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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: 1092994-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070916-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) did not provide vulnerable adults (VA1-VA3) with basic hygiene cares throughout his/her shifts on October 15 and 16, 2022, and that the SP “antagonized” a vulnerable adult (VA4). Date of Incident(s): October 15 and 16, 2022 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 November 11, 2022; from documentation at the facility; and through two interviews conducted with a facility supervisor (P1) and the SP. Attempts by telephone and mail to request interviews with three facility staff persons (P2, P3, and P4) were unsuccessful. However, P2-P4 provided information for the facility’s Internal Review and that information was included below. VA1-VA4 were not able to provide information because of their diagnoses and communication abilities. The facility staff person schedule provided the following information: · The SP was scheduled to work from 9 a.m. to 9 p.m., on both October 15 and 16, 2022. · P2 worked from 10 a.m. to 10 p.m., on October 15, 2022, and from 10 a.m. to 10:30 p.m., on October 16, 2022. · P3 worked 12 a.m. to 9 a.m., on both October 15 and 16, 2022. · P4 worked from 12 a.m. to 9 a.m., on both October 15 and 16, 2022. P1 provided the following general information: · On October 16, 2022, P2 notified P1 of multiple concerns at the facility and P1 went to the facility around 7 p.m. P1 observed the facility and said it was “very weird” that there was no clothing to be washed two days in a row. · The facility tried to have a minimum staff person to client ratio of 1:2 but could operate 1:4 if needed. VA1-VA4 had a shower schedule and were provided showers every other day. Staff persons provided and assisted VA1-VA4 with personal cares. VA1-VA4 were able to be transferred by one staff person. · P1 said the SP would spend hours baking cookies, painting, and browsing social media before completing the VAs’ personal cares. P1 provided additional training to the SP, but the SP seemed to “avoid” completing personal cares. The following were the concerns that were reported to have occurred on October 15 and 16, 2022: · The SP requested VA1 be left in bed for “long periods of time,” and VA1 was heard crying in his/her bedroom for over an hour. · VA2 was in his/her bed the “entire” weekend and VA2’s absorbent undergarments were not changed. VA2 did not receive daily cares such as showering, change of clothing, range of motion exercises, and repositioning. · VA3 was left in his/her bed until 11 a.m., on October 16, 2022, and the SP did not provide VA3 with any food until 2 p.m. VA3 was assisted with personal cares at approximately 9 p.m. on October 15, 2022, but was not assisted again until 11 a.m., on October 16, 2022. · It was reported the SP made statements to instigate issues between VA4 and VA1. VA1-VA4’s progress notes did not provide any information regarding whether cares were completed. Regarding VA1: Facility documentation showed VA1 was described as friendly and playful. VA1 enjoyed watching large semi-trucks and participated in one community activity per week. VA1 was diagnosed with developmental disabilities, cerebral palsy, and had a shunt due to congenital hydrocephalus. VA1 ate through a tube in his/her stomach and required extensive assistance with all his/her personal cares, however there was no specific information within the documentation which showed how often the VA’s personal cares needed to be completed. VA1 had muscular contracture due to cerebral palsy, and his/her range of motion and fine/gross motor skills were limited. VA1 used a power wheelchair that s/he relied on for mobility. VA1 liked going up and down the hallway at the facility in the wheelchair but would bump into walls/objects/people unintentionally and also use his/her wheelchair to run into people, or block people for being able to move. Staff persons would redirect VA1 to operate his/her wheelchair safely. VA1 was unable to manage his/her mental health symptoms/behaviors and would forcefully hit him/herself in the face. VA4 might be verbally or physically aggressive toward VA1 so staff persons were to encourage VA1 to keep a distance from VA4 and attempt to get VA1 involved in an activity in a separate room. VA1 needed repositioning of his/her body and limbs a minimum of once every two hours. P2 told P1 that the SP was “punishing” VA1 by threatening to take VA1’s power wheelchair away if s/he ran into “one more thing.” The SP also attempted to avoid VA1 and VA4 fighting by having VA1 stay in his/her bedroom until VA4 left the facility and that the SP “instigated” issues between VA1 and VA4. VA1 could spend time out of his/her wheelchair however because P2, P3, and P4 did not provide