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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: 1070640-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne/Alice Percy Suspected Maltreatment Reported: Allegation one: It was reported that on June 14, 2023, a staff person (SP) yelled at, swore at, and nagged a vulnerable adult (VA1). The SP told VA1 to shut up. The SP also locked VA1’s bathroom and bedroom doors so that VA1 was unable to access the rooms. Allegation two: It was reported that on September 4, 2023, a vulnerable adult (VA2) scratched the SP’s hands during a manual restraint. The SP grabbed VA2’s arm and twisted VA2’s wrist until VA2 screamed. The SP then called VA2 names and swore at VA2. Allegation three: It was reported that on August 22, 2023, the SP grabbed a vulnerable adult’s (VA3’s) arms and “nudged” VA3 with his/her knee so that VA3 would move from where s/he was sitting on a stairway. Allegation four: It was reported that after the SP checked a vulnerable adult’s (VA4’s) vitals, VA4 wanted to go to the hospital and the SP told VA4 that s/he was not going to the “damn doctor” and that VA4’s vitals “were fucking fine.” Date of Incident(s): Ongoing, prior to September 12, 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 (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 two site visits conducted on August 17 and September 19, 2023; from documentation at the facility and law enforcement records; and through 17 interviews conducted with six facility staff persons (P1 – P6), three supervisory staff persons (P7 – P9), the SP, VA1, VA2, VA4, VA1’s guardian (G1), VA2’s guardian (G2), VA3’s guardian (G3) and VA4’s guardian (G4). According to the facility’s Employee Code of Conduct, the staff persons were to demonstrate a high level of personal and professional conduct, including treating everyone with courtesy, professionalism, dignity, and respect, and providing a safe and therapeutic environment. According to the facility’s Workplace Relations Policy, the staff persons were not to engage in unacceptable behaviors, such as yelling, swearing, demeaning, name calling, teasing, bullying, intimidating, or provoking comments or behaviors. According to the facility’s Individual Rights policy, the residents had the right to be free from abuse, neglect, and humiliation, as well as free from any aversive or deprivation procedure. The residents were to be treated with courtesy and respect and to have access to their property at any time. According to the facility’s Emergency Use of Manual Restraint Policy, the staff persons were prohibited from using painful techniques, including intentional inflection of pain or injury, hyperextending or twisting an individual’s body parts, or tripping or pushing an individual. Facility documentation showed that the SP and P1 – P9 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on VA1’s, VA2’s, VA3’s and VA4’s plans prior to the incidents. Relevant Rules and Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (b), state that a person’s protection related rights include the right to be treated with courtesy and respect. Allegation one: It was reported that on June 14, 2023, the SP yelled at, swore at, and nagged VA1. The SP told VA1 to shut up. The SP also locked VA1’s bathroom and bedroom doors so that VA1 was unable to access the rooms. VA1 enjoyed going to dances and other community events, bowling, going out to eat, and spending time with his/her friends and family members. VA1’s diagnoses included a seizure disorder, major depressive disorder, psychotropic disorder, and a developmental disorder. VA1 attended a day program each weekday. According to VA1’s Self-Management Assessment, VA1 had access to his/her personal belongings and was able to lock his/her bedroom door. According to VA1’s Individual Abuse Prevention Plan (IAPP), VA1 was at risk of abuse. The staff persons were to work with VA1 on making safe decisions and were to intervene and move VA1 away from unsafe situations. According to VA1’s Outcomes – Supports and Methods, VA1 displayed verbal aggression by yelling, swearing, name calling and using other upset tones. The staff persons were trained to be positive in their interactions with VA1 and maintain a calm tone of voice because VA1 reacted to raised voices or negative body language. The staff persons were to model positive communication and actions. VA1 stated that s/he liked the staff persons at the facility. VA1 did not provide any information about the incident. P1, P2, P3, P4, P5, P6, P7, P9, and the facility’s documentation provided the following information: · P1 stated