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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: 1076573-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had abrasions or contusions on his/her chin, both knees, both shoulders, and left wrist. The injuries were observed immediately after a staff person (SP) worked. It was also reported that the SP yelled and swore at the VA during the incident. Date of Incident(s): March 23-24, 2024 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 (1) and (2); 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 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. 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 April 4, 2023; from documentation at the facility; and through nine interviews conducted with the VA, six facility staff persons (the SP and P1-P5), a guardian (G), and a home health therapist (HHT). The VA’s diagnoses included moderate intellectual disability, attention deficit disorder, seizure disorder, and oppositional defiant disorder. The VA liked to go out to eat, go to concerts, and get tattoos. The VA used a wheelchair for mobility. The VA frequently talked about getting married and fantasized about marrying various staff persons. The VA’s Community Support Plan stated that s/he “needs a bed alarm that will alert staff when [s/he] moves to warn them that [s/he] may be having a seizure or is trying to get out of bed.” However, P2, a supervisory person, provided information that the bed alarm was discontinued as the VA’s frequent coughing set off the alarm thus waking him/her and causing him/her agitation. The bed alarm was not deemed effective for alerting staff persons to the VA’s seizures and was discontinued after a discussion with the VA’s team. Information from the facility showed that just prior to the incident, a Hoyer lift was delivered to the facility and a medical company representative came to various shifts to train staff persons how to use the Hoyer. The one-story facility provided services to two clients (the VA and one other client). There were three bedrooms, one for each client and one for an overnight staff person who was allowed to sleep part of the night. The VA provided the following information to this investigator and a law enforcement officer (LEO). The VA fell out of his/her bed onto a carpeted floor of his/her bedroom. The VA said that his/her side bedrail was up when the incident occurred. Although the VA provided inconsistent information regarding whether or not the SP was present when the VA fell to the floor, the VA was consistent in saying the SP was working at the time of the incident. The VA said that s/he was not strong enough to get him/herself back into bed and called for assistance. The VA said that s/he crawled from next to the bed toward the door and verified that was how the abrasions on his/her knees occurred. The VA did not provide information regarding other injuries that were observed on his/her chin, wrists, and shoulders. The SP “cussed,” “swore at,” used “the F word,” and called the VA “nasty dirty names.” The VA told the SP that s/he did not like him/her. The VA said that the SP did not assist him/her with getting back into bed; however, did not provide information regarding how s/he got back into bed. P1 worked at 11 a.m. on March 24, 2024, and said that the SP was at the facility when s/he arrived for his/her shift. The VA was dressed and in the living room sitting in his/her wheelchair watching TV. The SP left shortly after P1 arrived, after having worked since 3 p.m. the previous day. The VA “kept saying” that his/her knee hurt and P1 observed that the skin on the VA’s knees was “peeling” and one of his/her knees was bleeding. The VA said that s/he fell off of the bed and his/her neck also hurt. The VA said something about the SP “trying to help or something.” P1 called P2 who then came to the facility. P1 had no additional information about the incident. P1 said that s/he never saw the VA on the floor but did not believe that s/he would be able to crawl since the VA “can’t use [his/her] arms very much.” P2, a supervisory staff person, provided the following information: · On Sunday, March 24, 2024, s/he received a call from P1 informing him/her that P3 did not show up for his/her shift that morning resulting in P1 working alone since the SP left around 11:30 a.m. P2 said that s/he would come to the facility and when s/he arrived, P1 told him/her that the VA said s/he fell out of bed and there were “marks” on the VA. When P2 asked the VA what happened, the VA said that the SP said “horrible, nasty, vile” things to the VA. The VA said that s/he fell out of bed and the SP would not help the VA. The VA did not respond when P2 asked the VA how s/he got off of the floor. P2 took photos of the VA’s knees, chin, and wrists. P2 also called his/her supervisor as well as an “on call” staff person to see if anything was reported to them about an incident and each told P2 that nothing was reported. · P2 called the SP and asked if the VA fell or if the SP observed the injuries to the VA and the SP said his/her shift was “fine,” and s/he did not see anything with the exception of “some redness” on the VA’s