|
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: 1103207-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady/Scout Peterson 651-431-6578 Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at a vulnerable adult (VA) which caused the VA to cry and isolate in his/her bedroom for a night. Date of Incident(s): October 13, 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 December 5, 2023; from documentation at the facility; and through seven interviews conducted with the VA, another resident (R) who lived at the facility, three staff persons (P1-P3), a supervisory staff person (P4), and the SP. The VA enjoyed going to the casino, working, and watching wrestling. The VA lived at the facility since it opened in December 2022. According to the VA’s Individual Abuse Prevention Plan (IAPP), the VA’s diagnoses included an intellectual disability and multiple mental health diagnoses. The VA’s IAPP also stated that staff persons will “gently” provide verbal intervention and redirect the VA if s/he shared “inappropriate” information or acted in a way that put him/herself at risk. The facility was a single level house with a finished basement, attached garage, and back patio that could be seen through a sliding glass door. The VA stated on October 13, 2023, the SP “yelled” at him/her twice because the SP told the VA not to eat something and that the VA could not get money out of the bank. The first time they were in the garage with P1 and the second time they were on the patio with P2 and P3. The SP did not call the VA names but was “disrespectful” and “nasty” towards him/her, and it made the VA feel “crappy.” . The VA stated that the SP only yelled at him/her on the one day. The R stated that on the day of the incident, the VA wrote a note because s/he wanted to go to Subway. When the SP saw the note, s/he ripped it up and “brought” the VA out to the garage. The R heard the SP yelling but could not make out the words the SP was saying. The SP and VA then came in from the garage and went outside to the back patio with P3. The R remained inside but could hear the SP yelling. The R could also see the SP through the sliding glass door pointing his/her finger and “waving” it at the VA. The SP was “mad” and the VA was crying. The R said that s/he was “shaking so bad from anxiety” after the incident and the VA was in his/her room “quite a bit” that night. P4 then arrived at the facility and walked the SP to his/her car. P1 stated that on October 13, 2023, s/he was at the facility in the garage when, the SP and VA came into the garage “discussing some behavioral stuff.” P1 did not hear the SP call the VA names and did not hear the SP raise his/her voice or yell at the VA. P1 stated in the facility’s internal review that “[s/he] did not hear what the conversation was but could tell by [the SP’s] body language while talking with [the VA], that [the SP] wasn’t happy about what [s/he] was talking with [the VA] about.” P2 and P3 provided the following consistent information to this investigator and in the facility’s internal review: · On the day of the incident, the SP, P2, P3, and the VA were in the kitchen and the VA made a list of things s/he wanted to do when s/he was out running errands that included buying a sandwich at Subway. When the SP saw the VA’s list, s/he crumpled it up and threw it in the garbage. The SP told the VA that s/he did not need to get Subway and that s/he could eat a frozen dinner the facility. The VA was “arguing [his/her] point” and trying to explain to the SP why s/he wanted to get something else to have for dinner. · The SP then took the VA into the garage to have a “private conversation,” and P1 was in the garage at the time. P2 and P3 each stated they heard the SP acknowledge P1 when s/he took the VA into the garage. P2 and P3 could not hear specifically what the SP was saying to the VA, but each stated that the SP was yelling. · At some point, the SP and VA reentered the home and the SP asked P3 to go outside to talk while P2 spoke with the VA. The VA told P2 that the SP “embarrassed” him/her in front of P1 and that the SP called him/her “rude” and “disrespectful.” After speaking with the VA, P2 went outside with the SP and P3 and told the SP that the VA was “upset” and crying. The SP asked the VA to come outside and when the VA did so, the SP began to yell at the VA again. P2 and P3 each stated that the SP called the VA names including “liar” and “selfish” at least five times. P2 stopped the SP from continuing to speak to the VA, by telling him/her “enough is enough” and then told P3 and the VA to go inside. P3 and the VA went inside and P3 took the VA and other residents into town to run errands. While they were gone, P3 called P4 and told him/her what happened and P2 notified P4 of the incident via email and wrote a progress note regarding what occurred. P4 arrived at the facility “within an hour” of being notified. · Later that day, when P3 and the VA returned from running errands, the VA made cookies with staff persons. P3 stated that the VA and the R were “expressing worry and fears” while on the outing. The VA then stayed in his/her bedroom for the evening. · P2 and P3 each stated that the SP’s actions were not consistent with his/her training. P2 stated that s/he was “uncomfy” working with the SP because the residents’ attitude changed and they were “scared” of the SP. P3 stated that “from the day [s/he] started working,” s/he was aware that the SP took the VA into his/her room and yelled at him/her, and that the SP stated the VA “got under [the SP’s] skin.” · P2 and P3 each stated that the SP yelled at the VA and other residents in the past. P3 also stated that s/he told P4 that s/he was “uncomfy” working with the SP because the residents are “scared” of the SP. The VA told P3 about other times (dates unknown) that the SP “yelled” at the VA in his/her bedroom on “numerous occasions.” P4 stated that s/he was not at the facility at the time of the incident, but received a call from P2 and P3 and they told him/her that the SP was being “extremely rude” to the VA and that the SP “berated” the VA and called him/her a “liar.” P4, was at another program about one hour away, and s/he left to drive to the facility. Once P4 arrived at the facility, s/he spoke to the VA who was “extremely upset” and told P4 that s/he was “scared” of the SP. P4 then told the SP to leave the facility. P4 stated that the SP’s actions were “absolutely not” consistent with that