that the SP was frequently “short tempered” when s/he spoke to VA1. When that occurred, the staff persons typically stepped in and told the SP that they “got this” so the SP would walk away from the situation. VA1 liked to talk and frequently repeated things, which “pissed off” the SP, who would “slam” his/her hand on the table or tell VA1 that s/he was repeating him/herself, which then upset VA1. P1 stated that the SP frequently yelled and cursed at the residents, including VA1. P1 did not provide additional information about when the incidents occurred or what the SP said. · P5 stated that the doors to the residents’ bedrooms locked automatically when the doors were closed. The staff persons had keys to the doors, but the residents did not have keys. P1 stated that s/he “heard” that there were two incidents where the SP locked the door to VA1’s bathroom so that VA1 was unable to enter the bathroom. P5 also “heard” that the SP locked the bathroom door to prevent VA1 from entering the bathroom right before the bus to his/her day program picked VA1 up. P3 stated that on one occasion the SP locked VA1’s bedroom door so that VA1 could not enter the bedroom. The SP told P3 that VA1 “would just putz around” in his/her bedroom instead of get ready to leave the facility for his/her day program. P3 stated that when VA1’s bedroom door was locked, VA1 continued to get ready to leave the facility. P3, P7, and P9 each stated that VA1 had a key to his/her bedroom door. P7 was not aware of any occasion where a staff person locked VA1’s bedroom door so that VA1 was unable to enter his/her bedroom. · P4 stated that s/he never heard any of the staff persons swear at VA1 or tell VA1 to shut up. The SP sometimes “got super frustrated” with VA1 and would tell VA1 to “go rest for a little bit.” At those times, VA1 typically ignored the SP. P5 stated that at times when VA1 repeated a story multiple times, the SP told VA1 to be quiet or that s/he did not want to hear the story again. P5 stated that at those times, the SP was “kind of bossy and rude and short,” and VA1 “shut down” and did not speak for the rest of the evening. On several occasions, P5 told the SP to “knock it off” and the SP would stop reacting to VA1’s stories for a while, but then start again. P5 never heard any of the staff persons swear at the residents. P6 stated that s/he “heard” from a staff person that no longer worked at the facility that the SP swore at and yelled at the residents, but it did not occur when P6 worked at the facility. P7 stated that s/he never heard any of the staff persons swear at VA1. · P9 stated that the staff persons were trained to give VA1 options on what s/he wanted to do and allow him/her to do the things that s/he could do. In the past, P9 had no concerns about the SP’s interactions with the residents. The SP was “direct” when s/he talked to the residents and would tell the residents that they need to try to do something before asking for the assistance of a staff person. The SP sometimes swore while s/he was in the common areas of the facility, but P9 had not heard the SP swear at a resident. The SP provided the following information: · The SP stated that VA1 was able to do many things for him/herself, but the staff persons had to give VA1 reminders to do something or to finish a task. · The SP stated that in the spring of 2023, VA1 moved into a bedroom at the facility that had an attached bathroom which was the bathroom VA1 typically used. The doors to each resident’s bedroom locked automatically when the door was closed and the staff persons had keys to the doors. VA1 did not have a key to his/her bedroom door. The SP stated that VA1’s bedroom door was typically left open, but “once or twice” the door was closed in the morning when the bus to VA1’s day program was at the facility to pick up VA1 and there was not time for VA1 to go back to the bathroom to put on lotion or perfume. There was another bathroom VA1 could use. · The SP stated that s/he sometimes used a “stern” voice with VA1 and used a louder tone to provide VA1 with the “facts of the situation.” VA1 seemed to better understand the SP when s/he spoke “a little more louder.” The SP did not believe s/he was too stern with VA1 because VA1 liked the SP. The SP stated that s/he never yelled or swore at VA1 and never told VA1 to shut up. G1 stated that VA1 was able to verbally advocate for him/herself was able to communicate when s/he either liked or did not like something. Prior to the incident, G1 had no concerns about the care VA1 received at the facility. Conclusion for Allegation one: P1 stated that the SP frequently