and other individuals in [his/her] home and wishing ill on others.” Staff educated the VA on the definition of physical abuse, intervened in potentially abusive situations, and reported suspected or known abuse on the VA’s behalf.

· The VA had a history of “yelling repeatedly” and using “verbal aggression” toward staff and declining or delaying staff from completing the VA’s cares. When the VA “is calm,” staff should engage, build rapport, discuss “positive” topics, offer options, etc.

· “When [the VA] begins displaying interfering behaviors, staff will tell [him/her] once in a calm, neutral tone that when they are available and [when the VA] is calm, they will assist [him/her]. Do not attempt to tell [the VA] to stop engaging in behavior or lecture about the behavior. Set the visual timer and return when the timer goes off and [the VA] is calm. Do not discuss the behavior after it has occurred- this will reinforce the behavior.”

· “When [the VA] makes a request that is not immediately available, staff should use first/then language. First indicate what needs to occur, then identify what will happen once that occurs.”

The VA told this investigator, “[The SP] hit me” with a “fly swatter” on October 15, 2023. “[The SP] hurt my face.” “I had bruises all over my face.” The VA did not know why the SP did this. “[The SP] went off the handle.” The VA said this occurred on other days too, but s/he did not sustain injuries during those other times and there were never any witnesses. The VA believed the SP hit the other housemates with something but did not know what was used or when. The SP also poked his/her fingernails into the VA’s skin causing the VA’s “whole body to hurt.”

The G, FM1, and FM2 provided the following information:

· The G, FM1, and FM2 each had ongoing concerns with the facility’s overall care.

· The VA told FM1 that on “different days” (more than one day) the SP hit the VA’s face with a fly swatter and the SP poked his/her fingernails into the VA’s skin. On October 15, 2023, the SP hit the VA’s face with the fly swatter, and it caused injuries to the VA’s face. The VA was “petrified” and “afraid” whenever the SP worked.

· The G and FM2 each said that the facility used to be responsive and notify the G anytime something occurred. However, over time, they stopped calling altogether. At the time of this investigator’s phone call with the G in mid-November 2023, the facility had yet to contact him/her about the VA being injured by the fly swatter.

Facility documentation and P1-P4 provided the following information:

· The facility’s daily notes, completed by various staff between October 1 and 14, 2023, included the following:

o On October 3, 2023, the VA was “mad at” the SP. “[The VA] got very upset and was verbally aggressive to [the SP] by calling [him/her] a liar, and I hate you.”

o On October 10, 2023, “[The VA] has been complaining all night about [P1 and the SP].”

o On October 12, 2023, “[The VA] has been complaining about [the SP] all day … [S/he] claims that [the SP] turned [the VA’s] phone off but [the SP] did not.”

o Between October 14 and 15, 2023, during the overnight, P3 documented, “[The VA] was not happy with [the SP].”

· On October 15, 2023, P1 worked with the VA between approximately 6 a.m. and 2 p.m. P1 did not see any marks on the VA’s face during this time and the VA did not say anything to P1 about being hit.

· At 2 p.m., the SP arrived and P1 left for the day. The SP worked alone between 2 and 10 p.m. [Note: The SP’s account of what happened during this timeframe is forthcoming in this report.]

· At 9:50 p.m., P3 arrived for the start of his/her shift and in relief of the SP. The SP told P3 that the VA was in bed at that time. Just then, the VA yelled for the SP stating that his/her undergarment needed to be changed. The SP and P3 both went to the VA’s bedroom and changed his/her undergarment together without issue. P3 did not see any marks on the VA’s face at that time and the VA did not say anything about being hit.

· After changing the VA’s undergarment, P3 left the VA’s bedroom while the SP remained in the room with the VA. P3 heard the SP tell the VA that his/her shift was over and that, now, “[P3] was here.” P3 did not hear any noises or yelling from the bedroom. Shortly thereafter, the SP left for the night.

· Around 10:30 or 11 p.m., the VA asked to be repositioned and P3 went into the VA’s bedroom for this purpose. P3 repositioned the VA’s body but did not see the VA’s face during this time. The VA did not say anything to P3 about being hit.

· The facility’s daily notes, completed by P3 on October 15 and 16, 2023, stated, “[The VA] was change[d] and rep[ositioned] at 10pm and at 2am [and] is now napping yet.”

· At 5:50 a.m., P3 checked on the VA in bed. P3 could not see the VA’s face. The VA did not say anything to P3 about being hit.

· At 6 a.m., P1 arrived for the start of his/her shift and in relief of P3.

· The facility’s daily notes, completed by P1 on October 16, 2023, stated, “When I got here this morning, I noticed a big red mark on the right side of [the VA’s] face. I didn’t say anything about the mark. I then asked [him/her] ‘how did last night go.’ [The VA] said ‘a staff hit me with the thing you kill flies with.’ I then said ‘oh where at’ [s/he] then said ‘on both my cheeks.’ I then told [the VA] ‘I’m sorry that happened.’ I seen the fly swatter by [the VA’s] bed on the right side, I then contacted a nurse and [s/he] came and looked at it ….” P1 told this investigator that the VA identified the SP as being the one who hit him/her. When P1 asked the VA where s/he was struck by the fly swatter, the VA pointed to the exact location of the red marks on his/her cheek. [Note: P1 documented, in his/her daily note, that this was the VA’s “right cheek” but all other information, including photographs, showed it was the VA’s left cheek.]

