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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: 1071889-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: Allegation one: It was reported that on January 22, 2024, a staff person (SP) kicked a vulnerable adult (VA) in the stomach. Allegation two: It was also reported that on February 26, 2024, the SP yelled at the VA and told the VA that if s/he stepped closer to the SP, the SP would “slap the shit out of you.” Date of Incident(s): January 22 and February 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), clauses (1) and (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: · 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 8, 2024; from documentation at the facility; and through five interviews conducted with two facility staff persons (P1 and P2), an administrative staff person (P3), the SP, and the VA. The VA enjoyed going on community outings, participating in Special Olympics, taking community education classes, bowling, and spending time with his/her friends and family members. The VA’s diagnoses included Down’s syndrome, anxiety, and intellectual disabilities. The VA went to a work program three days each week. According to the VA’s Risk Assessment Detail, the VA had the ability to protect him/herself or to avoid physical abuse. While the VA might be able to indicate that s/he was mistreated, s/he would not be able to give details about the incident. The VA sometimes became physically aggressive and spit, swore, punched holes in the walls, or hit the staff persons. At those times, the staff persons were to intervene and redirect the VA to help the VA calm. The VA stated that the staff persons did not hit him/her or threaten to slap the VA. Although the VA stated that s/he sometimes annoyed one of the staff persons, s/he did not provide any additional information about the incidents. Allegation one: It was reported that on January 22, 2024, the SP kicked the VA in the stomach. P1, P2, P3, the SP, and the facility’s documentation provided the following information: · On January 22, 2024, the SP and P2 worked at the facility. The SP stated that when the VA arrived at the facility from his/her work program, the VA said that the SP kicked him/her, even though the VA “had just come in from work” and the SP was on the upper level of the facility and could not have kicked the VA. P2 was on the lower level of the facility when the VA entered the facility and knew that the SP was on the upper level and not near the VA. P2 stated that the VA was upset because there was no Pepsi for him/her to drink in the facility. The VA did not tell P2 that any incident occurred between the VA and the SP that day, but on the following day when the VA returned to the facility from his/her work program, s/he pointed at the SP and told P2 and P3 that on the previous day, the SP kicked him/her. P2 believed that the VA would have told him/her about any incident immediately if anything had occurred. P3 stated that s/he took photographs of the VA’s stomach, where the VA indicated that the SP kicked him/her. P3 did not see any marks on the VA’s body and the VA told P3 that s/he was not in pain. · P1 stated that s/he did not work on the day of the incident, but worked on the following day. At that time, the VA showed P1 a “faint little mark” on his/her stomach and told P1 that a staff person kicked him/her the previous day. The VA did not provide any additional information about the incident to P1. · P1 stated that s/he was told that the VA sometimes was not an accurate reporter of events, but was not aware of any times when that occurred. P1 stated that if you told the VA “no” without giving him/her an explanation for why you said no, the VA “will hold a grudge against you.” P2 stated that the VA frequently told the staff persons that someone kicked him/her, even though no one was near him/her at the time. P3 stated that the VA sometimes said the staff persons did something like kick the VA, when they did not. Facility documentation showed that the SP, P1, P2, and P3 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 incidents. Conclusion for allegation one: On January 22, 2024, the SP and P2 worked at the facility. The SP stated that when the VA arrived at the facility from his/her work program, the VA said that the SP kicked him/her, even though the VA “had just come in from work” and the SP was on the upper level of the facility and could not have kicked the VA. P2 was on the lower level of the facility when the VA entered the facility and knew that the SP was on the upper level. P2 stated that the VA was upset because there was no Pepsi for him/her to drink in the facility. The following day, the VA told P1, P2, and P3 that on the previous day, the SP kicked him/her. P3 checked the VA for injuries and did not see any marks on the VA’s body. The VA told P3 that s/he was not in pain.
Given that P2 was present when the VA said that the SP kicked the VA and knew that the SP was on another level of the facility at the time, that the SP denied kicking the VA, that the VA had a history of saying that the staff persons kicked him/her, and that no injury was observed on the VA, there was not a preponderance of the evidence whether the SP’s actions caused physical pain to 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). Allegation two: It was also reported that on February 26, 2024, the SP yelled at the VA and told the VA that if s/he stepped closer to the SP, the SP would “slap the shit out of you.”
P1, P2, P3, the SP, and the facility’s documentation provided the following information: · On February 26, 2024, P2 and the SP worked at the facility. At approximately 2 p.m., the VA arrived at the facility from his/her work program. P2 stated that the VA became upset because there was no Pepsi in the facility for him/her to drink. The VA “immediately” began to say that someone hit and kicked him/her. When questioned, the VA said that s/he was “playing around” and was not kicked. The SP stated that when the VA became upset, s/he went upstairs to the staff office to let the VA “cool down” for a few minutes and P2 remained with the VA. At approximately 4 p.m., the VA again asked for Pepsi and was told there was no Pepsi in the facility. The VA began to spit on the SP, who put up his/her hands and told the VA to “leave me alone.” P2 told the SP to go back to the staff office. P2 and the SP stated that the VA then told the SP that s/he would slap the SP if s/he did not give Pepsi to the VA and the SP asked the VA, “Who are you going to slap?” The SP was walking toward the staff office when P1 entered the facility with some Pepsi and the VA “cooled down” and apologized to the SP. · P1 stated that on the day of the incident, s/he purchased Pepsi for the VA and then stopped at the facility to bring the Pepsi and some cake to the residents. The facility’s door was not locked, so P1 pushed the door open and walked into the facility. The VA stood at the bottom of the stairs and P1 heard “somebody” say, “I will slap the shit out of you.” The VA then told P1 that “[s/he] hit me.” The SP walked down the stairs and said, “This [VA] is going crazy, [s/he] wants the Pepsi, you know.” P1 helped the VA calm, gave the VA some cake, and the told the VA to take it upstairs, which the VA did. The SP stated that s/he did not threaten to slap or hit the VA. · P3 stated that the SP did not often work at the facility and the VA “wasn’t used to [the SP].” In the past, the VA told P3 that the SP “was not nice” to the VA. The VA would become upset if there was no Pepsi in the facility and sometimes “took advantage” of new staff persons. After the incidents, the SP worked at another residential program operated by the license holder. Conclusion for allegation two: On February 26, 2024, the SP and P2 worked at the facility. At approximately 4 p.m., the VA asked for Pepsi and was told there was no Pepsi in the facility. The VA began to spit on the SP, who told the VA to “leave me alone.” P2 told the SP to go to the staff office to allow the VA to calm. The VA then told the SP that s/he would slap the SP if s/he did not give Pepsi to the VA and the SP asked the VA, “Who are you going to slap?” The SP was walking toward the staff office when P1 entered the facility with some Pepsi. P1 stated that when s/he entered the facility, s/he heard “somebody” say, “I will slap the shit out of you.” The VA then told P1 that “[s/he] hit me.” P1 gave Pepsi and cake to the VA and the VA “cooled down.” Although P1 stated that s/he heard somebody say that they would “slap the shit out of you,” P2 and the SP each provided information that the VA made that comment to the SP and that the SP did not threaten to hit or slap the VA. Given that P1 was uncertain of who made the statement and that P2 and the SP each stated that the VA made the statement, there was not a preponderance of the evidence whether the SP’s actions would be considered by a reasonable person to be disparaging, derogatory, humiliating or threatening and could reasonably be expected to produce emotional distress to the VA. 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 completed two internal reviews and determined that the facility’s policies were adequate. The facility determined that the staff persons did not follow the facility’s policies during the second incident and that it was undetermined if the staff persons followed the facility’s policies in the first incident. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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