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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: 1098535-HCBS (Home and Community-Based Services) Investigator(s): Emily Kearns Suspected Maltreatment Reported: It was reported that a staff person (SP) arrived at a vulnerable adult’s (VA) residence prior to working, was drunk, was verbally abusive to the VA, and kicked the VA in his/her chest. Date of Incident(s): March 26, 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), 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 for this investigation was obtained remotely, including documentation from the facility, and law enforcement records; and through four interviews conducted with a facility supervisor (P), the VA’s case manager (CM), and two of the VA’s family members (FM1 and FM2). Attempts were made to interview the VA and the SP but were unsuccessful. The VA did not return this investigator’s calls or respond to requests sent through United States mail for an interview. The SP responded once to an interview request letter but then did not respond to subsequent phone calls to schedule an interview. The VA had a history of suicidal ideation and was diagnosed with neuropathy, diabetes, and was recovering from surgery. The VA enjoyed spending time with family, reading, and watching TV. The VA had eight hours of services for a staff person to provide services to the VA overnight. The VA was not subject to guardianship and lived in his/her own residence. Facility documentation and the SP’s timesheet showed that s/he started providing services to the VA on the evening of February 9, 2024, and the last date the SP worked with the VA was on March 25, 2024. The P provided the following information: · On March 27, 2024, at the start of the workday, the VA called the facility to tell them about an incident that had occurred the night before. On March 26, 2024, at about 9:50 p.m., shortly before the SP’s 10 p.m. work start time, the SP came into the VA’s residence “drunk.” The VA tried to get the SP to “lay down” and “sober up” but they got into an “argument.” FM1 then came in and tried to get “in between” the VA and the SP while the arguing continued. The VA tried to get the SP to go upstairs, but the SP turned around and “kicked” the VA in his/her chest and then “kicked” the VA in the ribs. The VA fell but was able to “break” the fall by grabbing the railings. The VA said that law enforcement had to remove the SP from the VA’s residence and that this was not the first time they had to do that, but that this was the first time the SP had gotten “physical” with the VA. The VA told the P that s/he was going to “sue” the SP. · The P had been to the VA’s residence and from his/her observation, s/he did not think that anyone could have “kicked” anyone from the “angle of the step” and it did not seem possible to kick someone in the ribs. The P asked the VA if s/he went to the hospital for a medical evaluation, but the VA stated that s/he declined to go with the ambulance that night and said that s/he would go to the hospital later that day. The P was unsure if the VA ended up going to the hospital for evaluation. The VA told the story of what happened during the incident repeatedly, so the P stopped asking for more information. · The VA received eight hours of IHS services a day from the SP, seven days per week, which was during an awake overnight shift starting at 10 p.m. and ending at 6 a.m. · The SP was acquainted with the VA, and was “staying” with the VA. The VA recommended the SP to the P to provide services. · After hearing about the incident, the facility and the P did not think the SP was a “good fit” for the VA based on how the SP “conducted” him/herself. One day, in February 2024, the SP was walking near the facility’s office with FM1 and was talking to another client outside of the building. Another facility staff person walked outside and observed the SP talking with “slurred speech” and was “very intoxicated.” The SP did not “realize” s/he was near the office area, did not recognize the facility staff person, whom s/he had had prior contact with, and as a result, this was a “concern” for the facility. · The facility attempted to contact the SP on March 27, 2024, but it “went to voicemail” and the following week, a facility administrator talked to the SP. The facility’s documentation of the SP’s statement showed that the SP said that s/he arrived at the VA’s residence at around 8:45 p.m. on March 26, 2024, and heard arguing coming from inside the house. The SP saw the VA and FM1 “arguing” over something “personal” and figured that they needed “alone time.” The SP then tried to go up the stairs, but the VA told the SP to “stay down[stairs].” The SP attempted to redirect the VA, but the VA “cursed out” the SP. The VA got “verbal” with the SP and no physical contact occurred. The VA called law enforcement. Law enforcement arrived and told the SP to leave. The SP did not “punch in” using the digital application staff persons used for tracking hours and did not get paid for providing services to the VA on March 26, 2024. The SP was no longer employed by the facility. Law enforcement records provided the following information: · On March 26, 2024, at approximately 8:43 p.m., law enforcement responded to the report of an assault at the VA’s residence. The following information was a combined summary from two 9-1-1 callers in the residence. Based on the statements and narrative, it was determined by this investigator that the callers were the VA and FM1. Computer-Aided Dispatch (CAD) notes from the 9-1-1 call showed that the SP “kicked” the VA in the stomach. The caller “hung up,” but did not know if s/he needed paramedics. There were no “weapons” seen on the SP. The SP was “drunk” and was “disrespecting” the VA and FM1. FM1 was “irate” when dispatchers called back and “refused” to answer additional questions. The VA or FM1 called 9-1-1 again and one of them stated that law enforcement needed to arrive “ASAP” because the VA “will kill [the SP].” Medical assistance was declined on one of the last 9-1-1 calls. · When law enforcement officers (LEO1 and LEO2) arrived at the VA’s residence, they went upstairs to talk to the SP. The VA was “yelling” and was “upset” that LEO1 and LEO2 were talking to the SP and would not wait on the main level for them to finish talking to the SP. LEO1 went downstairs to talk to the VA and FM1 was also there. The VA and FM1 were “irate” and “uncooperative,” both trying to talk to LEO1 at the same time. · The VA stated that s/he was “kicked” twice by the SP in his/her side. The SP was “barefoot” at the time. The VA lifted his/her shirt so that LEO1 could see any injuries. LEO1 did not see any “marks or apparent injuries.” The VA did not want to be “assessed” by paramedics. The VA said that the SP was “drunk” and that FM1 and the VA wanted the SP to go upstairs and “lay down” but then they got into an argument. They said that the SP only acted this way when s/he was “intoxicated.” · LEO1 was still trying to gather information and the VA became “upset” that the SP was not yet removed from the residence. FM1 then became “very upset” that law enforcement was in the residence and “did not have a warrant.” FM1 did not follow LEO1’s instructions when s/he told FM1 not to go back upstairs to where the SP was located. FM1 “calmed down” but the VA was “up and down” through LEO1’s interaction with the VA. The VA did not allow LEO1 to explain what law enforcement was doing to resolve the problem. The VA’s “behavior” made it “very difficult” for LEO1 to get a “clear statement.” FM1 would not answer LEO1’s question regarding if s/he saw the SP “kick” the VA. The SP then left the VA’s residence. · The VA told LEO2, upon LEO2’s arrival, that the SP “kicked” him/her in the stomach and that the SP was the VA’s staff person. FM1 was “agitated,” and the SP was “yelling” at the VA from the top of the stairs. When LEO2 spoke with the SP, LEO2 could “smell” the “odor of a consumed alcohol beverage on [his/her] breath.” The SP spoke with a “slow, slurred voice.” The SP stated that s/he was the VA’s nighttime staff person, and that his/her shift began at 10 p.m. The SP admitted drinking earlier in the day and had “taken shots” but denied being “drunk.” The SP said that it was “okay” because his/her shift did not begin until 10 p.m. The SP denied that any “physical altercation” occurred, including “kicking” the VA. The SP stated that the VA had a “drug problem.” The SP stated that s/he was a “mandated reporter” and would be “making a report” because FM1 was “manipulative.” · FM1 then began to attempt to go up the stairs to “remove” the SP him/herself. The SP planned to leave the residence and said that s/he was going to stop working as the VA’s staff person. The SP then left. FM1 provided the following information: · The incident between the SP and the VA started out as an argument between the SP (although FM1 would not tell this investigator the SP’s name, it was determined that FM1 was referring to the SP) and FM1 that took place on the steps. The SP had “been drinking” and the VA tried to “break it up.” FM1 denied that the SP “kicked” the VA. · The incident “wasn’t no big deal,” and was “done and over with.” The VA was not “pressing” charges against the SP. · The SP was no longer providing services to the VA. The SP’s timesheet showed that s/he worked every night from approximately 10 p.m. to 6 a.m. the next morning from the evening of February 9, 2024, until the end of the shift on March 25, 