· P1 took photographs of the marks, which were provided for this investigation. The photos showed two red parallel lines, appearing to be raised or swelled, vertical on the VA’s left cheek stretching from below

his/her left eye to his/her chin. The two lines connected just below the VA’s left eye in a curved loop, or upside-down “U.” The surrounding skin was red with one area of dried blood.

· The facility’s daily notes, completed by a facility nurse on October 16, 2023, stated, “I received a phone call from staff this morning saying that there was a mark on [the VA’s] face and that [the VA] reported to [staff] that [the SP] had hit [the VA] multiple times in the check [sic] area with the metal part of the fly swatter … I asked [the VA] how [s/he] was and [s/he] immediately said that [s/he] wasn't doing very good. I asked [him/her] why and [s/he] said that ‘[The SP] hit [him/her] with the hard end of the fly swatter.’ I asked [the VA] when [the SP] hit [him/her] and [s/he] said ‘yesterday.’ I asked [him/her] where [the SP] hit [him/her] at and [s/he] said the cheek. Staff asked if [the SP] hit [the VA] on just one side or both and [the VA] said ‘both.’ I asked [the VA] how many times [the SP] hit [him/her] and [s/he] said ‘multiple times.’”

· P2 said that the VA told him/her that s/he was “hit” in the face by the SP. P2 later heard from someone else that the SP used the metal handle of a fly swatter to hit the VA and that when staff held the fly swatter next to the VA’s face, the “marks matched.” [Note: One of the photographs provided for this investigation showed a fly swatter. The fly swatter had two ends. One end had a flat plastic head for swatting flies and the other end was the handle. The handle consisted of two long thin metal rods connecting at the far end in a “U” shape. A photograph showed the fly swatter handle overlaid on the VA’s injury and the marks on the VA’s face appeared to line-up with the metal rods of the handle.]

· P4 said, “It did look like the end of a fly swatter if you put it up to it.” P4 added that another staff person believed the mark looked like something that might occur if the VA struck his/her head on his/her nightstand. However, P4 told this investigator, “But, to me, it looked like the fly swatter. I didn’t have any doubt that it wasn’t. I was very shocked.” P4 added that the VA did not have a history of causing injury to him/herself while at the facility but did have some history of such conduct years ago.

· P1-P4 each did not have prior concerns with the SP’s conduct. The SP typically worked alone during the evening shift and might also work weekends, which was also single staffed.

· P4 said, “[The VA] does a lot of screaming at staff” and “making false allegations.” The VA “accused” staff of various things, including leaving him/her in bed all day when in reality s/he had just lay down. However, the VA’s previous allegations were not “to this extreme,” or involving being hit with a fly swatter. This was the first time the VA made statements about being hit by a staff person.

· P2 said that the VA did not want to live at the facility and seemed to think that s/he could get any staff person “fired” if s/he wanted. The VA did not like the SP. P2 said that the SP was “really nice” and that it was “hard to believe” the SP would strike the VA with a fly swatter. “But, then again, [the VA] has a way of getting to you. I could see [the SP] snapping but I found it hard to believe.”

· P1, P3, and P4 each did not believe the VA would be able to strike him/herself with a fly swatter and cause injury due to the VA’s limited mobility.

· However, P2 said that more than once, s/he saw the VA moving his/her body with greater ability and range than commonly believed by staff. P2 witnessed the VA moving his/her legs in a manner that helped P2 reposition him/her in bed and the VA was able to move his/her arms away from his/her body, which P2 had never witnessed before. “I was blown away. [S/he] can move to help if [s/he] wants to. [His/her] range of motion was more than what you normally see.” P2 did not see the VA touch his/her own face or scratch his/her own face but believed it might be possible. The VA only let one staff person trim his/her fingernails, which meant that at times his/her nails were long and capable of scratching. [Note: There was no information regarding the length of the VA’s fingernails on October 15, 2023.]

The SP completed a daily note regarding his/her interactions with the VA during his/her shift on October 15, 2023, and this included the following:

· The VA had uneventful phone calls with FM2 and then FM1.

· “After that i was getting meds ready and [s/he] had just got off the phone and yelled my name, i told [the VA] [s/he] needs to wait and ill [sic] be there as soon as im [sic] dine [sic] and [s/he] said ‘no you need to come here NOW’ (emphasis in original) and i said no i dont [the VA’s first name] i promise i'll get you as soon as i can and after that [the VA] started yelling “COME HERE! COME HERE NOW!” (emphasis in original) and ii [sic] told [him/her] again [s/he] needs to wait and [s/he] started crying, once i was able to i went back to [the VA’s] room with [his/her] meds and [s/he] told me ‘I'm going to the living room’ and i said ‘ok’ and started screwing [his/her] meds to [his/her] hoses and [s/he] yelled ‘GO NOW’ (emphasis in original) and i said "[the VA’s first name] you have no reason to be screaming in my ear, let alone be this disrespectful to me, If you are just going to be disrespectful i'll put football on you're [sic] tv and you can watch it here’ [the VA] said ‘no’ but calmer so i said ‘well then dont be disrespectful’ and [the VA] said ‘ok.’”