yelled and cursed at VA1. P5 stated that at times when VA1 repeated a story multiple times, the SP told VA1 to be quiet or that s/he did not want to hear the story again. At those times, VA1 “shut down” and did not speak for the rest of the evening. P5 and P7 each stated that they never heard any of the staff persons swear at the residents. P6 stated that s/he “heard” that the SP swore at and yelled at the residents, but it did not occur when P6 worked at the facility. The SP stated that s/he sometimes used a “stern” voice with VA1 and believed that VA1 seemed to better understand the SP when s/he spoke “a little more louder.” The SP did not believe s/he was too stern with VA1 because VA1 liked the SP. The SP stated that s/he never yelled or swore at VA1 and never told VA1 to shut up. P3 stated that on one occasion the SP closed VA1’s bedroom door, which automatically locked, so that VA1 could not enter his/her bedroom and bathroom. The SP stated that VA1’s bedroom door was closed “once or twice” in the morning when the bus to VA1’s day program was at the facility to pick up VA1 and there was not time for VA1 to go back to the bathroom to apply lotion or perfume. However, there was another bathroom that VA1 could use. Although P1 stated that the SP yelled and swore at VA1, none of the other staff persons heard the SP yell or swear at VA1 and there was no direct corroboration of P1’s statements. The SP denied yelling and swearing at VA1 and stated that VA1 understood the SP better when the SP spoke with a louder tone. Given that only P1 provided information that the SP yelled and swore at VA1 and that the SP denied yelling and swearing, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic in nature or whether the SP’s actions could reasonably be expected to produce emotional distress to VA1. 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). Allegation two: It was reported that on September 4, 2023, VA2 scratched the SP’s hands during a manual restraint. The SP grabbed VA2’s arm and twisted VA2’s wrists until VA2 screamed. The SP then called VA2 names and swore at VA2. VA2 enjoyed baking, working on crafts, playing games, shopping, bowling, listening to music, and spending time with his/her family members. VA2’s diagnoses included autism spectrum disorder, attention-deficit hyperactivity disorder (ADHD), anxiety, major depression, and obsessive convulsive disorder. According to VA2’s IAPP, VA2 might not be able to identify potentially dangerous situations and could put him/herself at risk unknowingly. The staff persons were to role model appropriate interactions with VA2 and praise VA2 when s/he displays appropriate behavior. VA2 had difficulty expressing him/herself and might become overwhelmed by verbally aggressive people. VA2 stated that s/he liked living at the facility and liked all of the staff persons working at the facility. The staff persons sometimes “held [VA2] down so tight that I can’t move,” but none of the staff persons “hurt” VA2. P1, P2, P8, P9, the SP, and the facility’s documentation provided the following information: · P1 stated that on September 4, 2023, VA2 was upset and threatening to harm him/herself. VA2 entered his/her bedroom and tried to break a window and P1, P2, and the SP implemented a manual restraint on VA2. When VA2 calmed, they released VA2 and s/he ran into the hallway and banged his/her head on the wall, causing his/her head to bleed. The staff persons implemented another manual restraint on VA2 and s/he fell to the floor and began to bang his/her head on the floor. P1 stated that the staff persons secured VA2’s hands and the SP placed a pillow under VA2’s head. P1 held VA2’s legs and P2 and the SP held VA2’s arms while VA2 lay on his/her side. The SP stated that s/he tried to hold onto VA2’s arm, but it was difficult because VA2 had thrown soap on the floor and it was slippery. · VA2 scratched the SP during the incident. P1 said that during the restraint, s/he saw the SP grab VA2’s wrist “much harder” than necessary and twist it. VA2 began to scream that the SP was “trying to break my fucking arm” and “you’re fucking hurting me.” P2 stated that the SP held VA2’s arm with enough pressure to hold his/her arm still and “maybe one time [the SP] got frustrated and [s/he] just kind of went a little hard.” · The SP stated that during the restraint, VA2 gouged the SP’s arms with his/her fingernails. The SP tried to hold VA2’s arm in different positions to stop VA2 from hurting him/herself and the SP. Because they implemented the manual restraint in the hallway, there “wasn’t much wiggle room.” The SP did not recall twisting