|
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: 1080200-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) grabbed a vulnerable adult (VA), shook the VA, and pushed the VA on more than one occasion. Date of Incident(s): January 1, 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 (1); 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. 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 January 24, 2023; from documentation at the facility; and through three interviews conducted with a facility staff person (P1), a facility supervisor (P2), the VA’s guardian (G), and the SP. This investigator met the VA face to face, but the VA was unable to provide any information related to the allegation as s/he was non-verbal. The facility had an open floor plan with three bedrooms on one level, with a kitchen and dining room. The facility’s lower level had a fourth bedroom (VA’s bedroom) and bathroom. The staff person office was located near the bathroom and the VA’s bedroom. The facility had multiple cameras and recordings of the alleged incidents were reviewed. Facility documentation showed the VA liked going into the community and seeing new things, and enjoyed using facial expressions during positive interactions. The VA would eat quickly, and not chew his/her food, which could cause issues with choking. The VA did not understand water temperature, and needed assistance regulating the water temperature. The VA had tonic clonic seizures and was unable to communicate when a seizure was about to occur. The VA was diagnosed with developmental disabilities and autism. The VA would engage in physical aggression and/or property destruction when s/he was frustrated. Staff persons were supposed to encourage the VA to utilize his/her coping skills when s/he was observed engaging in those behaviors. The facility was made aware of a concern related to the SP allegedly shaking the VA while in the bathroom on January 1, 2023, and while the facility reviewed video recordings two other incidents were identified. All three of the incidents occurred on January 1, 2023, and involved the SP and the VA. The following information was from the facility’s Internal Review (IR) and from this investigator’s review of video recordings during the site visit: · The IR showed that on January 1, 2023, at 3:12 p.m., the VA was seen in the living room throwing a CD (compact disc) and open handedly banging the protective plexiglass which surrounded the television screen. The SP approached the VA as seen in the living room camera while looking at his/her phone. The SP put his/her phone in his/her pocket and placed his/her hands on the VA’s back and “lightly push[ed]” the VA away from the television. As the VA attempted to sit down, and the SP placed his/her hands on each side of the VA’s waist area. Once the VA was sitting the SP appeared to “push” his/her hands against the VA before removing them, and then walked away. The SP looked back at the VA and then s/he threw a stuffed animal at the SP. The SP stood facing the VA and looked at his/her phone. The VA re-engaged in hitting the television and the SP moved in front of the TV but continued to look at his/her phone. The VA then hit the armrest of a chair, and the SP continued to “ignore” the VA. The VA walked toward the front door, and the SP walked out of the living room. The VA tipped over a chair and walked to the kitchen. This investigator reviewed a video recording of the incident that lasted thirty-two seconds. The video confirmed the incident involved the VA and the SP, and took place in the living room. The VA threw a CD to the ground and started to hit the TV between the seven second and twelve second mark in the recording. The SP was observed coming around the corner to engage with the VA at the twelve second mark of the video. The SP placed his/her hands on the VA back/waist at the nineteen second mark, and attempted to physically redirected the VA. However, the VA moved to a seated position on the ground at the twenty-two second mark. The SP disengaged with the VA and step back from the VA who remained on the ground until the recording ended at thirty-two seconds. · The IR showed that on January 1, 2023, at 3:15 p.m., the VA was in the kitchen and then the SP walked into the kitchen. The SP picked an item up off the floor and placed it in a drawer. The VA waved his/her hand “in a way that appears [s/he] is upset,” however the SP took his/her phone out and started looking at the phone. The VA appeared to shake his/her head, and the SP responded “as if mocking” the VA by shaking his/her head. The VA attempted to hit the SP’s arm, however the SP was able to get a hold of the VA’s wrist, to which the VA responded by hitting the SP with his/her other hand. The SP let go of the VA’s wrist after a “few seconds,” and the VA continued to “swat” at the SP. The SP proceeded to grab the VA’s arm, turn the VA around, and hold both of the VA’s arms by his/her wrist area as the VA tried to hit a kitchen cabinet. The VA “appear[ed] distressed” and fell to the ground while the SP continued to hold the VA’s wrists. Once the VA was on the ground the SP “appeared to throw” the VA’s arms while letting go of the VA. The SP walked away from the VA, and the VA sat on the floor and appeared upset. The VA got up and engaged in property destruction before walking out of the kitchen. The SP was observed looking at his/her phone, and the VA returned to the kitchen, and continued to engage in behaviors. The SP walked up to the VA and used his/her right arm to “shove” the VA toward the refrigerator. The VA than started “banging” on the refrigerator, and the SP placed his/her hands on the VA’s back to guide the VA away from the refrigerator. The SP kept his/her hands on the VA until they were out of the camera view. The VA appeared to sit on the ground and the SP again looked at his/her phone. The VA started engaging in additional property destruction, and the SP was seen walking in and out of the kitchen multiple times while the VA remained in the kitchen. P1 was observed coming into the kitchen and started to talk with the SP. This investigator reviewed a video recording of the incident that lasted thirty-six seconds, and took place in the kitchen. While in the kitchen the SP had his/her phone in his/her hand. The VA started to hit the refrigerator, and pointed towards something in the direction of the hallway. The VA proceeded to try to grab/hit the SP left hand with his right hand at the eight second mark, as the SP put his/her phone in his/her pocket, and was able to grab the VA’s right wrist. The SP let go of the VA at the eleven second mark. The VA continued to fail his/her arms, and at the fifteen second mark the SP held the VA’s wrists from behind, and the VA sat down at the eighteen second mark. The SP let go of the