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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: 1070650-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) was verbally aggressive toward a vulnerable adult (VA) while the SP assisted the VA with showering and that the SP slammed the door shut and held the door shut so the VA was not able to leave the bathroom. Date of Incident(s): Prior to June 15, 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 June 28, 2024, from documentation at the facility and through 16 interviews conducted with the VA, two facility clients (C1 and C2), a management staff person (P1), 11 facility staff persons (P2-P12), and the SP. The VA, C1, and C2 lived at the facility, which was a rambler style home. The VA’s support plan showed that the VA enjoyed waking up early in the morning, watching the news, and listening to music and television. The VA’s Self-Management Assessment showed that the VA had a mild developmental disability. The VA was “often incontinent during the night and will refuse to shower or change [his/her] soiled clothes or linens.” The VA needed some assistance with activities of daily living, such as bathing/showering and dressing. In November 2023, the Minnesota Department of Human Services (DHS) received a report with allegations similar to the allegations of this report and investigated those allegations in report 202308712 which was issued in January 2024. This report will include allegations regarding the SP’s actions after November 2023. P2 provided the following information to this investigator: · Although P2 was not certain of the date, P2 thought that on June 14, 2024, the SP began to assist the VA with showering and because the VA was not moving as fast as the SP would have preferred, the SP was verbally loud with the VA. When the VA was done with his/her shower, the VA asked the SP to place a towel on the floor, but the SP “refused” to do so. · P2 described the SP’s tone of voice as being “hard,” “yelling,” and “disgusted” with the VA. After the VA showered and was dressing, the SP left the bathroom and “slammed” the door, with the VA inside so the VA could get dressed. The SP then held the bathroom door shut for about ten seconds, while the VA tried to open the door from the inside and while P2 stood by the door. The SP told the VA that s/he could not come out of the bathroom. After the SP held the door shut, the SP opened the door and the VA got dressed. · When P2 was asked to describe the SP’s tone of voice used, with a one being talking quietly and ten talking very loudly, P2 described it as an eight. During the incident, the VA became “agitated” with the SP and raised his/her “fist” toward the SP. This was somewhat typical of the VA when the VA was upset. · The VA had the ability to independently dress/undress, and bathe/shower but often preferred staff persons to do those tasks for him/her. · P2 did not have concerns related to how the SP interacted with C1 and C2. However, P2 recalled one previous incident in which the VA needed to have his/her adult absorbent undergarment changed and when the SP assisted the VA with that, the SP said, “You stink,” and “Now I have to clean this up.” · On July 26, 2024, P2 was assisting the VA with showering and changing clothes before breakfast. Because the VA was “whining” about having to do this, P2 “reassured” the VA that once the VA was dressed, the VA could have breakfast. While this was happening, the SP “mocked” the VA and began repeating statements that the VA had made. When the SP did that, the VA continued “whining” and P2 could tell that the VA had increased anxiety. After the VA dressed, with assistance from P2, and went to eat breakfast, P2 was nearby and heard the SP raise his/her voice and tell the VA to “shut up.” When the SP said that to the VA, the VA became “quiet.” When P2 heard the SP say that to the VA, P2 told the SP that type of language was not necessary. The SP said, “I have every right to tell [him/her] that, if [s/he] can say it to me, I can say it to [him/her].” The VA stated that staff persons assisted the VA with undressing, showering, and dressing and that the VA did not have concerns related to the staff persons. C1 provided very limited information but stated that the SP treated him/her “fine.” C2 did not have concerns related to the SP’s work attitude or how the SP interacted with C2, C1, and the VA, but stated that there was one time that the SP “yelled” at a medical professional at a clinic because the SP wanted certain paperwork to be completed faster than they were able to. As a result of that incident, C2 felt “anxious.” P1 stated that since the previous DHS investigation related to the SP, P1 generally received “good feedback” from other staff persons on the SP’s work attitude with the VA, C1, and C2. When P3 was interviewed, P3 did not have concerns related to the SP’s work attitude with the VA, C1, and C2. P4 described the SP as being “very loud” when s/he talked to the VA, C1, and C2. P4 also said that it appeared that the SP easily got “irritated” with the VA and C1 and that the SP had a “short fuse.” P4 gave an example in which C1 would repeatedly ask the same question of the SP and the SP loudly responded, eight, on a scale of one to ten. When that happened, C1 usually swore at the SP and walked away. P4 also described the SP as being a “loud person generally.” P4 was not aware of a time that the SP held the bathroom door closed when a client was inside the bathroom. P5 said that since the previous DHS investigation, the SP’s work attitude had improved, but that there were still times that the SP had a “short fuse,” specifically with C1. P5 