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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: 1070626-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP1) did not allow a vulnerable adult (VA) to send money to his/her family members (FMs). It was also reported that a staff person (SP2) told the VA to “go die” and hit the VA’s head against a wall, that an unknown staff person hit the VA with a plate and did not allow the VA to cook for him/herself, and that SP2 and other staff persons the VA could not recall, called the VA a “dog” and other names. Date of Incident(s): Prior to December 5, 2023, and ongoing 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), clauses (1) and (2); and subdivision 9, paragraph (b), clause (1): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · The 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 29, 2023; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, SP1, and SP2), the VA, the VA’s guardian (G), and the VA’s case manager (CM). Facility documentation showed that the VA was diagnosed with high blood pressure, diabetes mellitus type II, gastroesophageal reflux disease (GERD), asthma, sleep apnea, and hypercapnia/hypoxic respiratory failure, and weighed significantly more than was recommended by his/her primary care physician. The facility provided the VA with one-to-one staffing, and s/he continuously used oxygen to keep his/her oxygen levels above 90%. A bi-pap machine helped the VA breathe regularly at night and helped decrease the amount of carbon dioxide in the VA’s blood when s/he slept, but the VA sometimes declined to use it. The VA understood that s/he was to eat a diabetic diet that was low in sodium because of his/her diagnoses, but preferred foods that were not included in the diet. Staff persons were to encourage the VA to eat recommended foods and assist him/her to cook, but the VA enjoyed cooking his/her own meals and prepared most of the food that s/he ate. In December of 2023, the VA had a rights restriction which was approved by the G that limited the amount of money the VA sent each month to his/her FMs to $55, which included fees. Staff persons assisted the VA with finances and Team Meeting Notes showed that the VA’s team and the VA agreed that the VA could send money to the FMs that s/he earned from working, but the money the VA received as benefits was for the VA’s needs. Facility documentation showed that the money was sent to the FMs as specified by the VA’s plans. When the VA was upset, s/he might yell or swear, call others names, use derogatory language including racial slurs and sexual language, play music loudly, or bang on facility walls. The VA might also repeatedly call the facility telephone or call 9-1-1 when s/he was disappointed that s/he did not get what s/he wanted, when s/he wanted it. Due to cognitive deficits or possible language difficulties, the VA might misinterpret situations or interactions that could lead to reports of maltreatment. The VA might call agencies to report that s/he was a victim of alleged maltreatment and frequently experienced paranoia or thought that s/he heard voices or sounds that others did not hear. Staff persons were to listen to the VA when s/he had concerns and offer to discuss them with him/her. The VA was vulnerable to all forms of maltreatment and staff persons were to intervene to protect the VA when necessary. The VA enjoyed dressing well, liked to watch airplanes take off, and wanted to live independently. Facility documentation and interviews with this investigator provided the following: · The VA said that s/he wanted to send money to the FMs, but SP1 did not let the VA send it, which upset the VA and the FMs. The FMs were hungry and “had nothing,” which caused stress to the VA. The VA knew that there was a rights restriction from his/her team which limited the amount of money s/he could send to the FMs, but s/he wanted to take the facility to court to remove the rights restriction, but the team did not allow the VA to go to court. · In addition, staff persons whose names the VA could not recall, called the VA a “dog” and other names, and hit the VA with a plate. SP2 told the VA to go “die,” hit the VA’s head against a wall several times and said that s/he could treat the VA this way because the VA had a mental illness. The VA could not recall the dates of the incidents, but s/he had thoughts of self-harm, was stressed, and had heart “palpitations.” The VA thought s/he was treated like an “animal.” · SP1 said that s/he had worked with the VA for more than 10 years and thought the VA had made great progress toward meeting his/her goals. The VA was calmer and had fewer aggressive behaviors but made more reports saying that s/he was abused than s/he previously made. When the VA called 9-1-1 or made allegations, staff persons were to talk with him/her about the difference between emergencies and non-emergencies. When the VA felt unsupported at the facility, s/he sought more contact with his/her FMs and called agencies more often to make reports. Over the years, the VA gave more than $5,000 to the FMs, and that was why the rights restriction was put into place. The VA thought that SP1 was responsible for controlling his/her finances and blamed him/her because the amount of money s/he could give to the FMs was limited. · According to SP1, the VA often said that staff persons and others called him/her a dog, monkey, or other animals, but SP1 did not hear anyone call the VA names. The VA became so upset, that the facility had to stop buying bananas, because the VA thought that staff persons were implying that they thought the VA was a monkey. When the VA made telephone calls, the person s/he called might not understand what the VA said and ask the VA if s/he was saying “d as in dog,” then the VA might become upset and think that s/he was being called a dog. · SP1 did not witness anyone hitting the VA with a plate or hitting the VA’s head against the wall or hear staff persons telling the VA to go “die.” However, staff persons talked with the VA about following recommendations from his/her physicians and told him/her that s/he might die in his/her sleep if s/he did not use the bi-pap machine and that declining to follow the diabetic diet might cause the VA to pass away, which were things that his/her physician had told him/her. The VA might also hit staff persons then say that the staff persons hit him/her. SP1 thought that the VA made false statements to get sympathy from others and