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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: 1116917-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas 651-431-3970 Suspected Maltreatment Reported: It was reported that the VA had purple, black, and blue bruising on the backs of his/her upper arms, elbows, both sides of the torso, and the back of both thighs. The VA stated that someone hit her/him, someone of the same gender. Date of Incident(s): May 24, 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); 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 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 a site visit conducted on June 6, 2023; from documentation at the facility; and through five interviews conducted with facility staff persons (SP, P1, and P2), a community healthcare professional (HCP), and the VA. Another staff person who worked the overnight shift (P3) did not respond to this investigator's attempts to request an interview. According to the VA’s Coordinated Service and Support Plan Addendum (CSSPA), the VA was diagnosed with severe cognitive disability, intermittent explosive disorder, bipolar mood disorder, congenital hip defect, obesity, hypothyroidism, seizure disorder, and tuberous sclerosis. The VA enjoyed spending time in the community. The VA had a limited ability to communicate verbally and therefore could not provide substantive information regarding the allegations in the report. P1 provided the following information: · On the morning of May 25, 2023, P1 noticed bruises on the back of the VA’s leg when assisting the VA with her/his morning routine and notified P2. · P1 asked the VA about the bruises but the VA did not indicate that someone had hit her/him at that time. P1 initially believed that the bruising might have been caused by the VA’s bed; at that time the VA’s slept on a foam mattress two to two and a half inches thick on top of a frame with metal support beams. P1 stated that when s/he went to help the VA out of bed, it was a “struggle” because the metal support beams had come apart. · P1 stated that the VA bruised easily because of circulatory problems. P2, a supervisory staff person, provided the following information: · P2 learned of the bruises from P1, on Thursday May 25, 2023, when s/he arrived at the facility around 8:30 a.m. P2 assisted P1 undressing the VA in preparation for a morning shower and noticed that the VA had bruises on the backside of his/her upper arms, shoulders, left flank, and the back of the VA’s thighs; pictures were taken of the bruises. P1 took the VA to urgent care between 10:30 and 11 a.m. · P2 stated that on the way to urgent care, P2 asked the VA about the bruises. The VA stated it was a staff person of the same gender as the VA who caused the bruises, at first the VA said the staff person was the SP but then said it was the overnight staff person. P2 also asked the VA if s/he had fallen but the VA shut down and did not respond, the VA later said s/he was hit, with a hand. P2 noted that the VA may identify the wrong person when asked specifically to identify someone, and the VA could be easily led to an answer. · P2 stated that the VA was prone to bruising; the VA would open-hand slap her/himself on the face, punch walls, and in the past had received bite marks from a housemate. The VA showed signs of physical aggression toward housemates when overstimulated by loud noises, staff persons would prompt the VA to wear noise cancelling headphones. P2 stated that the bruising noted in the allegations was not consistent with the VA’s self-injurious behaviors. · Around the time of the incident the facility used a temporary staffing provider to cover some shifts. P2 stated that the night before the bruises were noticed on May 24, 2023, the SP (who was from the staffing provider) worked at the facility from 1:30 to 10 p.m. P2 stated that the SP enjoyed working at the facility, was patient, was direct, and was reliable. P2 stated that s/he had no concerns about the SP. · P2 spoke with P3, who worked from 10 p.m. to 6:30 a.m., on May 24 to 25, 2023. P3 reported that the VA was already in bed when s/he arrived for this shift and P3 did not notice any bruises because the VA wore long sleeved pajamas. · P2 stated that s/he believed the SP was responsible for the VA’s bruises because the timeframe lined up. P2 stated that s/he had not noticed any bruises on the VA the day before when helping the VA get dressed, leading P2 to believe that the bruises had been caused sometime within that time period and that the SP had called P2 on May 24, 2023, and sounded “discombobulated.” The HCP, a community healthcare professional provided the following information: · The HCP examined the VA on May 25, 2023, and stated that the bruises on the VA appeared to be fresh because some areas around the bruising were still red indicating that they were fresh and the VA grimaced when those areas were palpated. · After the VA’s bruising was examined, the VA was given Tylenol for discomfort from the bruising. The HCP stated that the VA would nod or turn her/his head when asked questions. The VA appeared to be more comfortable being asked questions by P2 who had brought the VA to urgent care. The VA had a limited ability to communicate verbally, the VA was able respond to direct questions and responded in the affirmative that another person hit the VA, the person had short dark hair. The VA could not state if the person was light or dark skinned. The SP provided the following information: · The SP worked at the facility on May 24, 2023, from 1:30 to 10 p.m. The SP stated that the VA was a lovely person and would help around the facility. The VA’s behavior could be triggered by loud noises. · The SP stated that the VA did not have any bruising and that s/he would never harm residents. The SP stated that during that shift the VA’s bedframe had been placed against a wall in the living room and the VA attempted to carry it back to the VA’s bedroom because the VA wanted to lay down. The SP stated that s/he helped the VA and made space for the VA on a couch on the second level, so that the VA could lay down and relax. · The SP stated that another resident came upstairs and began to watch tv in the same room, the SP asked that resident to turn the tv down so the VA could relax. Later that resident began to scream because the VA had taken the tv remote, the SP separated them and the other resident hit the VA, but the two made up afterwards. · The SP stated that the VA would typically go to sleep around 7 to 8 p.m. The SP waited for the overnight staff person to arrive. The SP could not recall whether the VA was in bed by the end of his/her shift that night. · The SP stated that the facility provided a training book and maltreatment was a topic that was reviewed. According to the schedule provided by the facility, P3 worked after the SP from 10 p.m. to 6:30 a.m. The SP and P3 were the same gender as the VA. Facility documentation showed that P1 and P2 received training on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults. The SP and P2, each stated that the SP received the above training, but the facility did not provide documentation on the SP’s training. Conclusion: Information was consistent that on the morning of May 25, 2023, the VA had multiple bruises on the back of her/his body. The SP stated that s/he “would never harm my residents,” and did not notice any bruising on the VA during the shift. During the SP’s shift, the VA’s bedframe had been placed against a wall in the living room. When the SP saw the VA attempt to carry it back to her/his room, the SP helped the VA but had the VA rest on the couch instead. P1 stated that s/he thought the VA’s bruises were caused by the VA’s bed because the support beams had come apart and it was a “struggle” to help the VA get out of bed in the morning. P2 stated that s/he believed it was the SP that caused the bruises because the VA said a staff person of the same gender hit her/him and the overnight staff person, also of the same gender, had stated s/he did not see any bruises on the VA. At times the VA provided inconsistent information regarding how s/he sustained the bruises. It was not determined how the VA sustained the bruises, whether the bruises were a result of the VA’s bed, of the VA attempting to carry his/her bedframe, or of the SP’s or any other staff person’s action. Therefore, given that the facility sought care for the VA when it became aware of the bruises, there was not a preponderance of the evidence whether the bruises were caused by any other means other than accidental or whether there was a failure to provide the VA with care or services that were reasonable or necessary to obtain or maintain the VA’s health or safety. It was not determined whether physical abuse or neglect 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; 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, the facility could not determine the cause of the bruises. The facility determined that its policies and procedures were adequate and followed. When this report was written, both the SP and P3 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On May 31, 2024, the facility was issued a $600 fine for background study violations. The Order to Forfeit a Fine is subject to appeal.
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