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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: 1098464-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kim Huettl Anderson kimberly.huett.anderson@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) called a vulnerable adult a “fat ass” on more than one occasion. Date of Incident(s): Ongoing prior to October 30, 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 7, 2023; from documentation at the facility; and through nine interviews conducted with the VA, the VA’s guardian (G), and facility staff persons (P1 and P4), facility supervisory staff persons (P2, P3, P5, and the SP) and the VA’s housemate (H). The VA was diagnosed with autism. The VA enjoyed sporting activities, fishing, and being surrounded by animals. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to inappropriate interactions with others. The VA displayed the inability to interact with verbally, emotionally, and physically aggressive persons. When the VA felt that his/her concerns were not validated the VA had a history of verbal aggression, such as name calling and swearing to others. Staff persons were to remove the VA from the aggressive person and verbally redirect the VA to safety. The facility’s Incident and Emergency Report stated that on October 27, 2023, a staff person (P1) observed the SP not assisting the VA with preparing food, getting dressed, or putting on the VA’s medical foot boot. P1 attempted to intervene and assist the VA, but the SP told P1 to “mind [his/her] own business.” P1 heard the SP yelling at the VA and calling the VA, “stupid,” “fat,” and “lazy.” (Note: The VA had a broken foot at the time of the incident.) The VA told this investigator that the VA did not like the SP because the SP called the VA names such as “fat ass” and “twinkie.” The VA stated that the SP argued with the VA “a lot” and would yell “pull your skirt up bitch” to the VA. The VA did not remember how many times the SP called him/her names or yelled at him/her but stated that it was more than three or four times. The VA stated that it made him/her feel “terrible” when the SP yelled at him/her and called him/her names. The G stated that a facility management person (P2) contacted him/her to let the G know that P1 heard the SP call the VA a “fat ass.” The G was not aware of any name calling by the SP until P2 contacted them. The H said that the VA was involved in an accident and when the VA returned to the facility the VA was wearing a boot. The H heard the VA ask for a snack and the SP told the VA, “Get your fat ass off the bed and get your own snack.” The H said s/he only heard the SP say it “just one” time and the H told P5 about the incident. P1 provided the following information: · On October 27, 2023, P1 was working at the facility with the VA and the SP. The VA was not able to walk independently at that time because s/he had a broken foot. The VA asked the SP for help adjusting the position of the television. P1 heard the SP tell the VA that s/he did not need to watch television, so P1 adjusted the position of the television for the VA. Later that day, the VA asked the SP for some lunch and the SP told the VA to get his/her own food. P1 told the SP that the VA was to stay off his/her foot and that it was their responsibility to assist the VA with getting food and his/her cares. At that time, the SP was upset with P1 for “disobeying” the SP’s directives. · P1 stated that s/he did not hear the SP call the VA names, but on the day of the incident, P1 was in the office and heard the SP say, “You are a fat retard [hear in referred to as the r-word].” P1 did not know if the SP said that directly to the VA or who the SP said it to or in front of. P1 did not ask the SP about his/her comment and did not talk to the VA about what s/he heard. According to P1, the SP had a history of “venting” frustrations by making “derogatory” comments about the VA, such as “fat,” “lazy,” “dumb” and the r-word to other staff persons when the VA was not around. · P1 provided information that s/he had interpersonal conflicts with the SP. P2 said P1 told him/her that s/he heard the SP call the VA names and that the SP was not helping the VA with his/her cares when the VA’s mobility was limited due to his/her broken foot. P2 “immediately” brought P1’s concerns to another facility management person (P3). P2 did not have any further interactions with the SP and had not witnessed any inappropriate interactions between the SP and the VA prior to the incident. P3 provided the following information: · P3 stated that when s/he spoke to P1, P1 told P3 that on October 27, 2023, the SP refused to help the VA adjust the television and get food and that P1 heard the SP call the VA “stupid, fat, and lazy.” P1 told P3 that when s/he attempted to assist the VA, the SP told P1 to “mind [his/her] own business.” · Shortly after speaking to P1, P3 learned that two other staff persons (P4 and P5) overheard the SP call the VA names. · P4 told P3 that on October 25, 2023, the VA refused to use his/her crutches so the SP told the VA to “sit [his/her] fat ass in bed.” · P5 told P3 that s/he was working at the facility when the VA was upset and said that the SP called him/her a “fat ass.” P5 did not hear the conversation between the VA and the SP. · When P3 spoke to the SP about the concerns with the VA, the SP “immediately” denied the allegations and stated that the VA called the SP those names and denied ever calling the VA fat. P4 and P5 provided the