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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: 1069304-H_DSF (245D-Home and Community-Based Service-Day Services Facility) 1069297-HCBS (245D-Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) yelled at a vulnerable adult (VA), and told the VA s/he needed a medication adjustment. Date of Incident(s): October 19, 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 1, 2023; from documentation at the facility; and through four interviews conducted with the VA, a facility staff person (P1), a facility supervisor (P2), and the SP. The VA’s guardian (G) provided a written statement related to the incident and the information provided to them by the VA after the incident occurred. Facility documentation showed the VA worked at a business, and staff persons, including the SP, transported and assisted the VA at the business. There were other vulnerable adults and staff persons at the worksite. The VA was unable to independently contact or access community resources, and family and/or staff persons provided transportation for the VA. The VA was provided verbal prompts by staff persons when the VA was communicating his/her needs to other people. The VA enjoyed going hiking and looking for rocks with his/her family. The VA was diagnosed with autism. The VA’s client specific programming provided the following information: · Staff persons were to complete medication administration, which included reporting to the prescriber or a nurse any concerns about a medication or treatment, including side effects, effectiveness, or a pattern of the person refusing to take the medication or treatment as prescribed. · Staff persons were to assist the VA when interpreting social cues and facilitate group discussions regarding specific situations as needed. Staff persons were to allow the VA time to think, calm down, and process an incident if the VA was involved in an argument or disagreement. Staff persons would discuss the concerns with the VA to determine what actually took place. · The VA may not be able to recognize potentially dangerous situations, and may believe “everyone” was a “good person.” · Staff persons were to accompany the VA while in the community and staff persons would model/discuss appropriate precautions with strangers. · The VA may be loud and talk about inappropriate topics in public, and staff persons were to verbally redirect the VA to a private area and explain to the VA why his topic of conversation was inappropriate in a public setting. There was information provided through interviews which was included below about the SP’s behavior toward other vulnerable adults however, interviewees were not able to provide details regarding those incidents including who was involved and when the incidents occurred. Therefore, this investigation focused on the SP’s interactions with the VA. Interviews with the VA, P1, P2, and the facility’s Internal Review (IR) provided the following consistent information: · On October 19, 2023, the VA was visibly upset about an interaction with the SP. The VA informed P1 that the SP had yelled at him/her and got in his/her face. The VA shared consistent information with the G, as well as information that the SP spoke to other persons served in the same manner. · The SP declined to participate in an interview with the facility and did not attend a scheduled interview for the IR. · The VA, with assistance from the G, said s/he had felt harassed, intimidated and criticized by the SP for a while, but during the last week the SP had started “picking on” the VA and making “negative comments.” The VA said the SP would get into individuals’ faces. The SP made a comment about the VA needing a medication change, and said the VA was not completing his/her job/task correctly. The VA added the SP threatened to quit his/her job, and blamed the VA for him/her wanting to quit. The VA was emotional after the incident occurred and cried. · The G said the SP also threatened to send the VA home, or clock him/her out if the VA was not “working hard enough,” or did something incorrectly. The G did not believe the SP was supportive to the VA or other vulnerable adults. · P1 was working at the time of the alleged incident, but was not present when the SP allegedly said the VA was doing a job task incorrectly, and needed his/her medications adjusted. P1 said after the incident the SP made similar comments to P1 regarding the VA needing a medication adjustment, to which P1 told the SP, “Those types of comments were not appropriate.” · P1 said prior to the alleged incident the SP had been threatening to resign in front of the vulnerable adults, and would “blame” them for him/her wanting to quit. Additionally, P1 observed the SP having a harsh tone and/or yelling at vulnerable adults, and the SP singled out and “picks” on specific vulnerable adults, including the VA. The SP would state the vulnerable adults should not do a certain job or that they were doing a task incorrectly. P1 added that the SP had other interactions that were “inappropriate or unprofessional” with the vulnerable adults, which included the SP grabbing items out of their hands, yelling at them, and commenting on the vulnerable adults not working hard. · P2 spoke with the VA, who said the SP yelled at him/her for not doing his/her job correctly, and that s/he “probably needed a med[ication] change.” The VA said the