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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: 1070421-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that staff persons locked a vulnerable adult (VA) in his/her bedroom for the VA’s safety due to other clients in the home and that the VA was not able to exit his/her room independently. There were also concerns that the VA ate meals in his/her room and was “secluded” from others. Date of Incident(s): Ongoing and prior to October 17, 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), clauses (3) and (4): 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: · Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and · Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825. Summary of Findings: Pertinent information was obtained during a site visit conducted on November 15, 2023; from documentation at the facility; and through three interviews conducted with a facility supervisory staff person (P1), a staff person from the VA’s day program (DP), and the VA’s guardian (G). This investigator spoke to a facility staff person (P2) briefly during the site visit and then attempted to contact P2 via phone and email to set up an interview for additional information. However, P2 did not respond to this investigators attempts but P2’s limited information is below. This investigator also attempted to contact and interview a staff person (P4) for an interview but the attempts were not successful. This investigator met the VA but due to his/her disabilities, the VA was not able to provide information for this investigation. The VA was diagnosed with a “profound” intellectual disability and cerebral palsy. The VA was also vision impaired and nonverbal. The VA enjoyed eating at fast food restaurants and listening to calming music in his/her bedroom. The VA’s Intensive Support Self-Management Assessment provided the following information: · The VA only liked being in the community for a “very limited time” unless s/he was at a fast-food restaurant. The VA preferred listening to music in his/her room while being “completely” covered with a blanket because this “soothed” him/her. The VA liked “routine” and was “content” in his/her bedroom but it “benefited [the VA] to acclimate and be comfortable with other parts of [his/her] home.” The VA had an “outcome [goal]” to come out of his/her room to try and engage in an activity. · The VA had a history of scratching, pushing, and biting others. Additionally, when there was a change in routine, the VA became “more agitated and aggressive.” Staff persons were to give the VA one or two tennis balls to hold to “distract” the VA from injuring others. The VA also had a history of displaying self-injurious behaviors including hitting his/her head on “surfaces” or “slapping” his/her head. When this occurred, staff persons were to give the VA his/her as needed (PRN) medication. · Additionally, due to the VA being “legally blind,” staff persons were to provide “hand over hand” feeding for the VA’s “first spoonful” so that the VA was aware that the food was in front of him/her. Staff persons “may” also need to assist the VA with the “last few spoonful’s” of food. The VA was not able to chew his/her food so staff persons were to puree “all” of the VA’s food before serving it to him/her. · The VA wore an adult undergarment and relied on staff persons to change his/her undergarment to keep the VA’s skin clean. Staff persons were to check the VA’s adult undergarment every two hours when the VA was awake. · There was a staff person at the facility at all times when the VA was home. However, there was nothing noted in the VA’s plans requiring the VA to have one to one staffing. According to the VA’s Individual Abuse Prevention Plan, the VA was not able to recognize physical abuse or defend him/herself against physical abuse. The VA may not independently walk away if s/he were abused so staff persons were to take the VA’s hand and “guide” the VA to safety. The VA relied on others to keep him/her safe. The facility was a one level home and had four clients, including the VA and another client (C). The C moved into the facility in June 2023 and moved out in November 2023. The C had one to one staffing up to 14 hours per day and the remainder of the time, shared a staff person with the three other clients. The C’s plans showed that the C had a history of yelling, hitting, kicking, grabbing, pushing, and throwing items at others when “agitated or frustrated.” The C was “quick to anger and be defiant.” Staff persons were to remove items within the C’s reach so that the C could not throw items at “other vulnerable peers.” Staff persons may also ask others to leave the area when the C was “aggravated” for their safety and for the C’s safety, due to “risk or retaliation.” During the (unannounced) site visit, this investigator observed that the VA had a lock on the inside of his/her bedroom