2024, at 6 a.m. on March 25, 2024, except for the March 6 to March 7, 2024, overnight shift. FM2 provided the following information: · The VA lived at his/her own home with FM1 and at times, the SP, who was acquainted with FM1. · The VA told FM2 that the SP “kicked” him/her during an “incident” at the VA’s residence. No other details were given to FM2 other than the SP was “put out” of the VA’s house after this happened. The VA was “reluctant” to tell FM2 many details. · FM2 thought that once the “beef” between all of them “died down” that the SP would be back to providing services to the VA. FM2 was unsure if the SP was still staying at the VA’s residence. · FM1 had not said anything to FM2 about the incident. The CM provided the following information: · The CM talked to the VA earlier in the day of this interview but was not aware of an investigation. The facility that had been providing services emailed a letter to the CM, stating that they would not be providing services for the VA any longer, without any explanation as to why they were no longer providing services for the VA. · The VA was usually “pretty reliable” but sometimes would get confused about certain information, however it could be due to how it was explained to him/her. The P and the SP were trained on the VA’s care plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: According to the P, on March 26, 2024, at approximately 8:45 p.m., the SP arrived at the VA’s residence to work the overnight shift, which started at 10 p.m., but was “drunk.” FM1 and the VA tried to get the SP to “lay down” and “sober up” but an argument ensued. According to the P, the VA and SP were arguing, FM1 tried to step in, and at some point, the VA was “kicked” in the ribs by the SP while they were all standing near one another near the stairs. The VA fell but was able to break his/her fall by grabbing onto the railing. Law enforcement was called and arrived. Paramedics were declined by the VA. Law enforcement records from March 26, 2024, stated that the SP was “drunk” and “disrespecting” the VA and FM1. The VA was “yelling” and “upset” that law enforcement was talking to the SP. The VA stated she was “kicked” by the SP twice and showed LEO1 his/her skin. LEO1 did not see any “marks or apparent injuries.” The VA did not want to be assessed by paramedics. The VA and FM1 were “irate” and “uncooperative,” and the VA’s “behavior” made it “very difficult” for law enforcement to get a “clear statement” from the VA. FM1 would not answer LEO1’s questions regarding the SP “kicking” the VA. LEO2 could “smell the odor” of a “consumed alcohol beverage” on the SP and the SP spoke with a “slow, slurred voice.” The SP admitted to drinking and had “taken shots” earlier in the day but denied being “drunk.” The SP said that this was “okay” because s/he did not work until 10 p.m. The SP denied any physical altercation with the VA and denied “kicking” the VA. According to the facility’s documentation of their conversation with the SP, the SP arrived and heard “arguing” between the VA and FM1. The SP went to go upstairs to give them some time to talk and the VA told the SP to “stay down[stairs].” The SP attempted to “redirect the VA” but the VA “cursed out” the SP. The SP stated that no physical contact occurred between the VA and the SP. The VA called law enforcement and when they arrived, they told the SP to leave. FM2 was told by the VA that the SP had “kicked” him/her during an incident. The SP was “put out” of the house after this happened. The VA was “reluctant” to tell FM2 about this. FM1 stated that an argument started between the SP and the FM1 that took place on the stairs. The SP had been drinking and the VA tried to “break it up.” The VA was not kicked by the SP. FM1 did not want to share any additional information. The facility’s documentation showed that the SP did not “punch in” on March 26, 2024. Although the SP admitted to drinking and having “taken shots” prior to working, on March 26, 2024, and the SP said that it was “okay” because s/he did not work until 10 p.m., given that the SP was not working at the time of the incident, that the SP denied kicking the VA, that FM1 did not say if the SP had kicked the VA or not, that the VA declined medical assistance and LEO1 did not see marks on the VA, and that there was conflicting information regarding the incident, there was not a preponderance of the evidence of whether the SP kicked the VA. 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’s Internal Review showed that the policies and procedures were adequate, but not followed. There were no similar incidents and there was no additional training needed as the SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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