called agencies to have conversations with those employees. · SP2 stated that s/he had worked with the VA for more than 10 years and had a good relationship with him/her. The VA called agencies multiple times a day and had called to make reports regarding SP2 while SP2 was sitting with the VA at the facility. When SP2 asked the VA why s/he called the agency, the VA replied that s/he called because s/he was frustrated and upset that s/he did not have enough money to buy items that s/he wanted and thought that no one cared about him/her. · SP2 denied that s/he told the VA to “go die” or that s/he grabbed the VA’s head or hit the VA’s head against the wall. However, staff persons previously prompted the VA to use the bi-pap machine when s/he slept by telling the VA that it was possible that s/he might die in his/her sleep if s/he did not. According to SP2, the VA’s primary care physician told the VA that declining to use the machine might result in his/her death, and staff persons repeated this information to the VA. The VA’s plans had recently been changed, and staff persons no longer told the VA that s/he might die if s/he did not use the machine, but instead prompted the VA three times to use the machine, then documented whether the VA used the machine. SP2 did not hear anyone call the VA a dog or other names and did not witness anyone hitting the VA with a plate. The VA cooked for him/herself, and staff persons made food for the VA when s/he did not prepare it for him/herself, but the VA was not prevented from cooking. · P1 and P2, who were supervisory staff persons, provided consistent information that the VA had an extensive history of calling 9-1-1 and other agencies when s/he was upset. They had no concerns regarding the VA’s care at the facility and did not witness the incidents described by the VA. The VA had not had injuries consistent with being hit with a plate or having his/her head hit against the wall. · The G and the CM were concerned that discussing the allegations investigated in this report with the VA would cause the VA to be upset and cause him/her to call 9-1-1 and other agencies more frequently. The issues the VA voiced were “standard things” that s/he usually said, and were not alarming to the G. According to the G, the VA could cook his/her own food and had for years. The VA’s team tried to limit the money the VA sent to the FMs because the team thought the people who the VA believed were his/her relatives were not related to the VA at all, and the VA was being “scammed.” The VA thought of employees who worked at the Department of Human Services or other agencies as “friends” with whom s/he could chat, and it made the VA happy when reports of alleged maltreatment were investigated. Personnel files showed that the facility trained its staff persons on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s plans of care in November and December of 2023. Conclusion: Information was consistent that the VA often called 9-1-1 and other agencies when s/he was upset, and SP2 said that s/he had been present when the VA called to make reports about SP2. The VA might yell, swear, call others names, use racial slurs or sexual language, play music loudly, or hit walls when s/he felt stressed, and was vulnerable to maltreatment. Regarding financial exploitation SP1 and SP2 each stated that the VA was making progress toward meeting his/her goals and that the VA had one to one staffing at the facility. The VA worked a couple of days a week and could send up to $55 (including fees) that s/he earned at work, to his/her FMs. The VA said that SP1 would not allow him/her send funds to the FMs. However, there was a rights restriction approved by the G preventing the VA from sending more money to the FMs. According to SP1, the VA thought that SP1 controlled the VA’s finances and blamed him/her because the funds sent to the FMs were limited. Although the VA said that SP1 did not allow him/her to send money to the FMs, facility documentation showed that the VA sent $55 (which included fees) to the FMs monthly. Given this, that documentation showed the money was sent to the FMs, and that there was a rights restriction that limited the amount the money the VA could send, there was a preponderance of the evidence that SP1 did not willfully use, withhold, or dispose of the VA’s funds. It was determined that financial exploitation did not occur (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Regarding emotional and physical abuse Facility documentation showed that the VA was to use a bi-pap machine to assist with his/her breathing at night and follow a low sodium diabetic diet as recommended by his/her physician. However, the VA frequently declined to use the machine and preferred to eat foods that were not included on the diet. The VA said that staff persons whose identities s/he did not recall called the VA a “dog” and hit the VA with a plate, and that SP2 told the VA to go “die,” hit the VA’s head against a wall, and said that s/he could treat the VA this way because the VA had a mental illness. The VA was treated like an animal and had heart palpitations. SP1 did not witness anyone hitting the VA or telling him/her to go die, but SP1 and SP2 both confirmed that staff persons told the VA that s/he might die if s/he declined to use the bi-pap machine as recommended. SP2 denied that s/he told the VA to go die, denied that s/he grabbed the VA’s head, or hit the VA’s head against a wall. P2 and P3 were each aware of the VA’s history of calling 9-1-1 and other agencies and had no concerns regarding the VA’s care. The VA said that unknown staff persons called him/her a dog and hit him/her with a plate, and SP2 told the VA to go “die,” hit the VA’s head against the wall, and could do that because the VA had a mental illness. However, given that no information showed that the VA was called a dog or hit with a plate, that SP2 denied that s/he told the VA to go die, that SP2 denied that s/he grabbed the VA’s head or hit it against a wall, and that the VA did not have injuries to his/her head, there was not a preponderance of the evidence whether SP2 or other staff persons engaged in non-therapeutic conduct which produced or could reasonably be expected to produce physical pain or injury or emotional distress to the VA. It was not determined whether physical or 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; and the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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