door. The lock was part of the doorknob and could be locked/unlocked by turning the lock on the doorknob. The other client bedroom doorknobs had similar locks. The VA also had a child safety cover on the outside of his/her door that could be squeezed to open the door. The DP provided the following information: · The DP said that on October 16, 2023, P1, who was the “new” facility supervisory staff person, was at the VA’s day program. During this time, the VA was eating lunch. P1 asked the DP if the VA “always fed” him/herself at his/her day program and the DP said that the VA did. P1 seemed “surprised” that the VA ate “semi-independently” at the day program. However, because the VA was vision impaired, s/he needed a “little assistance” with eating. P1 then told the DP that at the facility, staff persons went into the VA’s bedroom and fed the VA meals there. · P1 also told the DP that when the VA returned home from his/her day program, that the VA was “set” in his/her room and then locked in due to other clients’ behaviors. Because P1 was new to the facility, P1 was trying to stop this but the DP said that it did “not seem urgent.” The DP did not know how long this had been happening and did not know which staff persons did this but P1 told the DP that it was “just what was done” so the DP “assumed” it was “all” staff persons. The DP had not been to the facility so did not see the lock and did not know what it looked like. · P1 also told the DP that on one recent occasion, s/he went into the VA’s bedroom and the VA was sitting backwards on his/her bed, with the VA’s back facing the edge of his/her bed. P1 said that the VA could have fallen to the floor and “no one would have known.” · P1 told the DP that the VA was “rarely” out of his/her bedroom but that P1 was trying to make a schedule for staff persons to bring the VA out of his/her room and walk with the VA. · The DP said that the VA did not typically “engage in a lot of activities” but enjoyed sitting in a recliner chair that “rocked,” holding two tennis balls, and listening to “soft” music. The VA also enjoyed “listening” to what was going on around him/her as long as it was at a “lower-level volume.” · P1 told the DP that staff persons were not able to hear the VA if s/he were to make any noise in his/her room. The VA was also not able to independently exit his/her room and the VA needed “help for everything.” However, P1 told the DP that on occasion when s/he walked near the VA’s bedroom, s/he placed his/her ear on the VA’s bedroom door to listen. The DP had concerns that the VA was “secluded” from others as staff persons were locking the VA in his/her bedroom and also eating in his/her room. The VA was blind and was not able to see what was going around in his/her environment. The VA was also not able to verbally communicate his/her wants or needs. The G provided the following information: · At some point, the DP told the G that staff persons locked the VA in his/her bedroom. The G then went to the facility and spoke to an unknown staff person who told the G that staff persons locked the VA’s bedroom door because of the C who could “potentially” harm the VA. The G then notified a facility supervisory staff person (P3) who said that the staff person was “incorrect” and that “never happened.” · The G had not seen staff persons lock the VA in his/her room. However, the VA “preferred” to be in his/her bedroom and listen to music. The VA would not be able to exit his/her bedroom on his/her own and “would [not] even know how to turn the doorknob.” · The G had concerns that staff persons did not know how to work with the VA or the C and that because of that, they were locking the VA’s bedroom door for the VA’s “safety.” The G thought that staff persons began locking the VA in his/her bedroom in the summer 2023, when the C moved in. · Additionally, at some point, the G cleaned the VA’s bedroom because s/he was “so appalled” by the “condition” of it and found pizza under the VA’s bed. The G asked staff persons why there was pizza in the VA’s room and they said because the VA ate in there. The G also had concerns that the pizza was not pureed, which it needed to be. P1 provided the following information: · The VA preferred to stay in his/her bedroom under a blanket or covers and listen to music. Staff persons tried to get the VA out of his/her room but after the VA returned home from his/her day program, the VA preferred to be in his/her room. Additionally, when the VA was out of his/her room, other clients “irritated” the VA. · If staff persons changed the VA’s routine, the VA displayed behaviors such as scratching or attempting to bite or pinch staff persons. Staff persons attempted to bring the VA to sit in a rocking chair in the living room or play with water, which the VA enjoyed, but the VA would get “agitated” and let staff persons know s/he wanted to go to his/her room and listen to music. · The C had a history