information in interviews to this investigator, there was no information regarding how long the VA was in his/her room out of his/her chair or if the VA requested to be out of his/her wheelchair. P1 provided the following information: · P2 contacted P1 regarding concerns after observing the SP on October 15 and 16, 2022. P1 reviewed the concerns with P2 and observed the facility. P1 sent the SP home for the remainder of his/her scheduled shift. P2 told P1 that s/he did not intervene as s/he was a new staff person and “wanted” to see how the SP completed his/her shift. · P1 spoke with P3 and P4 about their observations of the SP, however they had limited information as they only worked with the SP for a few hours on October 15 and 16, 2022. P1 said the SP left VA1 in his/her bedroom multiple times over the weekend and asked staff persons to leave VA1 in his/her bedroom until VA4 left the facility. · P2 told P1 the SP told VA1, “You’re done,” after VA1 dragged an item on the ground with his/her wheelchair. The SP added, “You keep running into stuff,” and the SP had VA1 move into a common area. P1 said there were no past issues between the SP and VA1, but the SP did not like VA1’s behavior of driving his/her wheelchair into the walls or objects. · P1 said there was no information VA1 had a negative emotional response to the SP’s statements, but P1 said VA1 tended to be “happy” most of the time. P1 said there was no skin breakdown or redness to VA1, and no concerns related to VA1 being provided food in a timely manner. The facility completed an Internal Review which provided the following information: · The SP requested VA1 be left in bed for “long periods of time,” and VA1 was heard crying in his/her bedroom for over an hour. · The SP was heard making “passive aggressive statements” to VA1 about taking away his/her wheelchair. The SP told VA1 that s/he was “doing it all day” (running his/her wheelchair into objects) and VA1 was going to “lose” his/her wheelchair. The SP did not remove VA1 from his/her power wheelchair but moved VA1 into a different room. · There was information that SP1 placed VA1 in his/her bedroom in a “bungee chair” and/or in bed. The facility determined the SP was responsible for “isolation” and “neglect” of VA1, and VA1 “experienced negative emotional outcomes” as s/he was “crying" in his/her bedroom for over an hour. Additionally, VA1’s power wheelchair was his/her primary mobility, and his/her favorite thing was to roam around the house playing with hangers and closing doors. VA1 would not have been able enjoy his/her home or personal space if the wheelchair was removed. The facility’s policy and procedures indicated seclusion was prohibited and any removal of access to the wheelchair was not authorized by his/her legal representative. The SP provided the following information: · The SP believed s/he provided VA1 with all the required care and services, including assisting VA1 out of bed and VA1 was provided a change of absorbent undergarments. The SP was not sure why there was information that the cares and services were not completed and said s/he was “baffled” by the allegation of maltreatment. The SP felt like multiple staff persons had issues with the SP. · The SP said s/he was doing “creative crafts” with the vulnerable adults. There was some irritation between VA1 and VA4, but the SP denied instigating any issues between VA1 and VA4. · The SP said s/he did not complete documentation on October 16, 2022, as P1 came to the facility and sent the SP home. The SP said s/he was doing laundry when P1 arrived and asked the SP to leave the property. P1 said s/he “did not want me writing anything” in VA1-VA4’s documentation. · The SP said s/he worked “mostly” with VA3 and VA4 on October 16, 2022, and the SP had asked P2 if s/he had done personal cares for VA1. P2 told the SP s/he had completed personal cares for VA1. Regarding VA2: Facility documentation showed VA2 was completely dependent on staff persons for all personal cares, including assistance with eating, and required support 24 hours a day. VA2 had a strong support network from his/her family. VA2 used a custom wheelchair, shower chair, hospital bed, and ceiling lift that had a track in his/her bedroom for transfers. VA2 could blink, laugh, and cry out/moan if experiencing discomfort, and there were some concerns that VA2 had stopped trying to communicate. VA2’s programming included completing range of motion exercises three time a day and having VA2 out of his/her bed daily. VA2 diagnoses included, but were not limited to, anoxic brain injury, seizures, anxiety, and depression. VA2 was in a chronic vegetative state caused by lack of oxygen to his brain during a cardiac arrest. VA2 was to be repositioned every two hours, and his/her skin was to be monitored for breakdown. VA2 was provided a shower/bath every other day. Staff persons