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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: 1069662-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne/Alice Percy Suspected Maltreatment Reported: It was reported that a staff person (SP) grabbed and pushed a vulnerable adult (VA), causing the VA to fall onto a couch and then to the floor. The VA sustained a bruise on his/her arm during the incident. Date of Incident(s): December 7, 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 January 4, 2024; from documentation at the facility; and through seven interviews conducted with a facility staff person (P1), an administrative staff person (P2), the SP, a day program staff person (DPSP), the VA, and the VA’s two guardians (G1 and G2). The VA enjoyed dancing, playing and watching various sports, cooking, camping, watching television, shopping, and spending time with his/her family members and friends. The VA’s diagnoses included mild intellectual disability, seizure disorder, hypertension, renal insufficiency, scoliosis, and mild muscular dystrophy. The VA used a walker to ambulate due to his/her poor gait. The VA attended a day program each weekday. According to the VA’s Community Support Plan (CSP), the VA’s physician had prescribed a diet for the VA, which included the need to drink water and limit certain foods because of his/her renal insufficiency. The VA had a history of verbal and physical aggression. According to the VA’s Individual Abuse Prevention Plan, the VA had a special diet that limited his/her intake of sodium, potassium, and phosphorus, but the VA did not always want to follow his/her diet. The staff persons were to assist the VA with following his/her diet and encourage him/her to eat healthy foods. Snack items and soda were kept in a locked area at the facility and the staff persons were to periodically check the VA’s bedroom and pockets for food items. The VA was at risk of falling due to seizure activity and very poor gait and strength. The VA wore a transfer belt while awake. In the past, VA threw items or broke things when angry. The VA also sometimes hit or kicked an object, which caused him/her to lose his/her balance and fall. The VA was vulnerable to emotional and physical abuse and had little knowledge of how to report abuse. The facility’s kitchen and living room areas were separated by a wall with an open arched doorway between the two. A small couch was located in the living room next to the kitchen doorway along the shared wall between the two rooms. A small table was placed next to the couch. There were wood floors in the kitchen and living room.
The VA stated at the time of the incident, s/he was in the kitchen and told the SP that s/he was getting a piece of cake when “all of a sudden” the SP grabbed the VA’s shoulders and the collar of his/her shirt and “threw” the VA on the couch. The VA then fell to the floor which resulted in a bruise on his/her left arm. The SP did not say anything to the VA during the incident. The VA did not recall which part of his/her body hit the floor first or if s/he hit anything else when s/he fell. The SP did not hold onto the VA’s arm during the incident. After the incident, the VA went into his/her bedroom and saw the bruise on his/her arm. P1 was in the staff office at the time of the incident. P1 heard the fall and went to the VA’s bedroom and asked the VA if s/he was okay. Prior to the incident, the VA had no prior concerns about how the SP interacted with him/her. The VA demonstrated to this investigator that at the time of the incident, s/he stood in the kitchen, next to the counter and the doorway. The SP grabbed the front collar area of the VA’s tee shirt and pushed the VA into the living room and toward the couch. The VA fell onto the couch briefly before rolling off and falling on the floor. The DPSP stated that on December 8, 2023, the VA told him/her that the previous day, a facility staff person was “mad” at the VA, grabbed the VA by the arm, and threw the VA onto the couch. The VA then “bounced off” the couch and fell to the floor. The VA had a bruise on his/her left arm. The DPSP described the bruise as being seven to eight inches in length and five inches wide. It was black and purple and looked like a “fresh” bruise. The VA did not tell the DPSP the name of the staff person who pushed him/her, but told him/her that it was “not the first time it happened” with that staff person. P1, P2, the SP, and the facility’s documentation provided the following information: · On December 7, 2023, the SP and P1 worked at the facility. The SP stated that at approximately 7:30 p.m., the SP was in the kitchen preparing snacks for the VA and the other residents. P1 stated that s/he was in the staff office completing charting when s/he heard the VA and the SP arguing. The SP stated that the VA wanted cake, but the SP told the VA that s/he should eat a healthier snack. The VA yelled at the SP. The VA was holding a bowl and became “extremely” angry and “charged” at the SP and then ran into the SP’s chest. The SP was afraid that the VA would either hit the SP with the bowl or throw the bowl at the SP, so the SP grabbed the VA’s left arm with one hand and stepped forward and assisted the VA onto the couch, which was right outside the door to the kitchen. The SP stated that s/he sat the VA on the couch in an attempt to deescalate the situation so that the VA did not fall or hit the SP with the bowl. The VA dropped the bowl, sat on the couch, and then fell to his/her side and rolled onto the floor. The VA crawled to a wall and the SP assisted the VA to his/her feet. The VA then apologized to the SP and gave the SP a hug. · P1 stated that after s/he heard a “loud noise” that sounded like the VA “hitting the floor,” P1 went to the living room and asked the SP if s/he