following information: · P4 started working at the facility in October 2023 and trained with the SP. P4 initially said that s/he heard the SP “yell” at the VA “multiple” times, “ignore” the VA, and “cuss” at the VA because the VA would not follow directions. One time the VA was not listening, and the SP said, “I’m talking to you dummy,” “Fuck you, and “flip [his/her] middle finger.” · The second time P4 worked with the SP was after the VA had his/her accident. The VA had to wear a brace on his/her leg and used crutches, so the facility had moved the VA’s bedroom downstairs. The VA needed to go to the bathroom and the SP told the VA to use his/her crutches to go. The VA would not listen, and the SP said, “You’re so stupid and you don’t listen to anyone.” The VA got “mad” and wanted to elope. The SP said, “leave [him/her] alone … I don’t care if [s/he] leaves … I will just call the manager.” P4 was “uncomfortable” with the situation and called P5 and told him/her about the incident. · P4 later contacted this investigator and said that s/he made “some mistakes” and his/her initial statements were incorrect because s/he did not hear the statements but was told by the H. P4 stated that s/he provided the inaccurate information because at the time s/he was upset with what the H said about the SP’s behavior and s/he did not want to SP to work with the H or the VA again so s/he told this investigator that s/he heard these things. P4 stated that s/he felt bad that s/he provided the wrong information so s/he wanted to contact this investigator to make his/her statement correct. P4 stated that s/he never heard the SP say the “fuck you” or “fat ass” to the VA. P4 said that the SP only yelled at the VA “once” and not “multiple times.” P4 said that the H and the VA told him/her that the SP swore at the VA and called the VA a “fat ass.” · P5 on an unknown date in October 2023, P5 had stepped out of the house for a “quick” “five minute” break. When P5 returned inside the H came and said that the SP called the VA “a fat ass.” The VA was upset and went upstairs to his bedroom and the SP was sitting in the living room. P5 went upstairs and asked the VA, “What happened?” The VA replied, “[The SP] called me a fat ass,” and refused to give the VA his/her as needed medication (PRN). P5 then spoke with the SP and told the SP, “You can’t talk to [him/her] that way.” The SP said, “[The VA] was a liar” and that the facility was out of PRNs. · P5 said that s/he had “witness” the VA lie before while working with him/her and that s/he had never seen the SP treat or talk with the housemates with “any maltreatment.” P5 did not work with the SP after the VA had his/her accident. The SP provided the following information: · The SP worked with the VA for four to five years and helped the VA with his/her daily routine such as reminding the VA to complete daily hygiene and helping the VA portion his/her food. The SP said that the VA was “difficult” and had a history of “lying.” · The SP denied calling the VA “a fat ass” or “cussing” at the VA. The VA called the SP names such as “ugly” or a racially derogatory name but the SP never “took it to heart” because the VA was “trying to get attention.” · The SP denied telling the VA “to get [his/her] own snack fat ass” after the VA’s accident. The SP said that P2 told staff persons that the VA needed to get his/her own snack because s/he “was taking advantage” of the staff, and that the VA needed to use his/her crutches. The SP said that “everyone” in the house told the VA to get his/her own stuff. The facility’s job descriptions stated that staff persons were to listen carefully and communicate respectfully and clearly with the people you support. Support people with daily living skills and personal support needs. Ensure that people are free of abuse, neglect, and exploitation. Facility documentation stated that P1, P2, P4, P5, and the SP were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that consumers have the right to be treated with courtesy and respect. Conclusion: Although the VA provided similar information as the H that the SP called him/her a “fat ass,” the VA said that the SP called him/her names more than three or four times and made him/her feel “terrible,” but the H said that s/he only heard the SP say it “just one” time. P1 said s/he heard the SP tell the VA “you are a fat [r-word]” but did not know if the SP said that to the VA. P1 also said that the SP made derogatory remarks about the VA when the VA was not around. P4 initially said that s/he heard the SP swear at the VA but then later stated that information was inaccurate and that s/he had provided inaccurate information and that s/he in fact had not heard the SP swear and only heard the SP “yell” at the VA once. P5 said that s/he had never seen the SP treat or talk to the housemates with “any maltreatment” and that the VA had lied in the past. The SP denied calling the VA a “fat ass” and denied “cussing” at the VA. The SP said that it was the VA that called him/her names and VA had a history of verbal aggression, such as name calling and swearing to others. Given that conflicting information regarding the SP’s verbal interactions with the VA, that P1 had interpersonal conflicts with the SP, and that it was not determined that had it occurred whether it was a single incident, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or repeated oral language 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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