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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: 1067789-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) referred to a vulnerable adult (VA) as a “bitch,” threatened to call the police on the VA, and made fun of the VA’s “disability.” Date of Incident(s): unknown dates 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 August 4, 2023; from documentation at the facility; and through six interviews conducted with facility staff persons (P1-P4), the SP, and the VA. The VA was diagnosed with mild intellectual disability, spinal cerebellar ataxia, and psychogenic seizures. The VA was subject to guardianship. The VA required the use of a wheelchair and walker for mobility. The VA was a social person and enjoyed being with people. P4 stated that the SP referred to the VA as a “bitch,” when talking to P4, threatened to call the police on the VA, and the SP “made fun of” the VA’s “disability.” P4 never witnessed any emotional abuse by the SP and never witnessed the SP say these things to the VA. The VA stated that staff persons had not made fun of her/his “disability,” and s/he was not called or referred to using the “b” word “bad word” by any staff persons. The VA stated that s/he got along with staff persons at the facility. The SP provided the following information: · The SP stated that the VA could be very aggressive, the VA had hit the SP with her/his wheelchair, swung at the SP, scratched, bitten, and “falsified stories” against the SP. The VA had “cursed out” numerous other staff persons at the facility. · The SP stated that staff persons were advised to try and de-escalate situations and remain hands off or block a resident’s attempts to hit staff persons, try to get away, and wait for another staff person to intervene. · On an unspecified date, the VA began to swing her/his arms at the SP, the SP backed away but was backed into a corner, the VA grabbed the SP’s arm and bit the SP. On another unspecified date, the SP told the VA in the presence of the VA’s parent that hitting the SP with her/his wheelchair was assault and the VA could not scratch, bite, and hit the SP and the SP could call the police. · The SP stated that s/he never called the police on the VA, never called or referred to the VA as a bitch, and never made fun of the VA’s “disability.” P1 through P3 provided the following information: The VA was able to advocate for her/himself if the VA had any complaints about staff persons. However, the VA had at times been less than truthful about events such as complaints regarding staff persons. P3 stated that sometimes the VA would get into arguments with staff persons regarding the topic of her/his independence; at times the VA liked to perform tasks on her/his own which required the assistance of a staff person. No staff person had any knowledge of any other staff person using derogatory names toward the VA. P1 stated that there were no concerns regarding the SP. The facility’s Rules for Staff Conduct policy stated that staff persons were to conduct themselves in a respectful, professional, courteous manner, and be goal oriented. Personal actions by staff persons s such as intimidation which hindered the progress of the service recipient would not be tolerated. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) stated that a person’s protection related rights included the right to be treated with courtesy and respect. Conclusion: Information was consistent that the VA could advocate for her/himself and raise any complaints or concerns that the VA had regarding staff persons. The VA was also known to have made inaccurate reports regarding staff persons. The SP denied referring to the VA as a “bitch” and denied making fun of the VA’s “disability” but admitted to telling the VA that s/he would call the police if the VA hit the SP again with the VA’s wheelchair, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Although the SP told the VA s/he could call the police which upset the VA, given that it was a single incident and that the VA and SP each stated that the SP did not call the VA a bitch or make fun of the VA’s “disability,” there was not a preponderance of the evidence whether the SP’s conduct was repeated or rose to the level of emotional abuse. 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 conducted an Internal Review and found that staff persons may not have adhered to the facility’s Rules for Staff Conduct policy which was adequate but not followed. All staff persons including the SP were retrained on residents’ care plans and the above policy. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because they took corrective action. On May 31, 2024, the facility was issued a $200 fine for a background study violation. The Order to Forfeit a Fine is subject to appeal.
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