face before the SP washed it. The SP denied that the VA fell. · P2 administered over-the-counter pain medication to the VA and applied ice packs to his/her knees. P2 called the SP a second time and said s/he was concerned that the SP did not notice the injuries to the VA nor did the SP call anyone when P3 did not show up for his/her shift at 9 a.m. The SP mentioned it was “a lot of work” and that s/he was tired. Again, the SP denied that the VA fell, however, the SP said that when s/he used the Hoyer to transfer the VA into bed at night and out of bed in the morning, the VA did not want the SP to use the Hoyer and was “cussing” at the SP. · P2 said that s/he “preferred” two staff persons transfer the VA with the Hoyer; however, it was okay for only one staff person to use it if a second staff person was not available. · The VA was seen at a local clinic and x-rays showed no acute fracture or dislocation. · P2 never saw the VA on the floor and did not know if the VA would be able to crawl if s/he was on the floor. P2 said that if the VA crawled “that made a little bit of sense for the injuries with the scuff on one knee.” P2 said it was possible that the bruising on the VA’s wrist could have resulted from falling out of bed. · There were no prior employment concerns regarding the SP. · The VA did not always like specific staff persons that the VA saw as possible “competition“ for the staff persons the VA talked about marrying. P3 worked on March 23, 2024, from the late morning until 3 p.m. When P3 arrived that morning, the VA was already dressed and in the living room. The VA had no complaints about his/her body hurting. The G came that day and was present when the VA ate lunch. P3 was not aware of any injuries to the VA until several days later when s/he observed a bandage on the VA’s knee. P3 said that “if [the VA] knows something [s/he] will tell you if [s/he] feels like it, but you have to be patient.” The VA did not tell P3 how the knee injuries occurred. P3 never saw the VA on the floor and did not believe the VA would be able to move him/herself on the floor. P4 worked on Saturday, March 23, 2024, beginning at 8:30 a.m. During that shift, P4 assisted the VA with a shower and did not observe any injuries. In addition, the VA’s progress notes showed that P4 documented “no concerns” regarding any illness or injuries. P4 said that if the VA was ever on the floor, s/he believed the VA had the strength to move him/herself “but not very far.” P4 was not aware of any injuries until March 27, 2024, when P4 accidentally bumped the VA’s knee, and the VA said it hurt. The VA did not tell P4 how s/he injured his/her knee. P4 said that the VA “could be a trickster” but did not lie. P5 worked the overnight shift on March 24, 2024, and said that the VA was already in bed when P5 arrived. P5 checked on the VA twice during the night and had no other contact until 6 a.m. on March 25, 2024, when s/he administered the VA’s medication to the VA while the VA remained in bed. P5 was not aware of the VA’s injuries until P2 told P5 about them on April 2, 2024. After hearing about the injuries, P5 asked to see the VA’s knees and the VA said that a staff person (P5 did not remember the name) was getting the VA out of bed and the VA fell. When asked about the VA’s ability to crawl or move him/herself if the VA was on the floor, P5 said that in “certain situations,” s/he believed “if [the VA] needs something [s/he] would drag [him/herself];” however, staff persons were always present and P5 never saw the VA on the floor. P5 also believed that the VA “can tell the truth when something happens.” On March 26, 2024, the HHT went to the facility and met the VA for the second time. On that same date the HHT observed abrasions on the VA’s knees “like a rug burn,” that were two inches by two inches. The VA also had a bruise “like a line under [his/her] chin” that was “purplish red,” as well as bilateral “half dollar” sized bruises on the front/chest side of his/her shoulders, and a bruise on his/her left wrist. According to the HHT, the VA was “unable to turn [him/herself] independently in bed.” The VA did not identify the staff person by name but did identify the staff person by gender. The VA said that s/he was “scared for [his/her] life” because the staff person was “yelling” at the VA and called the VA names. The HHT did not believe the VA’s injuries were consistent with falling out of bed or the Hoyer. The G said that after s/he heard that the VA had some injuries and was told that the VA initially said s/he fell out of bed, the G asked the VA if s/he fell out of his/her bed or the Hoyer. The VA said s/he fell out of bed and that the SP “said mean, nasty things” to the VA. The G said that although “sometimes [the VA’s] memory was not clear,” the VA did not “fabricate.” The SP provided the following information: · The SP worked by him/herself from 3 p.m. on March 23 until approximately 11:30 a.m. on March 24, 2024. On the evening of March 23, 2024, the SP used the Hoyer to assist the VA into bed. The VA did “did not want to get in the sling” and once the SP had the VA on the bed, the VA “sat up” and tried to “grab” the sling out from under him/herself. The