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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: 1116059-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 (SP) restrained a vulnerable adult (VA) when the VA was de-escalating and walking away. The VA sustained multiple scratches during the incident, and the SP placed his/her hand on the VA’s neck which impeded the VA’s breathing. Date of Incident(s): December 27, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on February 1, 2024; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, P3, P4, and the SP), and the VA’s case manager (CM). The VA moved from the facility into an apartment soon after the incident and initially agreed to an interview with this investigator but was not available at the date/time of the interview and did not respond to this investigator’s attempt to reschedule the interview. However, the VA provided information regarding the incident to the CM and in facility documentation, which was included below. Facility documentation showed that the VA was diagnosed with asthma and used both a scheduled inhaler and an emergency as needed inhaler when s/he had difficulty breathing. Other diagnoses included disruptive mood dysregulation disorder, attention deficit hyperactivity disorder, and reactive attachment disorder. The VA was not subject to guardianship. Speaking loudly and quickly was common for the VA even when his/her behavior was not escalated. When the VA was upset, s/he might have difficulty expressing his/her needs and use destructive behavior or profanity to communicate. The VA had a history of engaging in physically aggressive behavior including throwing liquids at staff persons and other individuals, and there was a rights restriction put in place by the VA’s team limiting the VA’s personal privacy. The VA might bring knives or other prohibited items into his/her bedroom and staff persons were permitted to make unscheduled biweekly checks of the VA’s bedroom to look for prohibited items and clean the bedroom. If the VA was at the facility, s/he was invited to participate in the bedroom checks but if s/he was not present, staff persons contacted him/her to say that they were going to check/clean his/her bedroom. The VA had a history of providing inaccurate information regarding staff persons and individuals who resided at the facility. The VA might say that s/he wanted staff persons to be fired or disciplined when s/he was angry with them or say that staff persons violated his/her rights. Staff persons were to take the VA’s concerns seriously and report them to the appropriate agencies. The VA often declined to take his/her prescribed medications and the facility was in the process of ending services to the VA when the incident occurred. The VA was creative and enjoyed expressing him/herself through art projects. Moving from the facility into an apartment to live independently was important to the VA. Facility documentation, the facility’s Internal Review, and interviews with this investigator, provided the following: · The CM said that on the morning of December 27, 2023, the VA called the CM and said that s/he fought with the SP, a supervisory staff person, that morning because the SP was “antagonizing” him/her. The VA “got in [the SP’s] face” and argued with him/her, but then “backed off.” swiped items off the kitchen table onto the floor and walked away. The SP restrained the VA with his/her hand on the VA’s neck and the VA could not breathe. When the SP removed his/her hand from the VA’s neck, the VA bit the SP. The VA thought that s/he was improperly restrained and a staff person whose identity the VA did not recall told the SP during the restraint that the SP was hurting the VA, but the SP said that the VA was not hurt because the VA would be crying if s/he was hurt. Law enforcement officers came to the facility but said there was no reason to press charges on the VA because s/he did not instigate aggression. The VA sustained scratches on his/her back and hand, and under his/her arm during the restraint. · P1, P2, P3, and the SP were involved in the incident and provided consistent information that immediately prior to the incident, the VA was upset regarding the transportation protocol in his/her plans. The VA wanted staff persons to take him/her on multiple outings that day, but the protocol limited the number of daily outings the VA could have. No information showed that the VA had difficulty breathing during the restraint and P4, who was a supervisory staff person and was talking with the SP on a telephone prior to the restraint and remained on the connected call when the restraint occurred, heard the VA yelling “put me in a hold, bitch, I’ll fuck you up.” In addition, P4 heard staff persons asking the VA whether s/he needed an emergency inhaler, but the VA responded with profanity. The VA was restrained in a supine position near a kitchen cabinet and photos taken of the VA’s injuries after the incident showed that s/he had a superficial scratch that was about three to four inches long on the outside of his/her left calf, a light scrape on his/her upper side/back, and a few red areas on the back of his/her right hand. · P1 said that s/he was in the dining/kitchen area with the VA when the SP walked into the kitchen while on the phone with P4. The VA “got in” the SP’s “face,” threatened to hit him/her and fight the SP when the VA moved from the facility. The SP told P4 that the VA had won two fights and thought s/he was “grown.” The VA came toward the kitchen table, pushed items from the table to the floor, and moved toward the stove, where a pot of water was heating. The SP intervened and said that staff persons needed to restrain the VA, then implemented a restraint by holding the VA’s upper body and moving him/her to the floor. P2 held the VA’s legs while P1 held the VA’s middle section and attempted to place his/her arm between the VA and a kitchen cabinet to prevent the VA from being injured, but the VA was “still fighting” so P1 helped P2 hold the VA’s legs. · P2 stated that when the SP entered the kitchen, the VA told the SP that s/he was tired of the SP and did not like him/her, and began to walk away, but then suddenly turned, knocked food from the kitchen counter, and walked toward the stove where a pot of water was boiling. The SP instructed P1, P2, and P3 to assist him/her to restrain the VA and implemented a restraint with the VA, who began kicking staff persons. P1 and P2 held the VA’s feet, and P3 called 9-1-1. The VA said that s/he would kill staff persons, but within a “couple of minutes,” the VA calmed, and staff persons released him/her. The VA went to his/her bedroom, and later staff persons learned that the VA sustained a couple of scratches on his/her back during the restraint. · P3 stated that on the date of the incident, s/he was in the kitchen but everyone else was in the living/dining