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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: 1070419-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) who required 1:1 supervision was attacked by another client (C) of the facility and the VA sustained “serious” injuries. It was alleged that staff persons (P1 and P2) failed to intervene. Date of Incident(s): April 14, 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 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.
Summary of Findings: Pertinent information was obtained during a site visit conducted on April 30, 2024; from documentation at the facility, law enforcement records, medical records; and through two interviews conducted with a facility staff person (P1), and a supervisory staff person (P3). Additional information was provided by an administrative staff person (P4) as part of the facility’s Internal Review and Investigative Summary (IRIS). Attempts were made via telephone and mail to contact and interview another staff person (P2) and the VA’s guardian, but neither responded to the requests. The VA and the C were unable to provide information for this investigation due to their diagnoses. The VA enjoyed going for outings in the community, eating vanilla ice cream, and listening to rain and thunderstorms. The VA was diagnosed with autism spectrum disorder and attention deficit hyperactivity disorder. At the time of the investigation, the VA lived at the facility for approximately 3 months. According to the VA’s Support Plan Addendum for Intensive Services (SPA), the VA “is assigned a 1:1 staff from 7 a.m. to 8 p.m. This means [the VA’s] staff is in the same room as [the VA] at all times and always has eyes on [the VA] to quickly intervene” and “if staff need to be away for any amount of time, they will communicate with another staff to cover for safety.” Additionally, according to the VA’s SPA, “[The VA] displays behaviors others may find irritating including kicking, hitting, and making loud noises yelling, belching, clapping [his/her] hands loudly or hitting surfaces,” and “[the VA] would not recognize physical abuse and would not be able to defend [him/herself].” Four clients lived at the facility, but only the VA required 1:1 staffing during awake hours. The C enjoyed being around other people and going on outings in the community. The C was diagnosed with severe to profound intellectual disability, cri du chat syndrome (a rare genetic disorder resulting in developmental and intellectual disabilities), and PICA (an eating disorder in which a person eats things not usually considered food). At the time of the investigation, the C lived at the facility for 32 years. According to the C’s SPA, the C did not have the self-preservation skills needed to remain alone at home or in the community, and “staff always remain on the premises when [the C] is home and will visually check in with him at least every 15 minutes when he is awake and every 30 minutes when he is sleeping.” The facility was a two-level home. On the main floor were two bedrooms, a bathroom, a dining room, a living room, and a kitchen. The lower level had additional bedrooms, a common living space, and a laundry room. The stairs leading from the main floor to the lower level were in the center of the home, between the kitchen and dining room, separated by a wall to the living room. Note: the living room could not be seen from the kitchen or the top of the stairway. The following information was obtained from the facility’s Internal Review and Investigative Summary (IRIS), completed by P4: · On April 14, 2024, P1 and P2 were each scheduled to work from 8 a.m. to 8 p.m. and another staff person (P5) was scheduled to work from 8 a.m. to 6 p.m. but had left prior to the incident. All three staff persons worked their shifts as scheduled. A fourth staff person (P6) was scheduled to work from 2 p.m. to 8 p.m. but did not work that day. P6 was assigned to work 1:1 with the VA. · On April 14, 2024, shortly after 6:00 p.m., P1 found the C “in an altercation” with the VA in the living room. The C was on top of the VA biting the VA’s face. Staff separated them and observed that the VA had bite marks on his/her ears, neck, nose and lips and blood on his/her eye lids, lips, and nose. Staff administered first aid to stop the bleeding and called 9-1-1. The VA was then transported to the hospital. The law enforcement records dated April 14, 2024, provided the following information: · At 6:47 p.m., law enforcement officers (LEO) arrived at the facility, one LEO spoke with P1 who said that the VA and the C were non-verbal so staff persons did not hear the assault occurring “right away.” · The LEO noted that the VA had bite marks “all up” the right side of his/her face and multiple lacerations and bruises. The VA was provided first aid and monitored the VA until EMS arrived. The VA’s hospital records dated April 14, 2024 provided the following information: · The VA presented to the emergency department for “evaluation of assault injuries.” The emergency medical staff (EMS) explained that the VA was assaulted by the C and facility staff person said the assault was unwitnessed, so it was unknown if the VA lost consciousness. The EMS staff noted facial abrasions, bleeding, bruising, and bite marks on the VA. · The VA had “multiple bite marks and blunt traumatic injuries to the face.” A CT scan of the VA’s head was negative for acute intracranial injuries. None of the VA’s wounds required sutures and s/he was prescribed antibiotics for “potential bite wound infections.” The physician also noted that the assault occurred at the facility and “there was very little involvement from the staff.” · The VA was admitted for “further “investigation and evaluation.” The VA was discharged back to the facility on April 16, 2024. P1 provided the following consistent information in an interview with this investigator and in the IRIS: · On April 14, 2024, at approximately 6 p.m., P1 and P2 were working. P5 had recently left because his/her shift ended at 6 p.m. so s/he was gone prior to the incident. P6 was scheduled to work that day but did not show up for his/her shift. · Shortly after 6 p.m. all the residents were in their rooms, so P1 went to the basement to do laundry and P2 was in the kitchen making dinner. P1 stated that s/he told P2 s/he was going downstairs, and that “[P2] knew” that s/he was the only staff person on the main floor. P1 thought that the VA and C were watching him/her and when they saw him/her go downstairs, they “started roaming.” · When P1 finished s/he went back upstairs and into the living room, where s/he saw the C “on top of” the VA. P1 immediately