· “After I gave [the VA] meds i took [him/her] to the living room and we watched tv for a while and then out of the blue [the VA] says ‘call [P1] tell [him/her] not to come tomorrow … i hope [P1] gets hit by a bus and dies.’” The VA then referenced his/her housemates, and said, “Well i dont care they can all die.”

· “So after that i figured that was enough disrespect for the day and took [the VA] to [his/her] room to watch football there and when [s/he] asked me what i was doing i said ‘well [the VA’s first name] i dont want to listen to you making threats to people and i can bet that the other people in this house don't like it either so yo [sic] can sit in here and in 15 minutes ill [sic] be back to check on you, but if you're just going to be mean i might take longer’ and [the VA] started crying so i left, after about 15-20 minutes i went back to [the VA’s] room and [s/he] started saying ‘i hope your [family member] is dead, when i get out of here im [sic] going to come kill your family, i hate you and everyone hear [sic]’ so i turned around and left to start making dinner but [s/he] then started screaming ‘HELP’ ‘HELP’ ‘HELP’ as if someone was breaking in so [I] stopped what i was doing and jogged to [the VA’s] room and [s/he] said ‘I'm getting out of here tonight, I dont care if i have to live alone’ and i said ‘good luck’ and left [him/her] in [his/her] room.” [Note: For more information regarding staff putting the VA in his/her bedroom in relation to his/her behaviors, see Allegation Three.]

· “After dinner it was time for meds so i got [the VA’s] ready and went back to [his/her] room, once i got [his/her] meds into [him/her] [s/he] told me ‘i'm not going to bed’ and i said ‘well [the VA’s first name] im [sic] sorry but its already 8:30 [p.m.] and i have to get you laid down so i can do what i have to do’ and the entire time i was getting [the VA] changed and putting [his/her] sling behind [him/her] [s/he] was crying and continuing to threaten my life and my family's lives so i got [the VA] down put [FM2] on the phone and left.” [Note: The VA said that s/he typically liked to go to bed before 8:45 p.m.]

The SP provided the following information:

· On the day of the incident, at 2 p.m., the SP arrived at work in relief of P1. The VA was in his/her bedroom and “was already in a mood when I got there having a tough day with [P1].” The VA appeared “riled up and in a mood.”

· The VA repeatedly called for the SP to come to the VA’s bedroom. “I was busy with dinner or another resident … [The VA] was cursing at me. Saying I need to do fucking this and that. I told [the VA] to wait.”

· After about 15 minutes, the SP went to the VA’s bedroom and maneuvered his/her wheelchair into the living room with his/her housemates. Once there, the VA almost immediately started to “threaten people.” The VA said that s/he wanted to “kill” his/her housemate and that s/he “hopes [H2] dies.”

· According to the SP, s/he had been trained by a former supervisor that when the VA was disrupting others in the house, staff should push the VA’s wheelchair to the VA’s bedroom. “Just put [the VA] in [his/her] room for 15 minutes but don’t let [him/her] sit in there for 15 minutes without checking on [him/her].”

· On the day of the incident, the VA was making “threatening” comments toward, and in the presence of, his/her housemates. The SP pushed the VA’s wheelchair into the VA’s bedroom to separate him/her from the others. “I checked on [the VA] every 15 minutes. [S/he] was still continuing to threaten people.”

· The SP said that s/he did not hit the VA with a fly swatter or anything else. The facility was “full of flies” and because of this, the SP typically carried a fly swatter around with him/her. “It’s not impossible for [the VA] to see me with a fly swatter.”

· The SP said that s/he did not poke his/her fingernails into the VA’s skin and did not hit the other housemates with a fly swatter or anything else.

· The SP did not see any injuries or marks on the VA.

· According to the SP, the VA had a history of “accusing me of things.” One time, the VA stated that the SP hit the VA’s legs and feet and another time that the SP flicked the VA’s face and nose. The SP denied doing these things.

A Blue Earth Police Department Report included the following information:

· A law enforcement officer (LEO) interviewed the VA. Per the LEO, “In my times making contact with [the VA] I have struggled to understand [him/her] in the same fashion that staff or [his/her] family are able to do so. That said I was able to understand that [the VA] again names [the SP] as the responsible party and [the VA] also told me about the fly swatter. I asked [the VA] what room it happened in and [s/he] referenced [his/her] bedroom. I asked if [s/he] was in [his/her] chair or if [s/he] was in bed and [s/he] said that [s/he] was in [his/her] bed.”

· An administrative staff person told the LEO that the VA would not be able to strike his/her own face with a fly swatter causing injury.