VA swore at the SP and called the SP derogatory names. The SP told the VA to “slow down” and rolled the VA’s body so that the VA was facing the wall that was next to his/her bed and the SP removed the sling. Once on the bed, the SP removed the VA’s clothing because the VA liked to sleep naked. The SP did not observe any injures and the VA did not mention anything hurting. The SP left the room and went to do laundry while the VA continued to be angry and called the SP names for about 15 minutes. · The SP was made aware of the VA’s injuries when P2 called him/her on Sunday, March 24, 2024, and said that the VA told P2 that the VA fell out of bed during the SP’s overnight shift. The SP denied knowing anything about the VA falling out of bed. The SP said the only thing that was “possible” was that the VA’s knees “maybe” hit the wall when the SP rolled the VA’s body to remove the sling. As far as the bruise on the VA’s wrist, the SP believed it was possible that the VA injured his/her wrist when s/he was “fighting when trying to get the sling from under [him/herself].” · The SP denied swearing or cussing at the VA and did not know why anyone would say s/he did such a thing. The VA liked to talk about “getting married and having sex.” If the SP said anything about certain staff persons the VA believed s/he would marry, the VA got angry with the SP. Staff persons were trained regarding the VA’s programs, how to use the Hoyer lift, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Regarding emotional abuse: The VA was consistent over time when s/he told the G, P2, the HTT, this investigator, and/or a LEO that the SP said mean, nasty, horrible, vile things and yelled at and called the VA names. The VA did not provide any additional details with the exception of saying the SP said the “F word.” P2 and the HHT each provided information that the VA disliked or saw certain staff persons as “competition” when the VA fantasized about marrying certain staff persons, and it was possible the VA did not like the SP for that reason. The SP denied the yelling or swearing at the VA and said on March 23, 2024, the VA swore at and called the SP derogatory names when the SP used the Hoyer to assist the VA into bed. Without further information to support or refute the incident, there was not a preponderance of the evidence whether the SP engaged in conduct or treatment of the VA that could reasonably be expected to produce 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. Regarding physical abuse: Around noon on March 24, 2024, the VA was observed with abrasions or contusions on his/her chin, both knees, both shoulders, and his/her left wrist. The VA did not require medical care and did not have fractures or dislocations. P4 confirmed that the VA did not have any injuries as of 3 p.m. on March 23, 2024, when P3 and P4 ended their shifts and the SP arrived. The SP was the only staff person working with the VA from the time P3 and P4 left until the VA told P1 on March 24, 2024, that his/her knee hurt and P1 observed injuries to the VA’s knees. After the injuries were discovered, the VA told multiple persons (P1, P2, P5, the G, this investigator, and the LEO) that s/he fell out of bed when the SP was working. The VA also said that s/he crawled a short distance on the carpeting resulting in abrasions on his/her knees (and possibly on his/her chin and shoulders near his/her chest); however, the VA did not indicate how s/he got off of the floor and back into bed as it was evident the VA did not have the strength to do that on his/her own. Given there was no information that the SP caused the injuries to the VA, and that it was possible that in the course of getting the VA into bed the VA’s knees “maybe” hit the wall when the SP rolled the VA’s body to remove the sling, or that the VA injured his/her wrist when s/he was “fighting when trying to get the sling from under [him/herself],” there was not a preponderance of the evidence whether the SP engaged in conduct which could reasonable produce physical pain. 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). Regarding neglect: The VA’s injuries on his/her knees, wrist, and front shoulders were reasonable for what the VA said occurred (falling out of bed and crawling on the carpeting). The VA also said that the bed rail was up/in place as required. Although it was concerning that the SP had no idea that the VA sustained injuries during his/her shifts, and denied that the VA fell out of bed, given that the VA did not provide information as to how s/he got back into bed, there was not a preponderance of evidence whether there was a failure to provide the VA 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). Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but were not followed when the SP did not report his/her difficulty when transferring the VA in the Hoyer. Additional training was provided to staff persons regarding reporting client resistance to use of the Hoyer. In addition, Hoyer transfers were to be completed with two staff persons whenever possible. The SP no longer worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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