room. The VA threatened to fight the SP and said that s/he would spit in the SP’s face on the last day the VA was at the facility. When the SP entered the kitchen, the VA got “nose to nose” with him/her, repeated threats to fight the SP, and told the SP to step outside. P3 attempted to redirect the VA, but the VA pushed everything off a table and the kitchen counter, then walked toward the kitchen stove and a pot of hot water. The SP implemented a restraint on the VA, guided the VA to the ground while holding the VA by his/her arm and shoulder, and instructed staff persons to assist him/her. P1 and P2 held the VA’s legs and P3 called 9-1-1 and tried to block the VA from hitting the SP. The restraint lasted for one to three minutes and was “absolutely justified” because the VA was upset and going toward the stove. P3 was unsure whether the VA sustained injuries during the incident. · The SP said that on the date of the incident, there was a “house meeting” with a special meal and everyone was excited. The SP and P4 were talking on a mobile phone while the SP walked into the facility toward the kitchen. The SP greeted staff persons and the VA as the SP approached the kitchen, but the VA was upset and spoke to the SP in a raised voice because s/he wanted staff persons to take him/her to a friend’s house. The SP told the VA that staff persons could not transport him/her to the friend’s house because staff persons were to take the VA on one outing per day, and s/he had already gone on the outing that day. · The VA approached the SP, stated that s/he was going to kick/beat the SP’s ass, tear up the SP’s car, fuck the SP up, and smack the SP’s face on the last day the VA resided at the facility. The SP redirected the VA, but the VA said that s/he did not give a fuck and added that s/he was going to whip the SP’s ass, then put his/her hands very close to the SP’s face and said, “Let’s go, meet me outside.” The VA started to walk outside and the SP “kind of chuckled” because the VA’s actions were typical of the behavior s/he had when s/he was upset. · The VA then swept the items from the kitchen table onto to the floor and started walking toward the boiling water on the stove. The SP grasped the VA’s arms/shoulders and pulled the VA to the floor onto his/her back, holding the VA’s arms against his/her mid-section while lying alongside the VA. The VA spit on the SP, hit the SP’s face, and bit his/her arm. The SP’s grasp on the VA was not firm, and s/he asked P1, P2, and P3 for assistance. P1 and P2 held the VA’s legs, while P3 called 9-1-1. The SP asked the VA whether s/he could breathe and turned the VA onto his/her side, with the VA’s back against a kitchen cabinet. The VA sustained superficial scratches during the incident, but the SP said that his/her hands were near the VA’s midsection and were not near the VA’s neck or chest. The VA could move during the hold, and s/he hit the SP several times when the SP held him/her. The SP was certain that restraining the VA was the correct action to take because of the SP’s history of throwing harmful liquids. · P4 said that s/he was talking with the SP on the telephone when the incident occurred and heard the VA use profanity, threaten to beat the SP up, and staff persons attempting to redirect him/her. The VA often made verbal threats and staff persons were to redirect the VA and ignore the threats. The SP was frequently targeted by the VA because of his/her supervisory position at the facility. After the incident, P4 met with the SP, P1, P2, and P3 to complete an internal review and P4 had no concerns regarding the restraint or how it was implemented. The VA had a few superficial scratches on his/her lower back/hips which staff persons treated with a topical antibiotic ointment and no other concerns were raised to P4 regarding the restraint. · Records from a law enforcement agency showed that the law enforcement agency came to the facility on the date of the incident and interviewed the VA, the SP and other staff persons, but took no further action. The facility’s Emergency Use of Manual Restraints Policy showed that staff persons were to attempt to de-escalate behaviors before they posed an imminent risk of physical harm to self or others but were allowed to block or re-direct a person’s limbs or body without holding the person to interrupt the person’s behavior with less than 60 seconds of physical contact. Restraints might be used on an emergency basis when a person’s conduct posed an imminent risk of physical harm to self or others and less restrictive strategies were unsuccessful. Allowed restraints included a two-person supine restraint where the individual was positioned on his/her back and a staff person placed his/her leg over the VA’s leg to secure it to the floor. Restraints were to end when the threat of imminent risk of harm ended. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: Information was consistent that on December 27, 2023, the VA was upset because s/he wanted staff persons to take him/her on a community outing, but staff persons declined to take the VA since they had already taken the VA out that day. When the SP arrived at the facility, the VA approached him/her, used profanity, and threatened to harm the SP and damage his/her personal property. P1, P2, P3 and the SP attempted to redirect the VA. However, the VA pushed items from the kitchen table/counter onto the floor, and moved toward the kitchen stove, where there was a pot of hot water. The SP, P1, and P2 then restrained the VA in a supine position on the facility’s kitchen floor while P3 called 9-1-1. The VA hit the SP and bit him/her and kicked at staff persons. The SP held the VA’s arms to keep him/her from hitting the SP, and P1 and P2 held the VA’s legs. The restraint lasted about three minutes and ended when the VA calmed. After the VA was released, s/he went to his/her bedroom. The VA had red marks on his/her hand and a few superficial scratches on his/her left calf and upper back/side, which were treated with a topical antibiotic. The VA told the CM that s/he could not breathe during the restraint and sustained scratches when the SP restrained the VA assisted by P1 and P2. However, the VA had a history of throwing harmful liquids and information was consistent that the VA was walking toward a pot of hot water prior to being restrained. Given this, and that no information showed that the VA was held near his/her neck or chest, or that the VA’s injuries were sustained by any means other than accidental, there was not a preponderance of the evidence whether the SP engaged in non-therapeutic conduct which could reasonably be expected to produce physical pain or injury or emotional distress. It was not determined whether 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 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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