VA2’s arm during the incident and stated that if it occurred, it was not “intentional” and s/he was trying to hold VA2’s arm securely. · P2 stated that during the incident, VA2 swore at all of the staff persons and threatened them. P1 and P2 each stated that VA2 called the SP a “bitch,” a “fat bitch,” and also said “fuck you” to the SP and after each occurrence the SP repeated the same words to VA2. The SP stated that s/he repeated things back at VA2 so that VA2 would focus on the SP instead of P3 because s/he wanted VA2 to listen to the SP’s attempts to redirect VA2. The SP did not recall everything that s/he said to VA2, but did not recall calling VA2 a fat bitch or saying “fuck you” to VA2. The manual restraint lasted approximately 20 minutes and P1 kept telling the SP that they had to switch positions because the SP was “just gone at this moment, losing [his/her] cool.” The SP did not release VA2’s arm. P1 believed the incident caused pain to VA2’s arm, but s/he did not observe any bruises to VA2’s arm. P8 stated that on September 5, 2023, s/he was at the facility and P1 talked to P8 about the incident. · P8 and P9 each stated that the staff persons received training on emergency use of manual restraints (EUMR). The staff persons sometimes needed to use a manual restraint when VA2 engaged in self-injurious behaviors such as hitting his/her head against a wall or the floor. VA2 sometimes calmed if staff persons called the local police because VA2 respected the authority of the officers wearing a uniform. P1 and P2 each stated that the SP did not implement the manual restraint as they were trained. P2 stated that the SP did not use de-escalation techniques when talking to VA2. P9 stated that s/he had no concerns about the SP’s interactions with the residents in the past, although there were some interpersonal conflicts between the SP and some of the other staff persons. The SP stated that some of the staff persons were unhappy because the SP sometimes “called them out” for not doing their jobs correctly. P9 stated that since VA2 moved into the facility, the staff persons typically implemented manual restraints on VA2 three to five times each week. G2 stated that VA2 was able to talk about events, but sometimes “exaggerated” when talking about what occurred. Prior to the incident, G2 had no concerns about the care VA2 received at the facility. Conclusion for Allegation two: P1 stated that on one occasion during a manual restraint, P1 saw the SP grab VA2’s wrist “much harder” than necessary and twist it. VA2 began to scream that the SP was “trying to break my fucking arm” and “you’re fucking hurting me.” P2 stated that the SP held VA2’s arm with enough pressure to hold his/her arm still and “maybe one time [the SP] got frustrated and [s/he] just kind of went a little hard.” P1 and P2 each stated that VA2 called the SP a “bitch,” a “fat bitch,” and also said “fuck you” to the SP and that the SP then said the same words back to VA2. The SP did not recall twisting VA2’s arm during the incident and stated that if it occurred, it was not “intentional,” and s/he was trying to hold VA2’s arm securely. The SP stated that s/he repeated VA2’s words back to VA2, but did not recall the words s/he used and did not recall calling VA2 a fat bitch or saying “fuck you” to VA2. Given that it was a single incident; that the manual restraint was warranted in order to keep VA2 safe; and that VA2 struggled during the manual restraint, which made it difficult for the staff persons to safely hold VA2; there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic in nature or whether the SP’s actions could reasonably be expected to produce physical pain, or injury or emotional distress. It was not determined whether physical and 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: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and/or 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). Allegation three: It was reported that on August 22, 2023, the SP grabbed VA3’s arms and “nudged” VA3 with his/her knee so that VA3 would move from where s/he was sitting on a stairway. VA3 enjoyed going on community outings, going on walks, watching movies, dancing, and spending time with his/her family members. VA3’s diagnoses included severe developmental delays, autism spectrum disorder, attention-deficit hyperactivity disorder (ADHD), and an anxiety disorder. According to VA3’s IAPP, VA3 was unable to foresee any potential danger or threat in situations. The staff persons were to remove VA3 from any unsafe situations. The staff persons were to model appropriate interactions with others and