· The LEO interviewed the SP. The SP said while making dinner, the VA “continued to yell” and “was making threats to [the SP] and towards [the SP’s family member].” “[The SP] told [the VA] that [s/he] was being disrespectful. [The SP] explained that when [the VA] was in the living room [s/he] was making threats and [the SP] told [him/her] that [s/he] was going to put [the VA] in [the VA’s] room if [s/he] kept doing it. Eventually [the SP] put [the VA] back in [the VA’s] room and [s/he] was mad at [the SP] about it.”

· “[The SP] admitted to having a fly swatter in [his/her] hand because there are lots of flies in the home.” The SP said that s/he did not strike the VA with the fly swatter.

· Per the LEO, “[The VA] is dependent on [his/her] mobility chair and in no way possesses the ability to physically follow through with any threat [s/he] might make. [The SP] is also a very large [person]. [The VA] is also extremely hard to understand when [s/he] speaks. Family and staff do get better at understanding [him/her] as they spend more time with [him/her]. But any verbal threats [s/he] might make will not carry even a small portion of the effect a threat would coming from someone who is able bodied and has more verbal ability.”

· “Information is being forwarded to county attorney for review for possible charges.”

Conclusion for Allegation One:

A. Maltreatment:

On October 16, 2023, P1 saw red marks on the VA’s face. The VA told P1 that on October 15, 2023, the SP struck him/her in the face with a fly swatter more than once. The VA then provided this same account to FM1, P2, a facility nurse, a law enforcement officer, and this investigator.

Although the SP denied the allegations, the VA repeatedly named the SP as the person who struck him/her. More than one person believed the marks on the VA’s face matched the handle end of a fly swatter and the pictures corroborated such. Information was also provided that due to the VA’s limited mobility, s/he would not be able to produce these same injuries to his/her own face. Although information was consistent that at times the VA might provide inaccurate information, P4 stated that the VA’s previous allegations were not “to this extreme,” or involving being hit with a fly swatter and this was the first time the VA made statements about being hit by a staff person. Given this and that the SP had reason to minimize his/her actions for fear of repercussions, it was determined that the VA’s account was more credible.

Therefore, there was a preponderance of the evidence that the conduct of striking the VA with a fly swatter and causing injuries to the VA’s face was not an accident or therapeutic and produced injury.

It was determined that 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).

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

The SP was responsible for the VA’s care and supervision. The SP received training on the VA’s support plan and support plan addendum and on the Reporting of Maltreatment of Vulnerable Adults Act.

The SP was responsible for maltreatment of the VA.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.”  Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. 

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury.  For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment.  For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke.  Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated physical abuse for which the SP was responsible was not “recurring” but was “serious” maltreatment. The SP was responsible for a single incident of maltreatment for which the VA sustained an injury that met the definition of “serious” maltreatment.

Allegation Two: It was reported that more than once, staff declined to assist the VA out of bed, which left him/her in bed longer than s/he wanted.

The VA provided the following information:

· The VA preferred to get out of bed in the morning at 9 a.m. Staff usually helped the VA out of bed last or after his/her housemates were up. This was because the housemates had jobs in the community that they needed to get to. The VA said, regarding this, “I hate that.” However, when this investigator asked what time staff typically got the VA out of bed after his/her housemates were up, the VA said, “It depends,” but did not give specific times.

· The VA preferred to go to bed before 8:45 p.m. FM2 typically called the VA to chat each night at 8:45 p.m. The VA said that staff usually helped him/her to bed around 8 p.m.

FM1 said that the VA told him/her that s/he was typically helped out of bed anywhere from 10:30 a.m. to 12 p.m., which the VA did not like. “[S/he] wants to get up earlier … [S/he] hates it.” Regarding bedtime, staff usually helped the VA to bed around 8:30 or 9 p.m., or in time for FM2’s nightly phone call. The VA needed assistance from staff to transfer in and out of bed.

The G said that the VA told him/her that there were times when s/he was in bed, calling out for staff, and the staff “shut [the VA’s] door.” “[The VA] has to call multiple times before they come in.” [Note: Information was provided that the VA did not have technology, including a call-button, to get staffs’ attention. As previously stated, the VA’s bedroom was down a longer hallway that wrapped around to the front of the house. The housemates’ bedrooms were in different hallways. Consistent information was provided that the sole means for the VA to get staffs’ attention was to yell from his/her bedroom. The Department of Human Services issued a recommendation to the facility to review the services provided to the VA and ensure they were in response to the VA’s identified needs as specified in the support plan and the support plan addendum.]

The facility’s daily notes provided the following information:

· Between October 1 and 31, 2023, P1 or another staff completed daily notes stating that they assisted the VA out of bed between 8:45 and 9:30 a.m. The only day this did not occur was October 14, 2023, in which, P1 wrote, “I went and was gonna get [the VA] up but [s/he] wanted to lay in bed till 10. So I went in at 10 and got [the VA] dressed and up for the day.”

· On October 1, 2023, between 2 and 10 p.m., the SP completed a daily note that stated, “When I got here [the VA] was just being brought into the living room … [The VA] said ‘[s/he] was in [his/her] room all day and only got out because i was coming.’” [Note: P1 was working when the SP arrived. P1’s daily note stated that the VA was out of bed after his/her 9 a.m. call with FM2. At some point after, the VA returned to his/her bedroom to watch the Vikings football game. There was no information in this daily note about the VA remaining in his/her bed or bedroom “all day.”]