of entering other clients bedrooms and being “disruptive.” The C also displayed aggressive behaviors towards “anyone and everyone.” When this occurred, staff persons tried to get other clients to their room or to “safety” and then would “direct their attention” to assist the C with his/her behaviors. · All the client bedroom doorknobs had locks on the inside knob so that the clients could lock themselves in their bedrooms. The VA was not able to lock or unlock his/her door. However, around the “second week” in November 2023, P1 put a child safety cover on the outside of the VA’s bedroom door to “prevent” the C from entering to keep the VA “safe.” P1 could not recall if s/he told the VA’s team about the cover. However, P1 was not aware of anyone having concerns with it. Due to the VA’s diagnoses, the VA was not able to open his/her door, even without the child safety cover on it. The VA would “pound” on his/her bedroom door when s/he wanted to come out or needed something. Additionally, staff persons checked on the VA at least hourly. Staff persons could also hear the VA moving in his/her bedroom and when that occurred, staff persons were to check on the VA. Staff persons could get into the VA’s bedroom by “squeezing” the child safety cover to open. The other clients did not have the child safety cover because they were able to independently lock and unlock their door from the inside. · In addition, in approximately July 2023, when the C moved to the facility (and prior to P1 working at the facility), staff persons began locking the VA’s bedroom door via the inside lock and staff persons used a key to lock/unlock it. However, once P1 began working at the facility (September 2023), P1 had concerns about this and said it was “not appropriate at all.” Staff persons said they were doing so as a “safety concern” including that the C could go into the VA’s bedroom and “strangle” the VA, which staff persons said the C had attempted to do. P1 had concerns that in an “emergency,” staff persons would have to take time to open the VA’s door with a key. The child safety cover was “quicker” than the key and was “still keeping [the VA] safe in [his/her] room.” However, regardless if the staff persons locked the VA’s bedroom door from the inside lock or had the child safety cover on the outside doorknob, the VA was not able to independently open his/her door. · After the C moved out of the facility (November 2023), the facility left the child safety cover on the VA’s bedroom doorknob to give the VA the “option” for “security and privacy” as another client also went into client bedrooms to take or “dig” in their belongings. · Additionally, after the C moved out of the facility, staff persons began leaving the VA’s bedroom door open so that the VA could “learn [his/her] surroundings.” However, when the VA’s door was open, the VA became “agitated” and would “not calm” so then staff persons closed the door. · When P1 began working at the facility, staff persons fed the VA meals in his/her bedroom. When the VA ate in his/her room, the VA’s food was “prepared” the same and there were no “choking hazards.” P1 thought that staff persons gave the VA meals in his/her room because the VA preferred being in his/her bedroom for “peace and quiet.” However, P1 stopped that practice because it was “not sanitary.” P1 “enforced” with staff persons that the VA was to eat at the dining room table. The clients typically did not eat dinner at the same time due to their schedules so the VA typically did not eat with the other clients. Additionally, after P1 spoke to the DP and learned that the VA was “very capable” of eating semi-independently with some staff assistance instead of staff persons feeding the VA entirely, P1 purchased plates and silverware that allowed the VA to eat more independently. · The facility sometimes had double staffing but other times was single staffed. P2 said that the VA often preferred to nap in his/her room when the VA returned from his/her day program. The C was not able to enter the VA’s bedroom with the child safety cover. The Internal Review and Investigative Summary completed by P3 said that the VA preferred to be in his/her bedroom after returning home from his/her day program with soft music on. Staff persons were “expected” to follow and respect clients’ rights. When the VA was out of his/her bedroom, s/he typically engaged in self-injurious behaviors, including hitting his/her head or hands on the wall. Staff persons encouraged the VA to eat meals out of his/her bedroom at the kitchen table and the VA needed his/her food pureed and thickened to prevent choking. If another client displayed behaviors, staff persons may sit with the VA in his/her bedroom and lock the inside of the door to prevent the other client from entering and potentially “hurting or upsetting” the VA. The VA was vision impaired but “very familiar” with his/her room and the VA was able to open