provide praise to VA3 when s/he interacted appropriately. VA3 had limited communication skills. P1, P3, P9, the SP, and the facility’s documentation provided the following information: · P1 stated that in April 2023, s/he was working with one of the residents, when s/he heard a “commotion” between VA3 and the SP at the top of the stairs leading to the lower level of the facility. When P1 checked on what was happening, s/he saw VA3 lying on the floor with his/her feet toward the stairs. The SP was standing behind VA3 and attempting to grab VA3’s arms. P1 believed that the SP was trying to push VA3 toward the stairs with his/her knee on VA3’s back. When P1 told the SP to stop, the SP told P1 that VA3 “was not fucking listening” and “stormed off.” P1 later talked to the SP about the incident and told P9 that the SP had “anger problems.” P9 asked P1 if s/he had information about specific incidents, but s/he did not, so P9 asked P1 to tell him/her about any incidents that occurred. P1 did not observe any injury to VA3. · P3 stated that on one occasion, the SP held VA3 by the wrist and appeared to be growing upset. P3 asked the SP to move away from VA3 because s/he wanted to “catch something before it got to a place where it could be where something were to happen.” P3 did not observe any injury to VA3. After P3 talked to the SP about the incident, P3 believed the SP was much more positive when s/he interacted with the residents. · The SP did not recall any occasion where s/he used his/her knee or foot to move VA3. The SP stated that when VA3 was upset, the staff persons sometimes “escorted” VA3 away from the other residents by taking VA3’s hands and trying to walk with him/her to another area of the facility. At times, VA3 sat on the floor rather than go with the staff persons. · P9 stated that VA3 frequently grabbed the arms or hair of the staff persons. The staff persons were trained to place their hands over VA3’s hands when that occurred and ask VA3 to “let go.” If VA3 did not release the staff person’s arm or hair, the other staff persons would restrain VA3’s arms and document the incident. P9 did not recall P1 telling him/her about the incident. G3 stated that prior to the incident, G3 had no concerns about the care VA3 received at the facility. VA3 would be unable to communicate his/her concerns to anyone. Conclusion for Allegation three: P1 stated that on one occasion, s/he heard a “commotion” between VA3 and the SP at the top of the stairs leading to the lower level of the facility. P1 saw VA3 lying on the floor with his/her feet toward the stairs and the SP standing behind VA3 and attempting to grab VA3’s arms. P1 believed that the SP was trying to push VA3 toward the stairs with his/her knee on VA3’s back. When P1 told the SP to stop, the SP told P1 that VA3 “was not fucking listening” and “stormed off.” The SP stated that the staff persons sometimes escorted VA3 away from the other residents when VA3 was upset and denied any occasion where s/he used his/her knee or foot to move VA3. Given the conflicting information provided by P1 and the SP regarding the incident, there was not a preponderance of the evidence whether the SP’s actions caused physical pain to VA3. 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). Allegation four: It was reported that after the SP checked VA4’s vitals, VA4 wanted to go to the hospital and the SP told VA4 that s/he was not going to the “damn doctor” and that VA4’s vitals “were fucking fine.” VA4 enjoyed participating in community events such as dances and community education classes. VA4 enjoyed going bowling, going to the library, going out to eat, and going shopping. VA4’s diagnoses included generalized anxiety disorder, borderline personality disorder, asthma, and chronic obstructive pulmonary disease (COPD). According to VA4’s Coordinated Service and Support Plan Addendum (CSSPA), VA4 preferred that the staff persons discussed his/her options and provide verbal redirection when s/he was anxious. VA4 did not like to be told what to do. The staff persons scheduled VA4’s medical appointments and attended VA4’s medical appointments with VA4. According to VA4’s IAPP, VA4 had a history of seeking medical attention by reporting injuries and illnesses inaccurately. The staff persons were to monitor VA4 for signs and symptoms of injuries or illnesses and make sure they are consistent with VA4’s reports prior to seeking medical attention for VA4. The staff persons were to offer currently prescribed medications or treatments to VA4 prior to assisting VA4 with making a medical appointment or taking him/her to the emergency room