· On October 4, 2023, between 1 and 10 p.m., P2 completed a daily note that stated, “[The VA] was in [his/her] room in bed, screaming when i arrived. I was met in the garage by staff to explain why [s/he] was yelling, and that i was not suppose to respond until [s/he] calmed down. [S/he] would not calm down. [S/he] was upset because [s/he] had been taken into [his/her] room to be changed and was scheduled to see the nurse for a regularly scheduled transfusion of antibiotics. The nurse wanted [the VA] left in bed as its earier [sic] and quicker for [the nurse] to do the procedure. [The VA] was yelling and screaiming [sic] for staff to come and let [him/her] out. [S/he] wanted to get up. Thhings [sic] were explained to [him/her] several times.” [Note: P1 was working the morning shift prior to P2’s arrival. P1’s daily note stated that the VA was out of bed in the morning and up until his/her 12 p.m. medications. At some point prior to 1 p.m., the VA was transferred back into bed. The facility’s nurse, P5, arrived at 1:57 p.m. to complete the VA’s wound care and medication infusion. “Once the treatment was completed (the VA) was assisted into (his/her) chair.”]

P1-P5 provided the following information:

· P1-P5 each provided information that it was necessary for the VA to stay in bed for various reasons. On Mondays, Wednesdays, and Fridays, a nurse visited the facility and completed wound care and a medication infusion for which the VA needed to be lying down in bed. In addition, every four hours, the VA needed to lie down to relieve pressure on his/her buttock wound. Staff also had to lay the VA down in bed to change his/her undergarment. The VA wanted to be in bed each night by 8:45 p.m., in time for FM2’s nightly call.

· Regarding nursing visits for the VA’s wound care and the medication infusion, P4 said that the nurses always notified staff of their planned arrival time. Staff might transfer the VA into bed in preparation for, prior to, the nursing visit. However, if a nurse was “running late,” they did not always notify staff of the time change.

· P1 said that s/he typically worked the morning shift and some evening shifts as well. Regarding the VA’s mornings, P1 typically transferred the VA out of bed around 8:30 or 9 a.m. The VA was then typically transferred back into bed around 8:30 p.m.

· P4 witnessed a time when staff helped the VA into bed for a treatment of some kind, and FM1 happened to call. P4 heard the VA tell FM1 that s/he had been in bed “all day.” This was not true. “[S/he] just laid down.”

Relevant Rules and/or Statutes:

Minnesota Statutes section 245D.06, subdivision 5, which states that the license holder is prohibited from using chemical restraints,​ mechanical restraints, manual restraints, time out, seclusion, or any other aversive or deprivation procedure,​ as a substitute for adequate staffing, for a behavioral or therapeutic program to reduce or eliminate behavior,​ as punishment, or for staff convenience.

Conclusion for Allegation Two:

It was reported that staff left the VA in bed longer than s/he wanted.

A progress note stated that on October 4, 2023, at some point prior to 1 p.m., staff transferred the VA into his/her bed to await a nursing visit. “[The VA] was screaming and yelling for staff to come and let [him/her] out.” Staff “explained” to the VA that the nurse wanted the VA “left in bed as it’s earier [sic] and quicker for [the nurse] to do the procedure.” The nurse arrived at 1:57 p.m. to start the procedure. P4 said that at times, staff might transfer the VA into bed in preparation for a scheduled nursing visit, but that the nurse might run late. Despite this, the conduct of subjecting the VA to seclusion and/or aversive or deprivation procedures as a substitute for adequate staffing or for staff convenience was in violation of Minnesota Statute section 245D.06, subdivision 5. [Note: For additional information regarding concerns of involuntary separation or seclusion, see Allegation Three.]

However, information was provided that it was necessary for the VA to lie down in bed more than once throughout most days for various reasons, including to relieve pressure on his/her buttock wound, to receive wound care and a medication infusion, and to have his/her undergarment changed. The aforementioned progress note on October 4, 2023, appeared to be in response to what staff believed was necessary for the nursing visit or what the nurse wanted; however, the staff did not take into account that the nurse might run late.

Although there was concern about what time staff transferred the VA out of bed at morning and into bed at night, consistent information from staff and progress notes stated that the VA was transferred out of bed almost every day between 8:45 and 9:30 a.m. and into bed prior to FM2’s nightly phone call at 8:45 p.m. The VA also did not provide information of times when s/he was left in bed longer than necessary. Given the aforementioned, there was not a preponderance of the evidence whether the staff conduct as it related to the VA being transferred into or out of bed was always therapeutic or whether there was a failure to supply the VA with care or services, which was not the result of an accident or therapeutic conduct.

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).

Allegation Three: It was reported that throughout the day, staff put the VA in his/her bedroom as punishment for behaviors.

The VA’s support plan and support plan addendum stated:

· The VA used an electric wheelchair and might need help from staff to maneuver the wheelchair. Staff used a mechanical lift to transfer the VA into and out of his/her wheelchair, bed, etc. Staff also helped reposition the VA’s body as needed.

