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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: 1067989-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a staff person (SP) dragged a vulnerable adult (VA) to his/her bedroom and restrained the VA. The VA had red marks and bruising on his/her arms. Date of Incident(s): June 4, 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), 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 June 14, 2024; from documentation at the facility; and through eight interviews conducted with four facility staff persons (SP, P1, P2, P3), the VA’s guardians (G1, G2), the VA’s case manager (CM), and the VA. The facility was a large one level house. Through the front entrance was a large living area with a kitchen, dining room, and living room. Around the perimeter of the house were four bedrooms including the VA’s bedroom. Across the hall from the VA’s bedroom was a bathroom and across the hall to the left was another living area with a recliner, a couch with end table, two exercise machines, a table and chair, and a TV stand. The VA was diagnosed with autism and developmental disabilities and enjoyed bowling. The Coordinated Service and Support Plan Addendum provided the following information: · As a result of a prior surgery, the VA had difficulty walking and was at risk for falling. The VA used a walker while at the facility. At times the VA did not hold the walker properly and his/her grip could slip. When upset the VA lifted and slammed his/her walker violently on the ground. · The VA had a very high pain threshold and may not report an injury. Staff persons checked the VA over when appropriate to look for cuts, scrapes, bruises, etc. Staff persons asked the VA if s/he remembered how an injury happened and assisted the VA in seeking medical attention if necessary. · The VA had a history of verbal and physical abuse toward others. In an abusive situation, the VA would most likely not defend him/herself against abuse due to his/her poor balance and slow mobility. · The VA had a history of self-injurious behaviors and when agitated may slap his/her face, hit his/her legs and bite him/herself. Staff persons physically blocked the VA’s hands to prevent the VA from injuring him/herself. Staff persons used redirection techniques and asked the VA if s/he wanted to talk about what was bothering the VA. if the VA did not calm down staff persons implemented an emergency manual restraint. The VA said that the SP “hurt me” and hurt the VA’s neck when the SP “drug” the VA’s shirt. The SP gave the VA scratches on the back of the VA’s neck. The VA was not able to provide more detailed information. P1-P3 provided the following information: · On the date of the incident, the SP and P2 worked the evening shift at the facility. At approximately 7 p.m., P2 left the facility. At 8 p.m., the SP text P2 to ask if s/he was coming back to the facility. The SP said s/he “drug” the VA to his/her room and the VA was “throwing a fit.” If the SP was not able to leave the facility s/he was going to “put [the SP’s] hands on” the VA. · P1 said that at approximately 9:30 p.m., the SP text P1 and asked P1 to come in early for P1’s overnight shift. The SP said that s/he was worried about “putting [the SP’s] hands on” the VA. P1 agreed to come in early. · When P1 arrived at the facility, the SP was in the staff office and the house was in “disarray.” The SP was “distraught” and “frustrated.” The SP said that the VA was having a “hard night” and tried to hit the SP. The VA had thrown him/herself on the ground. · P1 went to the VA’s bedroom and found the VA standing by the bed with the lights off. The VA said that the SP was mad at the VA. P1 encouraged the VA to get his/her pajamas on. When P1 assisted the VA in taking off his/her shirt, P1 noticed marks on the VA’s arms in the armpit area. The marks were red at that point and looked like scratches. The VA also said his/her neck hurt but P1 did not see any marks or bruising on the neck. The VA said that the SP put the VA in a restraint and hurt the VA. P1 gave the VA Tylenol, and the VA went to bed. In the morning, the marks in the arm pit area had started to bruise. · The following day when P2 worked, the VA kept complaining that his/her neck hurt, and that the SP put the VA in a “hold.” P2 saw a bruise near the VA’s left armpit that looked like someone had grabbed the VA. There was also some light bruising in the VA’s hairline. · P3 said that the VA had a history of being placed in holds. Since coming to this facility, the VA had not been put in a hold, but there was a prior incident in which a staff person was physical with the VA and the VA described it as a hold. The SP provided the following information: · On the date of the incident, P2 and the SP worked the evening shift. P2 left early leaving the SP alone with four individuals. Two individuals were already in bed, but one individual and the VA were still awake. · The VA was in the dining room and the SP said that it was time to get ready for bed. The VA said, “No,” and started yelling. The SP left the VA and checked in again approximately 10 minutes later. The VA had calmed down so the VA started walking with the VA to the VA’s bedroom. · The SP interlocked arms with the VA and walked with the VA toward his/her bedroom so the VA did not fall. The VA did not use his/her walker as the SP said that the VA would not have come on his/her own, so the SP asked if s/he could take the VA. When they got to the bedroom, the VA started hitting his/her arms, hands, and head on the door frame of his/her bedroom. The VA then started trying to hit the SP and threw him/herself on the floor. · The SP turned off the