or urgent care. VA4 stated that on one occasion s/he was very sick and the SP took his/her temperature and blood pressure and then “lied” about the results. The SP left VA4 in his/her bed even though VA4 kept saying that s/he did not feel well and the SP refused to take VA4 to see his/her physician. VA4 felt like s/he “was going to die” and was so sick that s/he could barely go to the bathroom. The SP told VA4 to wait until the morning to go to the walk-in clinic. When P1 began his/her work shift, s/he took VA4 to the emergency room. VA4 stated that the SP did not like VA4 and they frequently “got in fights” and the SP yelled and swore at VA4. The SP used the “f word” when s/he talked to VA4. VA4 stated that the SP made VA4 cry and “feel like dirt” every time s/he worked at the facility. VA4 often stayed in his/her bedroom when the SP worked at the facility because s/he did not want to interact with the SP. VA4 also stated that the SP was “mean” to VA1.
P1, P5, P9, the SP, and the facility’s documentation provided the following information: · P1 stated that on one occasion, VA4 wanted the SP to check his/her vitals. VA4 frequently sought medical attention and the SP became upset when VA4 wanted the SP to check his/her vitals. After checking VA4’s vitals, the SP told VA4 that they were fine, but VA4 still wanted to be seen by his/her physician. The SP told VA4 that s/he was “not going to the damn doctor and your vitals are fucking fine.” The SP threw a paper at VA4 that showed the results of his/her vitals check. P1 talked to the SP and “calmed [him/her] down.” · P5 stated on one occasion VA4 was “worked up” because s/he had to go to court and the staff persons tried to help VA4 calm. The SP told VA4 that s/he did not have to go to court that day and caused VA4 to become more agitated. The SP and VA4 “went back and forth” and VA4 became more upset and threatened to hit the SP. P5 asked VA4 to go to his/her bedroom to calm and P5 told the SP that s/he could not speak to the residents in that manner. P5 stated that the SP spoke in a “nagging, stern, bossy, loud, and tit for tat” manner during the incident with VA4. The SP stated that s/he had a loud voice, but never yelled or swore at any of the residents. · P9 stated that VA4 was not always an accurate reporter of events. VA4 frequently wanted to go to the emergency room so that s/he could get medications. VA4 preferred not to work with the younger staff persons. G4 stated that VA4 was not always an accurate reporter of events and sometimes “exaggerated” when talking about events. Conclusion for Allegation four: P1 stated that on one occasion, after the SP checked VA4’s vitals, the SP told VA4 that his/her vitals were fine, but VA4 still wanted to be seen by his/her physician. The SP told VA4 that s/he was “not going to the damn doctor and your vitals are fucking fine.” P9 stated that VA4 frequently wanted to go to the emergency room so that s/he could get medications. P9 and G4 each stated that VA4 was not an accurate reporter of events. P5 stated on one occasion VA4 and the SP argued about whether VA4 had to go to court, causing VA4 to become agitated. The SP and VA4 “went back and forth” and VA4 became more upset and threatened to hit the SP. P5 stated that the SP spoke in a “nagging, stern, bossy, loud, and tit for tat” manner during the incident with VA4. The SP stated that s/he had a loud voice, but never yelled or swore at the residents. VA4 stated that the SP did not like VA4 and they frequently “got in fights” and the SP yelled and swore at VA4. VA4 stated that the SP made VA4 cry and “feel like dirt” every time s/he worked at the facility. VA4 often stayed in his/her bedroom when the SP worked at the facility because s/he did not want to interact with the SP. Although it was reported that when VA4 wanted to go to the hospital the SP told VA4 that his/her vitals were “fucking fine,” given that it was a single incident; that VA4 had a history of seeking to go to the hospital; that the SP checked VA4’s vitals and found that they were fine; and that there was no information provided that VA4 sustained any harm by not going to the doctor, there was not a preponderance of the evidence whether the SP’s actions could reasonably be expected to emotional distress to VA4 or were a failure or omission to supply the VA with necessary care or services. 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). 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 the facility’s policies were adequate, but were not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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