separated the two and saw that the VA’s face was bleeding. · P1 called 9-1-1 and then P3, who was the on-call supervisor, to let him/her know what occurred. P1 obtained first aid supplies and assisted the VA to clean the blood off his/her face. P1 stated that the VA sustained bite marks on his/her face, ears, and behind his/her ears. P1 was unaware of any other injuries to the VA. · A few minutes later, EMS and LEO arrived and provided further first aid to the VA. The EMS then made the determination that the VA needed to go to the hospital and they transported him/her for further evaluation. P1 did not go to the hospital with the VA and did not work with the VA after that day. The VA returned to the facility after being in the hospital for “two to three days.” · P1 stated that no one person was responsible for supervising the VA, because s/he and P2 were “watching everyone” because there were only two staff persons working when there were usually three. P1 added that s/he and P2 were working “as a team” to provide supervision for the four clients who lived at the facility. P1 initially stated that staff were not required to be in the room with the VA, but were required to check on him/her “every two hours during the day” and “one hour overnight.” P1 then provided conflicting information and stated that staff had to “always be with [the VA]” and had to “keep an eye on [him/her] 24 hours a day otherwise [s/he] is going to be doing things.” P3 provided the following consistent information in an interview with this investigator and in the facility’s IRIS: · On April 14, 2024, P3 did not work at the facility, but was the on-call supervisor. P3 received a call from P1 who said that s/he called 9-1-1 because the VA and C had an “incident,” and the VA was “hurt pretty bad” and was being transported to the hospital. P1 told P3 that s/he was in the basement doing laundry and P2 was in the kitchen making dinner when the incident occurred and neither saw what happened. P1 did not provide additional information. · On April 14, 2024, P1, P2, and P6 were scheduled to be working at the time the altercation occurred but P6 did not come to work that day. Prior to 2 p.m. when his/her shift was scheduled to start, P6 called P3 and stated that s/he was running late, but that she was on his/her way to the facility. Until P1 called after the altercation, P3 was not aware that P6 did not go the facility that day and did not show up for work that day. · The VA did not require treatment at the hospital but had his/her wounds cleaned. The VA was admitted and monitored until his/her discharge. P3 stated that the VA was not prescribed anything at the hospital and did not take any medication after being discharged from the hospital. · The VA required supervision 24 hours a day and during the day staff persons were required to provide 1:1 supervision and be “right there with [him/her].” P3 stated that neither P1 nor P2 provided 1:1 supervision for the VA as required by the VA’s support plan, however, there were no similar issues in the past with the staff persons’ supervision of the VA nor were there incidents of aggression or violence between the VA and C in the past. The VA’s Medication Administration Record showed that the VA did not receive any dose of antibiotics ordered after the VA’s hospital stay. Facility documentation showed that P1-P3 were trained on the VA and the C’s support plans and the Reporting of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information obtained showed that on April 14, 2024, there was an altercation between the VA and the C, and that the VA sustained “multiple bite marks and blunt traumatic injuries to the face” from the C. The VA’s Support Plan Addendum for Intensive Services stated that the VA had a 1:1 staff person from 7 a.m. to 8 p.m. “This means [the VA’s] staff is in the same room as [the VA] at all times and always has eyes on [the VA] to quickly intervene” and “if staff need to be away for any amount of time, they will communicate with another staff to cover for safety.” Information obtained showed that no other client at the facility, including the C, required 1:1 staffing. Therefore, although P6 did not show for his/her shift as the third person, two staff persons met the supervision staffing requirements for the clients/facility. Information provided by P1 and P3 to this investigator and in the facility’s Internal Review and Investigative Summary, showed that neither P1 nor P2 were in the same room as or within sight of the VA at the time of the incident so they were not able to intervene when the altercation between the VA and the C began which resulted in injury to the VA. Therefore, there was a preponderance of the evidence that there was a failure or omission to supply the VA with care or services including supervision that was reasonable and necessary to maintain the VA's physical or mental health or safety. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). 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. When the VA’s 1:1, P6 did not arrive for his/her shift, P1 and P2, who were both working at the facility and were responsible for the care and supervision of the VA and ensuring the VA had 1:1 supervision. P1 said that shortly before the altercation between the VA and the C, s/he told P2 s/he was going downstairs, however, P2 did not provide information for this report. Therefore, it was not determined to what extent P2 was aware that P1 went downstairs. P1 and P2 were trained on the VA’s support plan and on the Reporting of Vulnerable Adults Act. P1 and P2 were each responsible for the maltreatment of the AV. 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 or 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 neglect for which P1 and P2 were responsible did not meet statutory criteria to be determined as recurring of serious as it was a single incident, and the VA did not require the care of a physician resulting in treatment and did not take the antibiotic that was prescribed. Action Taken by Facility: The facility completed and internal review and found that policies and procedures were adequate but not followed, and there was a need for additional staff training. A staff meeting was held on April 23, 2024, to retrain staff on the resident’s support plans, supervision requirement, and expectations surrounding what to do if a scheduled staff person does not show up for their scheduled shift. P1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: P1 and P2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each notified by the Office of the Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal.
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