were to complete checks on VA2’s absorbent undergarment every two hours. P1 provided the following information: · On October 16, 2022, P2 contacted P1 in the late afternoon and told P1 s/he had gone to change VA2’s absorbent undergarment and it was “heavy and discolored,” the chuck pad under VA2 was wet, and the pillows around VA2 were also wet. P2 said the description P1 provided was not normal and “that does not just happen.” Based on P1’s experience it seemed like VA2 had been in bed for a while without cares being completed. P1 believed VA2 was provided food, but no other basic cares. · P1 said VA2 required full assistance with personal cares, did not have the ability to refuse personal cares, and although VA2 could make noise, it was unknown what s/he was attempting to vocalize. P1 said VA2 had laundry every day, however during the weekend of October 15 and 16, 2022, there was no laundry. Based on that, and information from P2, P1 stated there was reason to believe VA2 had not been provided a change of clothing for the entire weekend. · The SP spoke with P2-P4 during the weekend and based on P1’s information the SP provided conflicting statements to P2-P4 regarding the cares provided to VA2. The SP told P2 s/he put VA2 back into his/her bed because s/he was uncomfortable, but told P3-P4 VA2 was returned to bed because VA4 was yelling and VA2 did not like it. · P1 said there was no skin breakdown or redness to VA2, and no change in VA2’s emotional stability, however it would be difficult to observe based on VA2’s abilities. The facility completed an Internal Review which provided the following information: · The SP said s/he completed personal cares for VA2 during the morning of October 16, 2022, and VA2 was out of bed until 2 p.m. · P3 and P4 told P1 that the SP lied about personal cares being completed and VA2’s absorbent undergarments were so “wet and heavy they were blowing apart.” · P1 observed that there were no clothing items in VA2’s hamper, and VA2 did not have his/her clothing changed for the duration of the weekend. Therefore, VA2 was also in bed for the entire weekend. · The facility summarized their findings and included that documentation from the facility did not support the statement from the SP regarding him/her completing VA2’s personal cares. Additionally, VA2’s personal care items had not been moved, and VA2 did not have any laundry in his/her laundry hamper. P2-P4 each stated the SP did not go into VA2’s bedroom during either shift on October 15 or 16, 2022. VA2’s absorbent undergarments were described as “blowing apart” due to the urine, however it was noted that staff persons said this happens frequently. It was unknown how often this occurred when the SP worked compared to with other staff persons as well. Also, VA2 did not receive sensory, range of motion, social interaction, and was not provided a scheduled shower. · The facility determined the SP did not provide VA2 with basic care and services. The SP provided the following information: · The SP believed VA2 had been provided all of the required cares and services during his/her shifts on October 15 and 16, 2022. The SP said s/he assisted VA2 with his/her morning routine which included, but not limited to completing his/her range of motion exercises, and brushed his/her hair, and the SP said s/he completed multiple changes to VA2’s absorbent undergarment during his/her shift. The SP said s/he worked “mostly” with VA3 and VA4 during the weekend, and asked P2 if s/he had completed VA2’s personal cares. P2 told the SP s/he had completed personal cares for VA2.
· The SP said VA2 was mostly asleep during the morning of October 16, 2022, but at 12 p.m., the SP provided VA2 his/her mediations, checked VA2’s absorbent undergarment, which was dry at that time. The SP said that around 1 p.m., P2 said s/he completed a change of VA2’s absorbent undergarment. The SP believed s/he changed VA2 clothing on October 16, 2022, and was not sure why it was reported that cares were not completed. · The SP said VA2 would occasionally “hold” his/her urine and would “let it go” causing his/her absorbent undergarment, and bedding/pillows to become saturated with urine. Regarding VA3: Facility documentation showed VA3’s family tried to spend time with him/her, and VA3’s face lit up when his/her family visited. VA3’s food needed to be cut into small pieces and was monitored while s/he ate. VA3 required some assistance with personal cares, including a “toileting plan for every couple of hours.” VA3 was described as “mostly non-verbal,” and VA3 had started sleeping more than what s/he did in the past. VA3 was diagnosed with development disabilities, cerebral palsy, and Rett’s syndrome. VA3 was able to reposition him/herself, but was a fall “risk” and required assistance for transfers. P1 provided the following information: · P1 said based on his/her observation