incident occurred in front of other vulnerable adults and the VA felt the incident was “inappropriate and embarrassing.” · The SP’s interactions with vulnerable adults had “always been very harsh” and the SP did not use an “appropriate tone” while providing supervision. · P1 and P2 said two community persons who worked at the job site business (who are not affiliated with the facility) brought forth concerns about the SP’s interactions with the vulnerable adults. They said the SP would speak “inappropriately” when P1 and P2 were not present, and that the SP did “not belong here” and “should not be allowed to work with [the vulnerable adults].” · P2 said there was consistent issues with the SP’s behavior, which included threatening to resign in front of the vulnerable adults, and the SP blamed the vulnerable adults for the SP disliking his/her job. The G provided a written statement which included the following information: · During a week of work the SP made multiple comments that upset the VA because the comments were insulting and unprofessional. These comments included the SP suggesting the VA needed to get his/her “medicine fixed.” The VA “indicated” to the G that “[the SP] was criticizing, harassing and intimidating everyone at work.” · The VA informed the G about concerns with how the SP treated other vulnerable adults, and that P1 was present during for the SP’s concerning behavior. The G picked the VA up from the worksite, and the G was surrounded by the other vulnerable adults and they provided “unsolicited information” about the negative interactions the vulnerable adults had with the SP that week. · The written statement from the G did not include specific details of what and/or whom the “unsolicited information” pertained to. The SP provided the following information: · The SP denied telling the VA s/he needed a medication change, but said s/he may have made the comment to P1 and/or to another employee. The SP said s/he tried to be professional, and ensure the job tasks that were being done correctly, however admitted to being frustrated at times.
· The SP said the VA’s anxiety was increased during the week of the alleged incident, and while the VA worked s/he tried to complete multiple tasks and be a leader, however the VA had been completing them incorrectly. The SP tried to address the VA completing those tasks incorrectly, and also expressed concern with the VA completing a task, which required the use of a knife, as the VA’s hands were shaking. · The SP said s/he wanted to provide information to the facility regarding the alleged incident, however the time of an interview was not clearly communicated. · The SP admitted that s/he threatened to quit his/her job because the vulnerable adults were not listening to him/her. The SP, P1, and P2 were trained on the client specific programming, facility’s policy and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: It was reported that on October 19, 2023, while at a worksite the SP yelled at the VA, and told the VA s/he needed a medication adjustment. The VA said the SP made a comment about the VA needing his/her medications changed and told the G the SP “was criticizing, harassing and intimidating everyone at work.” The VA provided consistent information to P1, P2, and the G, as well as to this investigator. P1 was not present for the SP’s comment about the VA’s medications, but the SP told P1 the VA needed to get his/her medications adjusted. Additionally, P1 said s/he observed the SP make unprofessional comments including threatening to quit, blaming the vulnerable adults for him/her wanting to quit. P2 said there was consistent issues with the SP’s behavior as stated above. However, there was no specific information regarding the SP’s behavior other than the incident with the VA. The SP denied telling the VA s/he needed a medication adjusted, but said s/he was frustrated and threatened to quit because the vulnerable adults were not listening to him/her. The SP said s/he tried to be professional and have the job tasks be completed correctly. The SP said s/he tried to explain to the VA s/he was not completing the job task correctly, however the VA was struggling with his/her anxiety. The SP talking about the VA's medication in front of other vulnerable adults, yelling, and saying VAs made the SP want to quit was behavior inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). Although the VA was upset and said s/he cried, given that the SP stated his/her interactions were to direct the VA to complete job tasks correctly but that s/he did get frustrated, and that there was a lack of details regarding other incidents it was unable to be determined if the SP's conduct was repeated, and therefore there was not a preponderance of the evidence whether the SP's conduct was repeated or could be reasonable expected to cause emotional distress. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, and followed. There was no prior similar incident involving the VA, however the SP had a “pattern” of speaking unprofessionally to people served, but the behavior had not “previously risen to the level of requiring reporting.” There was no corrective action or additional staff training completed as the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action to address the violations outlined in this report, a Correction Order was not issued.
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