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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: 1071504-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that for nine months, a staff person (SP) “rushed” a vulnerable adult (VA) during bathing and forced the VA to undress/dress and bathe causing the VA to scream, hit walls, scratch, and engaging in self-injurious behaviors (SIB) that led to bleeding. Date of Incident(s): Prior to March 16, 2024 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 17, paragraph (a): 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 March 21, 2024, from documentation at the facility, from law enforcement records, and through seven interviews conducted with a facility management staff person (P1), three facility staff persons (P2-P4), the SP, the VA’s legal representative (G), and a law enforcement officer (LEO). Although this investigator met the VA, the VA was unable to provide information in an interview due to his/her diagnosis. The VA lived at the facility with three other clients. The facility typically had two staff persons working during waking hours. Facility documentation for the VA showed that s/he had a developmental disability, but the level of disability was not identified. The VA’s support plan, dated January 22, 2024, showed that s/he enjoyed spending time with family and accessing the community. The plan also showed that the VA “lives with cognitive and psychiatric disorders, which impact [his/her] ability to self-manage [his/her] behaviors, emotions and symptoms, resulting in abuse towards others or [his/herself] at times.” A “new housemate this past year,” “seem[ed] to trigger” the VA’s “behaviors.” The VA’s Service Outcomes document showed that the VA engaged in self-injurious behaviors (SIB), which included biting, engaging in physical aggression toward others, kicking, spitting, throwing objects, and hitting walls and other objects. Also, the VA engaged in “irritable behaviors,” which included screaming, yelling, and threatening others. As a result, staff persons were trained to provided “verbal praise and compliments sporadically throughout the day when [the VA] displays alternative behaviors of calmness, friendly conversations, joking around, verbal communication, and smiling.” The document provided various ways for staff persons to intervene when the VA engaged in behavioral concerns, some of which included giving the VA some space, removing others from potentially dangerous situations, and allowing the VA to process his/her feelings after the incidents occurred. The plan showed that staff persons helped the VA in terms of “grooming and personal care,” but the level of support was not specified in the plan. The facility did not have specific documentation that outlined steps for staff persons to follow when they assisted the VA with bathing. P2 provided the following information: · For the past 9-12 months, P2 “witnessed” the VA “screaming and yelling and biting” when the SP assisted the VA with bathing. · On one occasion on an unspecified date, the SP came out of the bathroom and had a “smirk” on his/her face. When P2 checked on the VA in the bathroom, P2 found “blood everywhere” that was coming from the VA’s genital area. When that happened, P2 asked the SP, “How can you do this?” The SP did not respond to P2, but P2 described the SP’s affect at the time as being “very cold.” · When P2 assisted the VA with bathing, P2 did “not have a problem” with the VA because even though the VA would become “upset,” P2 would “wait” for the VA to be ready to take a bath. · P2 did not remember the date, but s/he talked to P1 about the concerns that P2 was observing regarding the SP’s behavior when bathing the VA. P1 did not say “much” to P2 and P2 did not notice any changes regarding the SP’s behavior after that date. · P2 did not remember the date, but remembered a time that the SP came out of the bathroom after the VA was having a hard time with bathing. When P2 told the SP that s/he was worried that the VA might have a “stroke,” the SP that the VA had a do not resuscitate (DNR) on file. P2 thought that the SP felt it was “okay” if the VA had a stroke because the VA had a DNR on file, but the SP did not say that. The G, who had not assisted the VA with bathing in several years, did not have concerns related to any of the staff persons at the facility. Information from the investigation showed that when the local police department received the report of possible maltreatment from the Minnesota Adult Abuse and Reporting Center (MAARC), an officer was assigned to the report. The law enforcement report showed that the LEO went to the facility on March 15, 2024, and an unnamed staff person said that the SP “would allow” the VA to “harm” his/herself and “appeared to get pleasure from the incident” when the VA was not cooperative with bathing. When the LEO talked to the SP, the SP stated that it was “common” for the VA to “self-harm.” When the LEO talked to P1, P1 stated that the VA had the “same behaviors” as described by the SP in terms of bathing. The LEO took “no further action.” P1 provided the following information: · When P1 provided training to staff persons in terms of assisting the VA with bathing, P1 told staff persons not to use the word bath because the VA could be “really triggered” by that word. Instead, staff persons were trained to tell the VA it was time to get undressed. · P1 said that “anything” could upset the VA in terms of taking a bath and that staff persons were expected to “just do their best.” When the VA was upset, “no redirection” was effective and staff persons just needed to give the VA “time” to calm down. Staff persons were trained to offer something positive to the VA, such as a van ride, after the bath was completed which was sometimes effective, but not always. · P1 did not have concerns related to how the SP assisted the VA with