and information from P2, VA3’s personal cares were completed “to a point,” but not in the way s/he should have had them completed. VA3 did not use an absorbent undergarment but was not provided assistance with using the bathroom for more than 12 hours, some of which was overnight. VA3 was not provided a shower. · P1 said there was no skin breakdown or redness on VA3 and no change in VA3’s emotional stability, however it would be difficult to observe based on VA3’s abilities. · VA3 was not provided breakfast but did eat a large lunch. The facility completed an Internal Review which showed VA3 was provided medications at 11 a.m., and when P2 asked about making VA3 food, the SP said VA3 would “just have lunch,” however lunch was not provided until 2 p.m., as VA3 went back to sleep. Additionally, there was no information VA3 was provided assistance with personal cares while his/her medications were completed. The facility determined the SP did not provide VA3 with basic care and services. The SP provided the following information: · The SP believed s/he provided VA3 with all the required cares and services. The SP said VA3 did not seem to feel well on the morning on October 16, 2022, and slept in until 10:30 a.m. The SP said VA3’s morning routine was completed including medications, and a shower. The SP said VA3 had an applesauce with the medications. After completing VA3’s routine, the SP assisted VA3 with walking around the facility, and VA3 relaxed in a chair in the common area. The SP took VA3’s temperature and spoke with P2 regarding VA3’s condition. VA3 indicated s/he was not interested in eating and appear irritated when offered food. Thereafter VA3 fell asleep in a chair in a common area. · The SP said VA3 was allowed to stay in the chair and did not want to “force” VA3 out of the chair or to eat. VA3 was provided lunch, and then a second helping as s/he did not eat much for breakfast. · The SP was doing VA3’s laundry when P1 arrived, and the SP was told to leave the facility. The SP was unsure if any other person’s laundry was completed on October 16, 2022. Regarding VA4: Facility documentation showed VA4 enjoyed craft activities, and s/he needed staff person assistance to set up and complete most activities. VA4 learned best if staff persons used short direct phrases or words paired with gestures, followed by verbal praise. VA4 liked to please staff persons and felt important when s/he did things to help staff persons. VA4 would become fixated on certain staff persons and if s/he saw that staff person talking with other staff persons s/he would become upset and yell. VA4 was diagnosed with developmental disabilities, cerebral palsy, and a seizure disorder, as well as other physical health issues. VA4 used adaptive equipment: a urinal, hospital bed which allowed him/her to reposition him/herself, and an electric and manual wheelchair for mobility. P1 provided the following information: · VA4 was provided all of his/her cares and services, however P4 informed P1 that the SP made statements to VA4, and believed the statements were “antagonistic.” The statements included, “Are you mad at [VA1]?” “Don’t you want to punch [VA1]?” and “Don’t you want to drown [VA1].” · P1 said the SP was “not a fan” of VA4, and VA4 was “not a fan” of the SP. However, there was no specific incident or reason for this between the SP and VA4. The facility completed an Internal Review which showed P2-P4 each said they had heard the SP make “passive aggressive comments instigating verbal aggression.” The SP’s comments to VA4 were made while performing daily routines and P2 observed the comments such as, "What's that? You want to drown [VA1]?" or "You said you wanted to punch [VA1]?" It was believed the SP said those statements knowing that VA4 would respond negatively. The comments occurred “routinely,” and VA4 was observed in distress after the comments; VA4 would target VA1 and VA4’s skin color turned bright red and VA4 had physical shaking. The SP provided the following information: · The SP denied making any statements to provoke VA4 to be verbally or physically aggressive towards VA1. The SP believed s/he provided VA4 with all of the required cares and services. · The SP said VA4 would “go after” VA1, and the SP would try and keep VA1 and VA4 separated. The SP said s/he had no idea why anyone would say s/he made those comments, but maybe “misconstrued” a conversation between VA4 and the SP. Conclusion: Regarding VA1: It was reported the SP was punishing VA1 by threatening to take VA1’s powerchair away if s/he ran into “one more thing,” that the SP also attempted to prevent VA1 and P4 from fighting by having VA1 stay in his/her bedroom until the other resident left the facility, that VA1 was in his/her room for an hour crying, and that the SP took VA1 out of his/her power wheelchair. VA1 was unable to complete an interview