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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: 1069196-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Henne/Alice Percy Suspected Maltreatment Reported: It was reported that a staff person (SP) slapped a vulnerable adult (VA) and told the VA that s/he “was acting like a baby” because the VA refused to walk to the table. Date of Incident(s): January 11, 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 6, 2024; from documentation at the facility; and through nine interviews conducted with three facility staff persons (P1 – P3), three administrative staff persons (P4 – P6), the SP, the VA’s case manager (CM), and the VA’s guardian (G). Although this investigator talked to the VA, the VA did not provide any information about the incident. The VA enjoyed going on community outings, going shopping, and spending time with family members. The VA’s diagnoses included schizophrenia, borderline intellectual function, hyperlipidemia, scoliosis, eating disorder, chronic kidney disease, anxiety, obsessive compulsive disorder, and bipolar disorder. According to the VA’s Individual Abuse Prevention Plan, the VA was unable to identify potentially dangerous situations. The VA might not be a reliable reporter of an abusive situation. The staff persons were trained to remove the VA from any situation that might be dangerous. P1, P2, P3, P4, P5, P6, and the facility’s documentation provided the following information: · P3 stated that the in the past, the VA had been able to walk, but after a hospitalization in December 2023, s/he typically used a wheelchair. The VA sometimes needed assistance with standing. The VA occasionally sat on the floor and usually needed assistance to stand and move to a chair, but could sometimes stand without assistance. P6 believed that the VA was currently able to stand when s/he was on the floor, but sometimes wanted the assistance of a staff person to do so. Two staff persons typically worked with the VA. P4 stated that the VA’s memory “wasn’t the best” and s/he did not always recall “all the details” correctly. · P2 stated that the VA had a ileostomy bag that s/he sometimes took off, especially during the night when s/he was in bed. At other times s/he touched and “played around with” the ileostomy bag until it came off. P6 stated that the VA sometimes tore his/her ileostomy bag or pulled it off. The staff persons then put a new bag in place and repeatedly reminded the VA not to touch the bag. · On January 11, 2024, the SP and P1 worked at the facility. P1 stated that late that afternoon, the SP, P1, and the VA were in the living room and the VA was sitting on the floor and crying because s/he wanted assistance to move to a chair. P1 stated that the SP told the VA that s/he could move to the chair without assistance and asked the VA why s/he was refusing to stand. The SP then slapped the VA’s right shoulder one time and told the VA to stand, causing the VA to cry and tell the SP not to hit him/her. P1 told the SP that the VA was sick and asked the SP why s/he hit the VA. The SP told P1 and the VA that the VA “was acting like a baby.” After the incident, P1 did not see any marks on the VA’s shoulder. A short time after the incident, P1 brought food and water to the VA. The VA told P1 that s/he could go to his/her bedroom by him/herself and the VA then “scooted” to his/her bedroom while sitting on the floor. On the following day, P1 telephoned P5 and told him/her about the incident. · P5 stated that P1 told him/her that s/he saw the SP slap the VA “multiple times” on the hand, shoulder, and head, called the VA a baby, and was “degrading” the VA. P5 then telephoned the SP and asked him/her about the incident. When asked if s/he hit the VA, the SP told P5 that s/he slapped the VA’s hand away from the ileostomy bag several times because the VA was pulling out the contents of the bag. The SP denied slapping the VA on the shoulder or the head. The SP believed s/he made a comment that the VA was acting like a baby because the VA was “capable of doing a lot more” than what s/he was currently doing. · P2 stated that on the day after the incident, s/he worked at the facility for approximately one hour and the SP told P2 that the VA “was faking it” and was able to stand if s/he wanted to. The SP did not force the VA to stand, but told the VA that s/he could stand on his/her own. The VA told P2 that the SP “smacked” the VA on his/her hand. P2 did not see any marks on the VA’s hand. P3 stated that when s/he worked with the VA several days after the incident, the VA told P3 that the SP hit the VA, but did not provide any additional information about the incident. P6 stated that several days after the incident, the VA told him/her that the SP hit the VA’s hand. P6 did not see any marks on the VA’s hands. · P1 stated that prior to the incident, s/he had no concerns about the SP’s interactions with the residents. P3 stated that s/he worked with the SP in the past and had no concerns about his/her interactions with the residents. The SP sometimes spoke in a “stern” manner. The SP provided the following information: · The SP stated that the VA frequently “dug” in his/her ileostomy bag and then wiped the