training but s/he was not aware of any other concerns with the SP’s treatment of consumers in the past. P4 provided the following information in the facility’s internal review, “[The VA] was in [his/her] room crying when [P4] went to talk with [him/her].” The VA told P4 that staff yelled at him/her and called him/her a “liar” and “rude.” The VA also told P4 that s/he did not feel safe in the home. The SP provided the following information to this investigator and in the facility’s internal review: · On October 13, 2023, the VA was going to run errands with P3 and showed the SP the list of what s/he wanted to pick up which included picking up a Subway sandwich and frozen dinner. The SP told the VA that s/he had already eaten out that week and already had a frozen dinner in at the facility s/he could eat. The SP stated that the VA responded to him/her in a “rude” and “harsh” tone that s/he did not want that frozen dinner. · The SP then asked the VA to go out to the garage to talk because s/he “[doesn’t] talk to individuals in front of other individuals.” The SP did not know that P1 was in the garage when they entered the garage but realized s/he was there when P1 left the garage halfway through the interaction. The SP said s/he told the VA “in a nice low voice,” that the VA “cannot talk to people like that” and that the s/he was being “disrespectful.” The SP and VA then discussed what errands the VA could do later that day. · The SP and the VA went back inside, at which point the SP asked P3 to go outside to talk because P3 was taking the VAs to run errands. P2 then came outside and told the SP that the VA was crying and “embarrassed.” The SP then “brought” the VA outside and “in a calm voice” stated, “Why did you lie about what I said, that you were being rude? I didn’t say that you were being rude, I said that you were disrespectful.” The SP denied calling the VA a “liar” or any other names but told the VA that s/he needed to be truthful and that it was not “right” to be “disrespectful.” The SP stated that s/he did not raise his/her voice at the VA and that s/he “kept it even” but his/her voice “carries” and was “naturally loud.” · The SP stated that when the VA returned from running errands, s/he was “fine,” and made cookies with P3 and the R. The SP stated that when the VA returned, the SP told the VA “I’m sorry you felt embarrassed.” · The SP stated that his/her actions were consistent with how s/he was trained to interact with VAs. The SP stated that the residents “manipulate” staff and that another staff person might say the SP “yelled” at the VA because the incident triggered another staff persons’ PTSD. The facility’s Code of Conduct stated, “Treat the individuals we serve with respect and dignity; verbal or physical abuse and neglect or financial exploitation of any kind will not be tolerated,” and “Take the time to listen to and understand the needs of the individuals we serve so that you may respond in a positive and efficient manner.” Facility documentation also showed that on June 9, 2021, the SP received Corrective Action for having “negative interactions” with residents and for neglecting to follow the Code of Conduct. Facility documentation showed that the SP was trained on the facility’s Code of Conduct, the VA’s Coordinated Services and Supports Plan, Individual Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clauses (6) and (15), stated in part that a persons’ protection-related rights include the right to be treated with courtesy and respect; and engage in chosen activities. Conclusion: Consistent information as provided that on October 13, 2023, the VA gave the SP a list of placed s/he wanted to go while running errands which included going to Subway, that the SP did not agree with the list, and that a verbal interaction then occurred between the SP and the VA. The SP’s actions of not allowing the VA to go to Subway was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause 15. The SP and the VA went into the garage and P2, P3, the VA, and the R provided consistent information that the SP “yelled” at the VA. When the SP and the VA returned inside, the SP and P3 then went outside and P2 came out shortly after and told the SP that the VA was crying. The VA then came outside. The VA, P1, and P2 each stated that the SP “yelled” at the VA and repeatedly called the VA a “liar” and “selfish.” The SP denied calling the VA any names or yelling at the VA and said that s/he spoke to the VA “in a nice low voice,” and “in a calm voice.” Given the consistent and/or similar information provided by the VA, the R, P1, P2, and P4 regarding the SP’s interaction with the VA and that the SP had reason to minimize his/her actions for fear of repercussions, it was more likely that the incident occurred as described by the VA, the R, P1, P2, and P3. The SP’s actions of yelling at the VA and calling the VA names were a violation of the facility’s code of conduct and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Given the incident on October 13, 2023; that P2 and P3 each stated that the SP had a history of yelling at clients including the VA; that the SP received, and a Corrective Action on June 9, 2021, for his/her “negative interactions” with residents and failure to follow the facility’s Code of Conduct in the past, there was a preponderance of the evidence that the SP’s engaged in repeated oral language that could reasonably be expected to produce emotional distress. It was determined that 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). 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. Facility documentation showed that the SP was trained on the facility’s Code of Conduct, the VA’s Coordinated Services and Supports Plan, Individual Abuse Prevention Plan, and 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 emotional abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious, because the SP’s actions were considered a pattern of behavior and therefore a single incident that did not meet the definition of serious. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies and procedures were adequate but not followed, and there was a need for corrective action to protect the health and safety of the adults in their care. All staff at the facility were retrained on maltreatment of vulnerable adults and reporting requirements. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report, however, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined above.
|