and provide information. P2-P4 were contacted during the investigation but did not participate in interviews so there was limited information regarding the allegations. P1 said s/he was informed of the concerns by P2 and P1 went into the facility on the day of the alleged incident. The SP denied the allegations and stated that s/he worked mostly with VA3 and VA4 on October 15 and 16, 2022. P3 and P4 provided statements concerning the SP’s conduct for the facility’s Internal Review, however neither worked with the SP during those shifts. P2 provided some information but additional information was not able to be obtained because P2 declined an interview with this investigator. Given that there was no information regarding how long VA1 was out of his/her power wheelchair and if the VA requested to be moved, that VA1 was not injured, and that the SP denied the allegations, there was not a preponderance of the evidence whether the SP failed to provide VA1 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). Regarding VA2: It was reported the SP left VA2 in his/her bed the entire weekend, VA2’s absorbent undergarments and clothes were not changed, and VA2’s other cares were not completed. VA2 was unable to provide information in an interview. P1 said P2 had informed him/her of the concerns and went to the facility. While at the facility P1 did not observe VA2 having any laundry and VA2’s personal cares supplies did not appear to be moved and/or used. P1 said P2 said the SP did not provide VA2 with personal cares, VA2’s absorbent undergarment was full of urine, and the urine was on the VA’s bedding/pillows. P2-P4 were contacted but did not participate in interviews so there was limited information regarding the allegations. P3 and P4 each stated they did not see the SP go into VA2’s bedroom however neither worked with the SP October 15 and 16, 2022, other than arriving to their shift when the SP was finished with his/her shift. The SP denied the allegations and said s/he had provided care and services to VA2, including changing VA2’s absorbent undergarment and range of motion exercises. The SP stated that s/he worked mostly with VA3 and VA4 those shifts and at one point asked P2 if s/he had changed VA2’s absorbent undergarment and P2 stated s/he had. Although P2 stated VA2’s absorbent undergarment was saturated, given that the SP stated s/he checked VA2 prior and the absorbent undergarment was dry, that VA2 could hold his/her urine causing a large amount to be released at once, that the SP denied the allegations, and that VA2 did not have skin breakdown or injuries, there was not a preponderance of the evidence whether the SP failed to provide VA2 with reasonable and necessary cares 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). Regarding VA3: It was reported VA3 was left in his/her bed until 11 a.m., on October 16, 2022, and the SP did not provide VA3 with any food until 2 p.m. and that VA3 had been assisted with personal cares at approximately 9 p.m. on October 15, 2022, but was not assisted again until 11 a.m., on October 16, 2022. VA3 was not able to participate in an interivew to provide information. The SP’s shift on October 15, 2022, ended at 10 p.m., and on October 16, 2022, started at 9 a.m. The SP denied the allegations and stated that VA3 was not feeling well and fell asleep so s/he did not eat breakfast but ate later when s/he was awake. Although P2 stated the SP did not assist VA3, given that the SP stated s/he assisted VA3, that VA3 was not injured, and that there was no further information to dispute or confirm either account, there was not a preponderance of the evidence whether the SP failed to provide VA3 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). Regarding VA4: It was reported the SP said things to VA4 instigate issues between VA1 and VA4. VA4 was unable to provide information in an interview. P1 said s/he was informed of the concerns by P2 and went into the facility the day of the concern. P2 did not participate in an interivew so did not provide further details. Although P2 stated the SP used phrases to “instigate” aggression between VA1 and VA4, given that the SP denied doing so, and that there was no further information regarding any incidents between VA1 and VA4 occurring, there was not a preponderance of the evidence whether the SP failed to provide VA4 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 the policies and procedures were adequate, but not followed. The facility completed additional training to staff persons. The report was similar to past events as the SP has been given previous corrective action regarding verbal responses to individuals receiving services. The SP was no longer employed at the facility, and no corrective action was taken. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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