bathing. P1 believed that s/he had a good rapport with the VA because P1 had worked with the VA for a long time. However, there were many instances in which the VA was not cooperative when P1 assisted the VA with bathing and that the VA was uncooperative, at times, with every staff person at the facility, including P2. P1 described the SP’s tone of voice as being “calm and firm” when the SP assisted the VA with bathing. · When P1, and other staff persons, assisted the VA with bathing, the VA engaged in self-injurious behaviors, sometimes to the point that the VA bled. Staff persons were trained to offer redirection, which was not usually effective, and provide other options to calm the VA. Also, staff persons were trained to provide first aid to the VA, as needed. · P1 stated that P2 “did not like” the SP and that they had a previous “disagreement.” P1 had not heard the SP say anything about the VA having a DNR on file. P3 and P4 each provided information that was like the information P1 provided. P3 described the SP’s tone of voice as being “normal” when the VA was upset and P4 described the SP’s tone as being “calm.” Both P3 and P4 said that the VA engaged in SIB to the point that s/he had minor bleeding incidents during bathing and that verbal redirection was only minimally effective with getting the VA to stop engaging in SIB. In addition, P3 and P4 did not hear the SP say anything about the VA having a DNR on file. The information provided by the SP was consistent with the information provided by P1. The SP provided the following additional information: · When the SP was going to assist the VA with bathing, the SP approached the VA and told the VA to go to his/her bedroom to pick out clothing to wear and “socks” because the VA “really likes” socks. · When the VA was in the bathroom and undressed, the SP offered the VA a pair of “headphones” because the VA did not like the noises that a peer made. Other times, the SP offered to turn a radio on in the bathroom, so the VA had music to listen to. · When the VA engaged in behavioral concerns in the bathroom or SIBs, the SP told the VA to “please stop” and that was sometimes effective. When it was not effective, the SP waited until the VA was calm and ready to continue bathing. · The SP did not remember the dates but remembered that the VA scratched his/her genital area and small amounts of blood were noted. When that happened, the SP asked the VA to stop and sent an email message to the VA’s medical doctor because the SP thought that the VA had a urinary tract infection (UTI). The SP obtained a sample of the VA’s urine, and it was determined that the VA had a UTI and/or yeast infection, but the SP did not know the timeframe of when that happened. After the VA received medication, the VA stopped scratching his/her genital area. · The SP denied doing anything to escalate the VA’s behaviors and denied ever saying anything about the VA having a DNR. The facility’s Internal Review provided the following information: · The SP stated that the VA “often displays behaviors during [his/her] baths and that the behaviors occur with all staff [persons].” The SP also stated that there were a “couple” times in February (the year was not provided) in which the VA engaged in SIB to his/her “private areas to the point of bleeding.” When that happened, the SP “attempted to redirect [the VA] during these episodes to stop the self-harm, which eventually [the VA] did” and provided medical care, as needed. The review also noted that the VA had a urinary tract infection (UTI) at the time. · The SP stated that the VA’s behaviors “have substantially increased recently and is possibly due to a housemate that [the VA] shows signs of disliking.” · The information P1 and the SP provided for the Internal Review was consistent with the information each provided to this investigator. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to March 21, 2024. Conclusion: P2 stated that s/he “witnessed” the VA “screaming and yelling and biting” when the SP assisted the VA with bathing including one occasion where the VA had blood coming from his/her genital area. Information from the investigation showed that the VA did not like to bathe and exhibited aggression and SIB that sometimes caused bleeding when all staff persons, including P2, assisted the VA with bathing. Staff persons were to redirect the VA and provide first aid as needed. The SP denied causing the VA to escalate during bathing and information showed that the VA scratched his/her genital area causing bleeding likely due to a UTI/yeast infection. After the VA received medication, the VA seemed to be better and stopped scratching his/her genital area. P2 said that on one occasion, P2 was worried about the VA having a stroke and the SP said that the VA had a DNR on file. P2 thought that meant that the SP would have been okay if the VA had a stroke, but P2 said that the SP did not say that. P1, P3 and P4 denied ever hearing the SP say that the VA had a DNR, and the SP denied making that comment. Although P2 said the VA was screaming and yelling and had blood coming from his/her genital when the SP assisted the VA with bathing, given that there was consistent information from P1, P3, P4, and the SP that the VA commonly had those behaviors including SIBs causing bleeding because s/he disliked bathing, that the SP denied causing the VA to escalate, and that P1, P3, and P4 each described the SP’s tone of voice as “calm” while working with the VA, there was not a preponderance of the evidence whether the SP failed to provide the VA with reasonable and necessary care and services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an Internal Review and determined that its policies and procedures were adequate, followed, and that no additional training was needed. Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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