· “When [the VA] begins displaying interfering behaviors, staff will tell [him/her] once in a calm, neutral tone that when they are available and [when the VA] is calm, they will assist [him/her]. Do not attempt to tell [the VA] to stop engaging in behavior or lecture about the behavior. Set the visual timer and return when the timer goes off and [the VA] is calm. Do not discuss the behavior after it has occurred- this will

reinforce the behavior.” [Note: There was no additional information regarding what was meant by “calm” and/or more instruction about the use of the timer.]

At the time of the site visit, the VA was in the living room in his/her electric wheelchair. A staff person used the wheelchair’s steering device to drive/maneuver into the VA’s bedroom to meet with this investigator. When the interview was over, the staff person returned and steered/drove the VA’s wheelchair back to the living room. This investigator did not see the VA touch the steering device or operate his/her own wheelchair.

The VA said that the SP “usually” drove/maneuvered the VA’s wheelchair, with the VA in it, into the VA’s bedroom when “[the SP] didn’t want anything to do with me.” P1 sometimes did this as well. Other staff did not.

The facility’s daily notes, for October 1 through 31, 2023, provided the following information:

· On October 9, 2023, the SP completed a daily note that stated, “After dinner [the VA] came out to watch football but i told [him/her] [s/he] can not lay all the way back (in his/her wheelchair) due to [his/her] (colostomy) bag being full and then [s/he] started screaming ‘You dont follow any rules’ ‘You need to tilt me back’ i told [the VA] im sorry but i have not been told you need to be tilted i only do it cuz [sic] you like it but right now its either you sit up or lay down early and [s/he] said [s/he'll] stand up but once i got [him/her] in [his/her] bed [s/he] was screaming that i dont follow rules and i told [him/her] if [s/hes] not going to talk to me like an adult then im going to leave and [s/he] then kept yelling so i left.” [Note: This daily note stated that the VA decided to “stand up” when the SP gave him/her the option. Given that “stand up” was not an option or even possible given the VA’s diagnoses, it was likely that the SP mistyped “sit up” as “stand up.” The SP’s next sentence indicated that s/he put the VA to bed. The SP did not provide information in this daily note about why s/he transferred the VA into bed when the VA said s/he wanted to sit (or stand) up.]

· On October 15, 2023, the SP completed a daily note that stated the VA was in the living room and made comments about staff getting hit by a bus and the housemates dying. “So after that i figured that was enough disrespect for the day and took [the VA] to [his/her] room to watch football there and when [s/he] asked me what i was doing i said ‘well [the VA’s first name] i dont want to listen to you making threats to people and i can bet that the other people in this house don't like it either so yo [sic] can sit in here and in 15 minutes ill be back to check on you, but if you're just going to be mean i might take longer’ and [the VA] started crying so i left, after about 15-20 minutes i went back to [the VA’s] room and [s/he] started saying ‘i hope your [family member] is dead, when i get out of here im going to come kill your family, i hate you and everyone hear [sic]’ so i turned around and left to start making dinner.”

· On October 16, 2023, a facility nurse completed a daily note that stated, “[The VA] also reported that [the SP] took [the VA] to [his/her] room and put [him/her] in bed after day time staff left and never got [him/her] back up.”

· On October 29, 2023, P1 completed a daily note that stated the VA was “yelling” for staff at various points. “[The VA] then started to yell and disrupt the other client in the house. So I brought [the VA] to [his/her] room and told [him/her] [s/he] needs to calm down and sit in here for 5 minutes, I turned [his/her] tv on and opened [his/her] curtains. I went in 5 minutes later and brought [the VA] out. [S/he] did calm down in those 5 mins.”

· On October 30, 2023, P1 completed a daily note that stated, “[The VA] was good up until 1:40 [p.m.] when [s/he] was just screaming when I was trying to do things. I asked [him/her] to stop and [s/he] didn’t. So I put [him/her] in [his/her] room and opened the curtains and left. I told [the VA] ‘I will have the next staff come and help me change you since you won’t let me.’ And ‘I will come back in a couple minutes and bring u [sic] back out but right now your [sic] not cause [sic] you won’t stop disrupting the housemates [the VA] then continued to yell my name”

· On October 30, 2023, P2 completed a daily note that stated, “[The VA] was yelling and crying in [his/her] room when i arrived because [P1] would not let [him/her] come out of [his/her] room until [s/he] calmed down. [The VA] continued to scream until [unknown person] went in and talked to [him/her].” The VA then continued to “yell” for staff throughout the day. “It was constant!!! It wears on you mentally. I tried joking with [the VA] … and explained that [s/he] is going to be treated how [s/he] treats people.”

· On October 31, 2023, a staff person completed a daily note that stated the VA told staff that s/he “hated” an unidentified staff person because “[this staff person] left me in my room all day until (next staff) came in."