was okay. The SP told P1 that the VA “got hurt” so P1 went to the VA’s bedroom, where the VA told P1 that the SP “hurt” him/her. The VA also told P1 that the SP grabbed the VA by his/her shirt and “tossed” him/her onto the couch. P1 then told the SP that the VA had a bruise on his/her arm. The SP told P1 that s/he would document the incident and telephone P2 and G2 and tell them about the incident. A short time later, P1 left the facility because it was the end of his/her work shift. · P2 stated that at approximately 8 p.m., s/he received a telephone call from the SP telling him/her that the VA became angry about wanting a snack and was “flailing” his/her arms. The VA then “charged” at the SP, “bounced off” the SP onto the couch and fell onto the floor. The SP told P2 that the VA had a small mark on his/her left arm. P2 reminded the SP to document the incident. The following day, P2 talked to the VA and looked at the bruise on the VA’s arm. The VA told P2 that the SP grabbed the VA’s clothing, dragged him/her to the couch, and “threw” the VA onto the couch. P2 stated that the VA told several staff persons about what occurred and was very consistent when talking about the incident. P2 stated that when the VA was not accurately reporting what occurred, the VA would be inconsistent and s/he would “look away.” · The SP stated that “everything happened quick” and s/he did not feel like s/he had many options at the time of the incident. After the incident, the SP documented the incident. The SP noticed a “redness” that was about two inches long on the VA’s left arm. · The SP stated that when the VA became upset, the staff persons were to help the VA deescalate by redirecting the VA. In the past, the SP had a good relationship with the VA. P1 stated that prior to the incident, s/he had no concerns about the SP’s interactions with the residents. G1 stated after the staff persons told him/her about the incident, G1 talked to the VA about the incident. The VA told G1 that s/he wanted to eat cake instead of the other dessert that the SP offered him/her, but the SP did not want to give cake to the VA. The VA began to kick the SP and the SP “set” the VA on the couch, but because the VA was kicking and hitting the SP, the VA fell to the floor. The VA told G1 that s/he did not know if the SP “threw” or “set” the VA on the couch. G1 stated that the bruise on the VA’s arm did not look like a handprint and G1 did not believe the SP caused the bruise. G1 believed the SP and the other staff persons worked well with the VA and G1 had no concerns about the care the VA received at the facility. G1 stated that the VA sometimes “exaggerated” when talking about what occurred. G2 stated that the SP telephoned G2 and told him/her about the incident. The SP told G2 that s/he “picked up” the VA and placed him/her on the couch. The SP did not describe how s/he put the VA on the couch. G2 stated that if the VA “did not get [his/her] way, [s/he] would have a meltdown.” The VA told G2 that s/he was “misbehaving” and s/he had a bruise on his/her arm. According to the facility’s Client Notes, on December 7, 2023, at 7:50 p.m., the SP documented, “[The VA] charged at me over snack today and [s/he] barreled into my chest. I blocked [the VA] and [s/he] fell onto the living room couch and then onto the floor. I helped [him/her] to [his/her] feet and then walked [the VA] to this room where [s/he] calmed down. [The VA] was yelling at me and swinging [his/her] arms when [s/he] charged me. [The VA] has some marks on [his/her] left arm from hitting either the couch or the floor.” A review of a photograph taken by P2 of the front side of the VA’s left upper arm just below the shoulder, showed a large oval-shaped bruise that was dark purple and red. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245D.06, subdivision 7, paragraph (b), states that permitted actions and procedures include being able to block and redirect limbs or body without holding or limiting the movement that may result in injury with less than 60 seconds of physical contact by staff. Conclusion: On December 7, 2023, the SP and P1 worked at the facility. At approximately 7:30 p.m., P1 was in the staff office completing charting while the SP was in the kitchen preparing snacks for the residents. The VA wanted cake, but the SP encouraged the VA to eat a healthy snack. The VA and the SP began to argue about the snack. The SP stated that the VA “charged” at the SP while holding a bowl. The SP was afraid that the VA would hit the SP with the bowl or throw the bowl at him/her, so the SP grabbed the VA’s left arm with one hand and stepped forward and assisted the VA onto the couch, which was right outside the door to the kitchen. The VA fell off the couch onto the floor. The SP stated that the incident happened “very quickly” and s/he sat the VA on the couch in an attempt to deescalate the situation. The VA provided information that the SP grabbed the VA’s shoulders and the collar of his/her shirt and “threw” the VA on the couch. After the incident, the VA had a large bruise on his/her left upper arm. Given that the VA was holding a bowl and charged at the SP, it was reasonable for the SP to take some action to prevent the VA from hitting the SP with the bowl or throwing the bowl at the SP. Although the VA had a large bruise on his/her left arm after the incident, given the conflicting information provided by the VA and the SP about the incident, that VA fell onto the couch and floor during the incident, and that it was unclear whether the bruise was caused by the SP grabbing the VA or by the fall, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or whether the VA sustained the bruise by any means other than accidental. 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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