light and left the VA in his/her bedroom on the floor as the VA would not get up and was yelling at the SP. The SP called P1 and asked if s/he could come in early to get the VA into bed. · The SP said that the only time the SP had physical contact with the VA was when the SP had interlocked his/her arm with the VA’s arm to assist the VA to his/her bedroom. The SP did not feel the VA could have been injured when s/he went to the ground in his/her bedroom. The SP said s/he did not grab the VA on his/her arm or neck and did not know how the VA sustained the bruising and scratching. The SP had surgery the week prior and was sore and “could not do much.” When this investigator asked the SP about the text message that indicated that s/he dragged the VA to his/her bedroom, the SP said that the VA was leaning on the SP when s/he was walking with the VA but that s/he did not drag the VA. Texts messages between P2 and the SP stated that at 9:01 p.m., the SP said, “I almost put my hands on [the VA] istg [I swear to god].” The SP said that the VA was in his/her bedroom now but was “making the most biggest fit cussing me out and I had to literally drag [the VA] into the room.” The SP went on to say the VA was “hitting me and shit,” and “I just need to get out of here, Imma explode.” Text messages between P1 and the SP showed that the SP text P1 at 9:04 p.m. asking if P1 could come in early because the SP needed to “cool down.” The SP said that s/he was upset and crying because of the VA’s behavior and “almost wanted to put my hands on [the VA] because [the VA] kept trying yo [sic] hit me.” When asked if the SP put the VA in a hold, the SP said, “No, every time [the VA] tried to hit tho I just moved.” Daily shift documentation stated that on June 4, 2024, when P1 arrived, the VA was in his/her bedroom standing at the end of the bed with the lights turned off. P1 turned the lights on and assisted the VA with brushing the VA’s teeth and getting his/her pajamas on. The VA was “somewhat escalated” due to the situation that occurred before P1 arrived. The VA said that the SP placed the VA in a “hold” and that the VA’s neck hurt. The VA had what appeared to be scratches on the “back sides and under arms.” P1 gave the VA two tablets of 325 milligram Tylenol for pain. Photos taken by staff persons showed a one to two inch red scratch on the front of the VA’s neck. Another photo showed a large purple bruise near the VA’s left armpit where the arm meets the shoulder. All staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s Coordinated Service and Support Plan Addendum. Conclusion: A. Maltreatment: The VA said that the SP “hurt me” and hurt the VA’s neck when the SP “drug” the VA’s shirt. The SP gave the VA scratches on the back of the VA’s neck. The VA also provided consistent information to P1 and P2 that the SP “hurt” the VA and/or put the VA in a “hold.” On the date of the incident, P2 received a text from the SP that said that the SP “had to literally drag [the VA] into the room.” P1 received texts from the SP asking P1 to come in early because the SP needed to “cool down” and the SP “almost wanted to put my hands on [the VA].” When P1 arrived at the facility, s/he said the house was in “disarray.” The SP was “distraught” and “frustrated.” P1 found the VA standing in his/her bedroom with the lights off. When P1 assisted the VA with getting his/her pajamas on, P1 saw marks on the VA’s arms in the armpit area that later started to bruise. The VA said his/her neck hurt but P1 did not see any marks on the VA’s neck at that time. The VA told P1 that the SP put the VA in a “hold” and hurt the VA. The following day P2 worked, and the VA kept complaining that his/her neck hurt, and that the SP put the VA in a hold. P2 saw a bruise near the VA’s left armpit that looked like someone had grabbed the VA. P2 saw some light bruising in the VA’s hairline and photos taken showed a scratch on the VA’s neck. The SP said that on the night of the incident, the VA did not want to go to bed and started yelling. Later when the VA had calmed down the SP walked the VA with interlocking arms to the VA’s bedroom, so s/he did not fall. When they got to the bedroom, the VA started hitting his/her arms, hands, and head on the door frame. The VA threw himself on the ground and declined to get up, so the SP left the VA in his/her bedroom and turned the lights off. The SP said that s/he never had any physical contact with the VA besides interlocking arms with the VA when s/he walked the VA to the VA’s bedroom. The SP did not know how the VA could have sustained the bruising and scratches. Although the SP denied the allegations, the VA repeatedly named the SP as the person who “hurt” the VA, given this and that scratches to the VA’s neck and bruising in his/her armpit area did not match the SP’s account of what occurred, that the SP had reason to minimize his/her actions, and that the SP sent text messages that indicated s/he was upset, frustrated, and “had to literally drag [the VA] into the room,” there was a preponderance of the evidence that the SP’s actions likely caused injuries to the VA’s arms and neck that were not accidental or therapeutic. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was responsible for the VA’s care and supervision. The SP received training on the VA’s Coordinated Service and Support Plan Addendum and on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated physical abuse for which the SP was responsible was not recurring but was serious as it was single incident that resulted in an injury that met the definition of “serious” maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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