his/her door if s/he chose. Staff persons also checked on the VA every 15 to 30 minutes while in his/her room as a “safety check” and to see if the VA needed his/her adult undergarment changed. The Home and Community Based Services Service Recipient Rights said that the clients had the right to have services and supports provided to them in a way that respected and considered their preferences. Clients also had the right to personal privacy, including the right to use a lock on their bedroom door. Clients had the right to access common areas and the freedom to come and go at will. Facility documentation showed that staff persons, including P1 and P2, were trained on the VA’s plans and on facility policies including client rights and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.06, subdivision 2, clause 1, item 3 states that the license holder must ensure doors are locked from the inside to prevent a person from exiting only when necessary to protect the safety of a person receiving services and not as a substitute for staff supervision or interactions with the person. If doors are locked from the inside, the license holder must document an assessment of the physical plant, the environment and the population served, identifying the risk factors which require the use of locked doors, and a statement of specific measures to be taken to minimize the safety risk to persons receiving services at the serviced site. Conclusion: The DP said that on October 16, 2023, P1 told him/her that when the VA returned home from his/her day program, that the VA was “set” in his/her room and then locked in due to other clients’ behaviors. The DP also had concerns that the VA ate in his/her room. P1 said that in approximately July 2023, when the C moved to the facility, staff persons began locking the VA’s bedroom door from the inside, due to the VA’s behaviors. After P1 began working at the facility (September 2023) and became aware that staff persons were locking the door, P1 added a child safety cover on the outside of the VA’s bedroom door which prevented or delayed the C or other clients from entering but did not affect the VA’s ability to open the door from the inside and told staff persons not to lock the VA’s bedroom door. Although the VA was not able to provide information to this investigator whether or not s/he preferred his/her door open, P1 said that staff persons attempted leaving the VA’s bedroom door open but that when they did so, the VA became “agitated” so they closed it. There was inconsistent information whether the VA could exit his/her bedroom independently when the door was closed, even when the lock was not engaged. The DP, the G, and P1 each said that the VA would not be able to exit his/her room independently, including that the VA would not know how to turn the doorknob. The Internal Review said that the VA was vision impaired but “very familiar” with his/her room and the VA was able to open his/her door if s/he chose. P1 also said that when s/he began working at the facility, that staff persons fed the VA meals in his/her bedroom as the VA preferred it due to it being “peace[ful] and quiet.” However, P1 stopped this practice and the VA began eating at the dining room table. However, the VA did not eat with other housemates due to their schedules. In addition, the VA’s plans and information from the G, P1, and P2 showed that the VA preferred to be in his/her room. The VA had a goal to come out of his/her room but P1 said that when the VA did so, the VA would become “agitated” or “irritated” and want to go back to his/her room. Locking the VA in his/her bedroom was a violation of Minnesota Statutes, section 245D.06, subdivision 2, clause 1, item 3. However, there was no information that locking the VA in his/her room occurred as anything other than a safety measure and that due to the VA’s disabilities, it was unknown if the VA was aware that his/her bedroom door was locked. In addition, the VA preferred to be in his/her bedroom and was able to let staff persons know when s/he wanted out by knocking/banging on his/her door and staff persons then opened the door for the VA. Therefore, there was not a preponderance of the evidence whether the VA was unreasonably confined or involuntarily secluded in his/her bedroom or that the actions produced or 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: Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and Use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The facility did not take any further action. However, the facility would continue to “monitor and evaluate” the VA to determine if the VA’s plan was appropriate for him/her and notify the team with the VA’s “progress.” Action Taken by Department of Human Services, Office of Inspector General: On May 8, 2024, the facility was issued a Correction Order for the violation outlined in this report.
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