contents on “everything.” The staff persons were trained to redirect the VA at those times and try to ensure that the VA did not take the ileostomy bag off or make a hole in it so that s/he could access the contents. On the day of the incident, at approximately 5 p.m., the VA was sitting on the floor of the kitchen and was “constantly digging” in his/her ileostomy bag by breaking the seal and putting his/her fingers in the bag, so the SP lightly slapped the VA’s hand and moved it away from his/her ileostomy bag. The SP demonstrated that the slap was light and would not have caused an injury to the VA and that s/he did it to get the VA’s hand away from the ileostomy bag. The SP told the VA that s/he had fecal matter on his/her hands and they had to wash the VA’s hands. The SP believed P1 was watching television and using his/her cell phone in the living room at the time of the incident and was uncertain if P1 would have been able to see his/her interaction with the VA from where s/he was sitting. · The SP changed the VA’s ileostomy bag and the VA remained sitting on the kitchen floor and refused to stand and go to the table, so the SP and P1 served dinner to the VA while s/he sat on the floor. Later that night, the VA still refused to stand and s/he crawled to his/her bedroom. · The SP stated that s/he told the VA not to play with his/her ileostomy bag, but did not tell the VA that s/he was acting like a baby. The SP also stated that s/he did not hit the VA’s shoulder or tell the VA to stand up. The only time the SP would touch the VA’s shoulder would be to assist the VA with sitting up or standing up. When the SP worked with the VA in the past, the VA was able to walk and stand with minimal assistance from the staff persons. · The SP stated that in the past, s/he had interpersonal conflicts with P1. The SP stated that P1 frequently used his/her cell phone when s/he worked at the facility instead of interacting with the VA. The G stated that on one occasion s/he called the VA at the facility and heard the SP in the background talking to the VA and telling the VA that s/he had to move across the room to get to the telephone. The VA told the SP that s/he needed assistance, but the SP told the VA that s/he “could do it.” The VA’s mobility had worsened in the last few months and the G believed that two staff persons were needed to assist the VA with transfers and with standing. The G did not believe the VA was a reliable reporter of events. The CM stated in December 2023, the VA was prescribed new medications that affected the VA’s mobility and fine motor skills. The medications were recently changed so the CM believed the VA’s mobility was improving. The VA was not always a reliable reporter of events and sometimes had hallucinations. The VA frequently continued to touch his/her ileostomy bag even after the staff persons tried to redirect him/her.
Facility documentation showed that the SP and P1 – P6 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 incident. Conclusion: On January 11, 2024, the SP and P1 worked at the facility. P1 stated that late that afternoon, the SP, P1, and the VA were in the living room and the VA was sitting on the floor and crying because s/he wanted assistance to move to a chair. P1 stated that the SP told the VA that s/he could move to the chair without assistance and then slapped the VA’s right shoulder one time and told the VA to stand, causing the VA to cry and tell the SP not to hit him/her. P1 asked the SP why s/he hit the VA and the SP told P1 and the VA that the VA “was acting like a baby.” The SP stated that on the day of the incident, s/he and the VA were in the kitchen while P1 watched television in the living room. When the VA tore his/her ileostomy bag and pulled out the contents, the SP slapped the VA’s hand and told him/her to stop touching the bag because s/he was getting his/her hands dirty. The SP stated that s/he told the VA not to play with his/her ileostomy bag, but did not tell the VA that s/he was acting like a baby. The SP also stated that s/he did not hit the VA’s shoulder or tell the VA to stand up. After the incident, the VA provided consistent information to several staff persons that the SP hit the VA’s hand. The VA did not sustain an injury during the incident. P1 and the SP provided inconsistent information about the incident, but the VA and the SP each provided information that the SP hit the VA’s hand, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. However, given that it was a single incident, that no information was provided that it was anything other than a “light” slap, that the SP denied saying the VA was acting like a baby, and that the VA did not sustain any injury during the incident, there was not a preponderance of the evidence that the SP’s actions could reasonably be expected to produce physical pain to the VA or was repeated oral conduct which 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 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). 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 staff persons. The SP was retrained on the facility’s policies and no longer worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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