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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: 1070003-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069963-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) called a vulnerable adult (VA) an “evil ‘B word’” and a “bitch” during a verbal altercation. Date of Incident(s): April 3, 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 (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: 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 May 6, 2024; from documentation at the facility; and through five interviews conducted with the VA, a facility supervisor (P), the VA’s guardian (G), the VA’s case manager (CM), and the SP. Facility documentation showed the VA’s sense of humor could “come off harsh at times,” as s/he made “jokes at others’ expense.” The VA enjoyed spending time with friends and listening to music. The VA volunteered at a preschool in his/her free time. The VA had a history of verbal aggression and refusal to follow instructions if s/he was dysregulated. Staff persons supported the VA by providing him/her with space and assistance in processing his/her emotion after s/he returned to baseline behavior. The VA was diagnosed with developmental disabilities, depression, anxiety, and multiple congenital conditions. A video recording from April 3, 2024, included audio of an interaction between the VA and the SP. During the interaction the SP said, “You are such an evil little ‘B word,’” and, “I don't care…bitch.” The facility completed an Internal Review which provided the following information: · The SP “would not participate fully” in the investigation and was suspended pending the investigation. · There were no concerns with the SP’s behavior or interactions with the VA prior to the April 3, 2024, incident. · Prior to the incident on April 3, 2024, there were concerns regarding other staff persons’ interactions with the VA, including staff persons telling the VA they would press charges against the VA, refusing to assist the VA with tasks, and other verbal interactions. The facility addressed these concerns by providing additional guidance to staff persons regarding conversations with the VA and how to handle the VA’s challenging behaviors with positive responses. The VA provided the following information: · The VA said that during the morning of April 3, 2024, the SP called the VA “an evil little ‘B word.’” The VA said s/he recorded the interaction with his/her cell phone because staff persons were “rude” and “yelling at me,” but that was the first time the SP called the VA a name. · The VA wanted to “cry” after the verbal interaction with the SP. The VA felt like staff persons would blame the VA for the staff persons’ “actions.” The P said s/he was on leave when the VA contacted him/her about the incident by text message, and was not aware of the recording or interaction between the SP and the VA. The P described the SP and the VA having good rapport until the SP requested the VA clean up after him/herself, and thereafter the VA treated the SP like the VA treated the rest of the staff persons at the facility, which was described as the VA having an “attitude.” P2 did not have any concerns about the SP working at the facility. The G and the CM said there were previous concerns related to staff persons being rude while speaking with the VA, however this was the first incident which was recorded. The SP provided the following information: · The SP acknowledged making the comments in the video which included calling the VA a "B word" and a "bitch." The SP said that before the video recording started, the VA had directed profanity at the SP. · The SP denied calling the VA any names prior to or after the recording. · The SP was not aware of any other staff persons calling the VA any names. The P and the SP were each trained on Reporting of Maltreatment of Vulnerable Adults Act and the VA’s client specific programming. The SP’s job description stated the SP’s responsibilities included, “Observe, listen, and respond to the people we support with dignity and respect.” Relevant Rules and/or Statutes:
Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: A video recording showed that on April 3, 2024, the SP called the VA an “evil little ‘B word’” and a “bitch” on one occasion, and the VA said s/he wanted to cry after the SP called him/her a name. The SP’s actions were inconsistent with the role of a professional caregiver in a facility licensed by the Department of Human Services, and were in violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that the VA and the SP each said there were no other incidents of similar conduct by the SP, there was not a preponderance of the evidence as to whether the SP engaged in repeated or malicious conduct that could be reasonably expected to produce emotional distress. 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 an internal review and determined the facility’s policies and procedures were adequate, but not followed. The alleged incident was similar to past events as there had been similar previous allegations involving the VA and various staff persons. The facility provided all staff persons additional training on Person Centered Services and Positive Supports. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action to address the violations outlined in this report, a Correction Order was not issued. No further action was taken.
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