P1-P4 and the SP provided the following information:

· P2 said that the VA had a history of “disrupting” H1 and H2 by “yelling … constantly” for staff. H1 had “sensory issues” and whenever the VA was yelling, H1 put his/her weighted blanket over his/her head. H2 got “agitated” and sometimes yelled back at the VA. P2 once saw H2 responding to the VA’s yelling by trying to cover his/her ears and “growling” at the VA. P2 was not aware of the VA yelling directly at H1 and/or H2.

· P1, P2, and P4 each said that staff set a visual timer for the VA whenever s/he was yelling repeatedly for staff. The VA understood the timer and understood that s/he was supposed to be “patient” and stop yelling, and that when the timer sounded the staff would tend to the VA’s needs.

· Staff had been using a “big clock” as the timer but when this broke, they started using the VA’s cellphone. Staff set the cellphone next to the VA so that s/he could see how much remained on the timer.

· P4 said that staff might set the timer for five minutes. P1 said that the timer should not be set for over 30 minutes. The SP said that it should not be for over 15 minutes.

· P2 added that the VA “never really calms down.” P2 estimated that the VA might remain in his/her bedroom for 30 minutes before staff brought him/her back to the living room. The VA would be yelling from his/her bedroom that whole time.

· P4 said that staff could use the timer anywhere in the house. The timer was typically started wherever the VA was at that specific time. There was no reason to bring the VA to his/her bedroom to start the timer. The timer could be started when the VA was sitting in the living room.

· P1 said that at least once, s/he moved the VA to the VA’s bedroom to set the timer; however, “a (facility) higher up” read P1’s daily note, which recorded this information, and told P1 this was not allowed. P1 did not know this was not allowed.

· P1 was trained that if the VA screamed or yelled out before the timer sounded, staff reset the timer. If the VA screamed or yelled at that point, after the timer was reset, staff turned off the timer and addressed the VA’s needs.

· P3 said that one time, “a long time ago,” P1 told P3 that s/he put the VA “in a timeout” in his/her bedroom. The VA had been “screaming and yelling” in the living room. P1 told the VA to “calm down” and the VA “kept going.” “[P1] put [the VA] back [in the VA’s bedroom] as to not interrupt others.” P1 did not tell P3 how long the timeout lasted.

· P4 was not aware of times when staff brought the VA to the VA’s bedroom for a timeout or to set the timer.

· Regarding the VA’s ability to drive/maneuver his/her own wheelchair, P4 said that the VA was able to do so but wanted staff to do it instead. The VA had lost “some mobility” over time and although staff encouraged the VA to operate his/her own wheelchair, the VA declined and requested this help from staff. If the VA were in his/her bedroom and the bedroom door was closed, P4 did not believe the VA would be able to open the door without help. P4 added that the bedroom door was “always” left open. [Note: This investigator attempted to contact other staff for follow up regarding the VA’s ability to drive/maneuver his/her own wheelchair but did not receive responses by the completion of this investigation.]

The facility’s Internal Review included an interview with a staff person (P6), who was a facility nurse and not interviewed by this investigator. P6 told the facility that one time s/he told P1, “If [the VA] is disrupting others’ lives, [s/he] can go back to [his/her] room and could come out when [s/he] calms down. [P6] said [the VA] needs to go where [s/he] can be alone to calm down. When (the facility) asked if [P6] understood that this is not allowed, [P6] stated [s/he] did not know that.”

Conclusion for Allegation Three:

A. Maltreatment:

The VA said that staff put him/her into his/her bedroom when they did not want anything to do with him/her.

Consistent information was provided by the SP, P1, P2, P3, and P6 (via the facility’s Internal Review) that staff put the VA in his/her bedroom when s/he was yelling and disrupting his/her housemates. Although it was not clear if the VA was able to drive/maneuver his/her own wheelchair to leave his/her bedroom, it also did not appear the VA believed s/he could do so. Information was provided that each time staff put the VA in his/her bedroom and set the timer to “calm down,” the VA remained there and repeatedly “screamed” and “yelled” for staff to let him/her out. There was also no information in the progress notes or from staff interviews of the VA operating his/her wheelchair or leaving his/her bedroom on his/her own accord or without staff assistance. The conduct of involuntarily secluding the VA to his/her bedroom was a violation of Minnesota Statutes section 245D.06, subdivision 5.

In addition, although the VA’s support plan had information about staff setting a timer when s/he was yelling and disrupting others, there was conflicting information by staff and lacking information in the support plan about where in the house, and for how long, the timer should be set.

Given that consistent information showed staff put the VA in his/her bedroom when s/he was yelling and disrupting others; that the VA appeared to not understand s/he could leave the room on his/her own or was unable to do so due to his/her mobility; and that based on the daily notes documenting the VA’s statements, the VA did not voluntarily go to his/her bedroom and did not want to remain in his/her bedroom, there was a preponderance of the evidence that the VA was subjected to the use of aversive or deprivation procedures, unreasonable confinement, or involuntary seclusion including force separation which could reasonably be expected to produce emotional distress.

It was determined that 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 any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and/or the use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825).

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(2) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(3) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(4) whether the facility or individual followed professional standards in exercising professional judgment.

