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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: 1071975-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas 651-431-3970 Suspected Maltreatment Reported: It was reported that on or about July 4, 2023, a staff person (SP) pushed a vulnerable adult (VA) into a chair leaving a bruise on the VA’s arm and above the back of the left hip. Date of Incident(s): July 4, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on November 7, 2023; from documentation at the facility and law enforcement records; and through five interviews conducted with facility staff persons (P1 and the SP), the VA’s case manager (CM), a relative of the VA (R), and the VA. The VA was diagnosed with a cerebral infarction, diabetes, and had paralysis on her/his left side. The VA enjoyed spending time with family and friends and watching her/his favorite show on TV, “Catfish.” According to the VA’s ISSA Assessment Detail: · Due to a stroke, the VA had limited mobility and was paralyzed on the left side. The VA had difficulty performing everyday tasks, such as transferring, getting dressed, using the bathroom, etc. · The VA used a wheelchair for mobility. At times the VA would transfer her/himself from the wheelchair to her/his bed or recliner which in the past had resulted in falls. Staff persons were to remind the VA the importance of transferring with assistance. The VA provided the following information: · The VA recalled an occasion when s/he needed assistance to use the bathroom but was told to wait because the SP was busy. The VA responded, “What do you want me to do, I have a [adult absorbent undergarment] on, gotta go out there.” The VA stated s/he ended up soiling her/himself. The VA stated that at times the SP would have her/him wait because the SP was assisting another resident. · The VA recalled having the bruise and sending a picture of it to her/his relative, the R. The VA stated that staff persons did not use any kind of brace or straps to assist the VA in and out of her/his wheelchair. The VA stated that staff persons “throw me in the chair.” The VA stated that when the SP came back to work because the SP had left for a while after the incident, the SP “treated” the VA “better.” Note: The VA was brought to her/his bedroom by a staff person for an interview with this investigator and that staff person assisted the VA onto the bed. When asked if other staff persons assisted the VA in the same way, the VA stated “always,” but later retracted and said, “No.” This investigator observed the VA being transferred out of her/his wheelchair in a careful manner without any signs of rough handling. The R provided the following information: · On or about July 5, 2023, the R received a picture of the VA’s bruise that had been taken by an unknown staff person. The R spoke with the VA on the phone who told the R that the SP had thrown the VA into her/his wheelchair causing the VA to hit her/his backside on the arm of the wheelchair. · The R later visited the VA at the facility and the SP stated that the VA probably caused the bruise him/herself when s/he transferred her/himself; the R reminded the VA that s/he had been saying the SP threw her/him into the wheelchair. According to the R, the VA would regularly complain about the SP being mean. · The R was aware that the VA would “plop” her/himself down when being assisted by staff persons in and out of his/her wheelchair, but the VA had never hit the arm of the wheelchair before or been injured. Note: The picture provided showing the bruising on the VA only showed a bruise on the VA’s left backside of the upper hip area. The bruise began at the left side of the VA’s hip and wrapped around to the back for several inches in an elongated oval shape. The outer edges of the bruise are yellowish with a bluish-purple at the center. The VA’s CM had no knowledge of the VA making inaccurate reports against staff persons. The CM stated that the VA would scream at staff persons because s/he did not like “how things went” at the facility. The SP provided the following information: · The SP stated that every time the VA was transferred to or from the wheelchair, the VA accused a staff person of “tossing” the VA around. The VA would not wait for assistance in transferring in and out of the wheelchair. The SP recalled on occasion when the VA had fallen on the floor because s/he did not wait for assistance and the brake on the wheelchair was not yet set. · The SP denied rough handling the VA when transferring the VA to and from his/her wheelchair. The SP did not notice any bruises on the VA. P1, a supervisory staff person provided the following information: · P1 did not learn of the July 4, 2023, allegation until sometime in August 2023, when police contacted the license holder. Upon learning of the allegation against the SP, the SP was taken off the schedule while an internal investigation was conducted.
· The VA had a history of making inaccurate reports against staff persons at the facility. P1 stated that the VA made inaccurate allegations to the point that staff persons were instructed on how to talk to the VA when inaccurate reports are made, such as asking the VA if it really happened and what would it look like if somebody was rough with the VA. The VA was not discouraged from reporting allegations of maltreatment. Law Enforcement (LE) was notified of the incident and followed up with the facility on August 4, 2023. P1 informed LE that the facility was not aware of the incident. P1 told LE that the matter would be addressed through staff person training. LE did not investigate further and the report was closed. Facility records showed that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act, the care plans for the VA, and the faciliy’s policies and procedures. Conclusion: On July 4, 2023, the VA stated that while being transferred by the SP into his/her wheelchair, the VA hit her/his left upper hip on the arm of the wheelchair. The VA alleged that the SP threw her/him into the wheelchair. Information was consistent that the VA had a history of making inaccurate reports against the SP and would attempt to transfer her/himself into and out of the wheelchair which in the past had resulted in falls. Given that VA’s history of inaccurate reports and attempts to transfer her/himself, and witness statements that the VA would “plop” her/himself down into the wheelchair when being assisted, there was not a preponderance of the evidence whether the VA obtained the bruise by any other means than accidental or if the VA sustained the bruise while being transferred to her/his wheelchair by the SP. 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and the VA’s support plans were implemented as applicable. The SP was returned to the schedule at the conclusion on the facility’s internal investigation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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