VA’s wrists once the VA sat down, and the SP moved out of the kitchen area. The VA got up and started engaging in property destruction including tipping over a chair and throwing a CD. The video this investigator reviewed did not include a portion of the incident described in the IR, which included the VA being shoved against a refrigerator, the VA banging on the refrigerator, the additional property destruction, and/or P1 coming into camera view. · The IR showed that on January 1, 2023, at an unspecified time there was an incident that occurred in the lower bathroom, however there was no video recording in the bathroom. There was a recording in the hallway near the bathroom. The recording was eleven seconds in length and showed the VA and SP in a hallway between the bathroom and the VA’s bedroom. The VA and the SP were observed at the eight second mark and the VA walked from the bathroom to his/her bedroom. The SP followed behind the VA, and the SP appeared to touch the VA’s back with his/her hand and extended his/her arm. The force used by the SP did not appear to cause any significant change to the VA’s gait or speed of movement. · The video recordings did not have audio and it was unknown what or if anything was said during the incidents. · The facility reviewed the camera footage of the incidents, and determined the SP did not utilize the VA’s coping skills and did not appropriately attempt to de-escalate the VA per his/her programming. The facility was unable to determine whether the SP shook the VA while in the bathroom and pushed the VA while going into his/her bedroom on January 1, 2023. The SP no longer worked at the facility as a result of the incident. P1 provided the following information: · P1 said s/he was at the facility during the incident(s) and described witnessing incident three. P1 said s/he saw the SP “hold” the VA’s hands and the SP “pushed” the VA into his/her bedroom. P1 said the VA was irritated prior to the physical contact with the SP. The SP left the VA in his/her bedroom and closed the door. The VA remained in the bedroom for a little while, but there were no further concerns. P1 did not observe the SP shake the VA during the incident. · P1 did not observe any injuries to the VA during or after the physical contact. P2 provided the following information: · P2 was not present for the incident, but observed the video recordings. P2 believe the physical contact between the VA and the SP was “unnecessary” and there was no “imminent harm” to the VA or someone else during the incident. P2 said the VA was not injured during the physical contact with the SP. · P2 did not talk with the SP about the incident. · P2 did not believe the SP followed the VA’s programming, and should not have been using his/her phone while the VA was having a behavior. P2 did not believe the phone was a trigger for the VA, but the VA did react when s/he did not get the attention s/he wanted. The SP provided the following information: · The SP said prior to the incidents the VA was upset throughout the morning and was engaged in property destruction such as flipping a table and chairs. The SP tried to reach out to multiple supervisors via his/her phone but did not receive a response from the supervisors. The SP added the VA had a new housemate, who had been verbally aggressing and made threats of harm toward the VA. The SP said s/he was concerned the housemate was going to hurt the VA, and was concerned for the VA’s safety during the incident. The SP tried to physically “redirect [the VA] the way I was taught to” per training, but the VA “flopped to the ground.” The SP said after s/he redirected the VA, the VA went to the ground, and the SP stepped away from the VA. The SP said the redirection occurred to ensure the VA’s safety. The SP said the VA physically aggressed toward the SP which resulted in the SP holding the VA’s wrist. · The information the SP provided was consistent with the video recordings this investigator reviewed. · The SP said s/he did not know the other staff person working (P1), and while P1 was in the bathroom with the VA, the VA became upset. Thereafter, the SP engaged with the VA, and redirected the VA into his/her bedroom. The VA shut the bedroom door and the SP heard the VA throw items inside the bedroom. The SP said the SP guided the VA with an open hand on the VA’s waist/back to redirect the VA. · The SP felt that s/he followed his/her training during the interactions with the VA. The SP denied shaking the VA at any time, and added s/he would “never intentionally try and hurt” a vulnerable adult. · The SP did not believe the VA was harmed during the interactions and physical contact. The SP felt it was “absolutely” the best thing for the VA to be redirected out of the behaviors. The SP believed his/her actions were “necessary” based on the VA’s behaviors. · The SP did not believe s/he was frustrated with the VA during the incident. P1, P2, and the SP were trained on the VA’s programming plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: It was reported the SP grabbed, shook, and pushed the VA on more than one occasion on January 1, 2023. The VA was unable to provide information in an interview as s/he was non-verbal. There was no information the VA was injured during the incident. P1 denied observing the VA being shaken during the incident, but said the SP had “push[ed]” the VA. The video recording of the incidents showed the SP did have physical contact with the VA including holding the VA’s wrist, redirecting the VA by placing his/her hands on the VA’s back/waist, however the SP said s/he believe the physical contact was necessary due to the VA’s behaviors. Additionally, the physical contact occurred after the VA engaged in behaviors such as throwing a CD, and hitting a refrigerator, and the SP believed the VA could be harmed by a housemate and/or the property destruction the VA had attempted to engaged in. Although the SP had physical contact with the VA, given that each time the SP made physical contact it was to redirect the VA and the SP thought intervention was needed for the VA’s safety, that each physical contact lasted less than nine seconds, that the VA was not injured,, and that when the SP had his/her hand on the VA’s back, the SP did not appear to push the VA, therefore there was not a preponderance of the evidence whether the SP engaged in conduct which produced or could reasonably be expected to produce physical pain or injury. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. There was similar incident involving the VA and a different staff person in the past, but no additional training was completed by the facility. The facility completed corrective action completed to ensure the safety of the persons served at the facility and the SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
|