More than one staff person said they were trained to put the VA in his/her bedroom when s/he was yelling and disrupting others and that a timer could be set for between 5 to 30 minutes, and that staff did this. Given that multiple staff put and/or were aware that the VA was confined in his/her bedroom against his/her will and that the VA yelled repeatedly to be taken out of his/her room, yet no one intervened or stopped the conduct, individual staff person responsibility was mitigated, and this represented a systemic failure by the facility. Therefore, the facility was responsible for maltreatment of the VA.

C. Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.”

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious. There was no information the VA sustained an injury, which met the definition of “serious” maltreatment.

Allegation Four: It was reported that the VA had a pressure sore on his/her buttock that was infected.

The VA’s support plan and support plan addendum provided the following information:

· The VA relied on assistance from staff to schedule and attend his/her medical appointments.

· “[The VA] will refuse to let staff give [him/her] a shower. [The VA] will yell and scream, ‘No. I will not shower today.’ [The VA] will also refused [sic] to let staff brush [his/her] teeth, reposition [him/her], change [him/her], wash [his/her] clothes.” [Note: Regarding the expected facility and/or staff response for this, it was noted that the VA did not need or want supports in this area and as such, a support plan was not created for this concern.]

FM1 said that the VA had a wound on his/her buttocks. The VA told FM1 that staff were not repositioning him/her, which should have been once every two hours.

The VA said that s/he had a wound on his/her buttocks and that staff routinely repositioned him/her. The VA did not state any concerns with his/her wound care.

Facility documentation and P1-P5 provided the following information:

· P5 was a nurse and worked at the facility with two other nurses. P5 said that among the three of them, they visited the VA at least three times a week, sometimes four and were responsible for the VA’s wound care. Staff persons were instructed to replace loose bandages and/or contact a nurse if they had concerns with the VA’s wounds and the staff persons were good about this. “Staff are not afraid to reach out to us.” P5 said that the VA’s wound was “chronic.” When the VA first moved in, s/he had this same wound that healed but had since reformed. It was “very small” or about the size of “the tip of a Q-tip.” P5 said that the wound had “zero drainage” and “at no time has there been an active infection.” P5 did not have concerns with the handling or care of the VA’s wound.

· P2 said that staff repositioned the VA three times throughout the night. The VA typically got out of bed around 9 a.m. Staff then transferred him/her into his/her wheelchair. The VA liked to tilt back in his/her wheelchair. Staff changed the VA’s undergarment every two hours. Around 8 or 8:15 p.m., staff transferred the VA back to bed.

· P4 said, “[The VA] is repositioned every couple of hours.” The VA was also required to lie down for periods throughout the day to remove pressure from his/her buttock/pressure sore. This occurred every four hours or so, and s/he would typically remain lying down for 30 minutes each time. “Typically, [the VA] doesn’t like going back to bed.”

· P1 and P3 each said that they repositioned the VA every two to three hours. They were not aware of times when the VA was not repositioned every two to three hours. P1 also talked about how the VA was required to lie down throughout the day for various wound care treatments.

· The facility’s daily notes for October 1 through 31, 2023, which were completed by multiple staff persons, including P1, P2, P3, and P5, stated that the VA was repositioned each day, more than once, and also documented nursing visits regarding wound care. On October 13, 2023, P5 documented, “No other concerns at this time, [the VA’s] skin looks great with no rashes, or other sores.” On October 27, 2023, a facility nurse documented that the VA’s wound had “minimal discharge … was colorless and odorless.”

Conclusion for Allegation Four:

It was reported that the VA’s wound care and repositioning were inadequate and caused additional infection and concern. However, consistent information was provided by multiple staff persons, the VA, and facility documentation that this was not the case. Staff persons recorded repositioning the VA throughout each day and the VA’s wound did not show any signs of infection. At the time of the site visit, the most recent daily note, stated that the VA’s wound had “minimal discharge … was colorless and odorless.” Given this, there was a preponderance of the evidence that there was not a failure to supply the VA with care or services, including health care, which were reasonable and necessary to maintain the VA’s wound care and prevent infection.

It was determined that neglect did not occur (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:

Regarding Allegation One:

The facility completed an internal review and determined that policies and procedures were adequate but not followed. “[The SP] was suspended pending the investigation and [his/her] employment will be terminated.”

Regarding Allegations Two and Four:

The facility completed an internal review and determined that policies and procedures were adequate and followed. “Charting has been implemented to document repositioning and changing. Staff meeting held to discuss documentation and better approaches with [the VA]. [Behavior Support Plan] will be revised and all staff trained. Home is trying to have double staffing each day. Other support options are being discussed with [the VA’s] team.”

Regarding Allegation Three:

The facility completed an internal review and determined that policies and procedures were adequate but not followed. “All staff were retrained on prohibited procedures. [The VA’s] support plans will be updated, specifically [his/her] Behavior Support Plan. All staff will be trained on any revisions. Corrective action will be completed with the staff involved.”

Action Taken by Department of Human Services, Office of Inspector General:

The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.

On April 3, 2024, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.

The Department of Human Services also issued a recommendation to the facility to review the services provided to the VA and ensure they were in response to the VA’s identified needs as specified in the support plan and the support plan addendum.

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
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