stated that the SP went “out of” his/her way to be “super nice” to the VA, C1, and C2. P6 did not have concerns related to the SP’s work attitude with the VA, C1, and C2. P7 said that the SP had been “going through a lot of stress” because one of the SP’s family members was ill. P7 described the SP’s work attitude as changing positively over time and that the SP was now “very kind.” P8 did not remember dates but stated that the SP told C1 to “get out of here” and “get away from the office.” When the SP talked to C1 on those occasions, the SP’s tone of voice was a seven on a scale of one to ten. P8 did not think that C1 was affected by the SP’s actions because C1 just “walks away” from the SP. P9 stated that when the SP talked to the VA, C1, and C2, the SP’s tone of voice was a six or seven out of ten, but that the SP normally had a “loud” voice. P9 was not aware of time that the VA, C1, or C2 were negatively impacted by the SP’s conduct. P10 did not remember the exact date, but stated that one time in June 2024, the VA had a bowel movement in his/her adult absorbent undergarment and the SP told the VA that s/he was a “baby” and that the VA “intentionally pooped.” When the SP said that the VA “gave it right back” to the SP, “yelled” at the SP, and said that s/he did not do it “on purpose.” P10 felt that the comment was “very degrading.” When the SP said that P10 felt “very uncomfortable.” P10 described the SP’s tone of voice as being at a five or six out of ten. P10 did not have concerns related to the SP’s interactions with C1 and C2. P11 said that the SP had a “louder personality” and described the SP’s tone as being a seven out of ten. P11 had not heard the SP talk loudly to C2 at all, but heard the SP talk loudly to C1 mostly because C1 asked repetitive questions. P11 also stated that the SP’s conduct changed for the better after the previous investigation. P12 stated that the SP was “short” when s/he talked to the VA, C1, and C2, but P12 did not remember specific dates or what the SP said. P12 described the SP’s tone of voice as being a six or seven out of ten. P12 recalled an incident in June 2024 when C1 waited for a particular staff person to come to work and refused to go to bed until C1 could see that staff person. P12 thought that the VA had a “crush” on that staff person and when the SP heard that, the SP told C1, “That’s gross,” while the VA and C2 were present. P12 did not hear or see how C1 responded but knew that C1 left the area when the SP said that because C1 went to his/her bedroom and slammed the door shut. The SP provided very limited information and stated that when C1 would ask for assistance, the SP helped C1 as needed. When the SP was asked to describe his/her interactions with the VA, C1, and C2, the SP stated that his/her tone of voice was the same as when s/he spoke to others and that if a client did something that was inconsistent with what was documented in the client’s plan, the SP used a “stern” tone of voice. The SP did not provide more information about that and decided to discontinue discussions with this investigator. When a subsequent call was made to see if the SP wanted an opportunity to provide more information, the SP did not respond. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to June 28, 2024. Relevant Rules and Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), stated that a person’s protection-related rights include the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: P2 said that on June 14, 2024, the SP assisted the VA with showering and was verbally loud with the VA. P2 described the SP’s tone of voice as being “hard,” “yelling,” and “disgusted” with the VA. P2 also stated that the SP “slammed” the bathroom door, with the VA inside, and held the door shut for about ten seconds. P2 stated that the VA was agitated by this. P2 stated that on one occasion the SP told the VA, “You stink,” when the VA needed his/her adult absorbent undergarment changed. P10 stated that one time in June 2024, the VA had a bowel movement in his/her adult absorbent undergarment and the SP told the VA that s/he was a “baby,” and that the VA “intentionally pooped.” P10 stated this was “very degrading” to the VA. P2 stated that on July 26, 2024, the SP told the VA to “shut up” and “mocked” the VA when the VA was “whining” about getting dressed. The SP told P2 if the VA could say that to the SP then the SP could say that to the VA. When the VA, C1, and C2 were interviewed by this investigator, they did not express concerns related to how staff persons treated them. P1, P3, P6, and P7 did not have concerns related to the SP’s work attitude, but P4 described the SP as being “very loud;” P5 said that even though the SP’s work attitude had improved, there were still times that the SP had a “short fuse,” specifically with C1 and times that the SP went “out of” his/her way to be “super nice” to the VA, C1, and C2; P9 stated that the SP normally had a “loud” voice; P11 said that the SP had a “louder personality” and described the SP’s tone as being a seven out of ten; P11 stated that the SP talked loudly to C1 because C1 asked repetitive questions and that the SP’s work attitude had improved since a previous DHS investigation; and P12 stated that the SP was “short” when s/he talked to the VA, C1 and C2. The SP, who provided limited information for the investigation, stated that s/he was “stern” when s/he talked to the VA, C1, and C2. The SP’s actions were inconsistent with the standards of a professional caregiver in a program licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Although some staff persons did not have concerns about the SP’s conduct, given that other staff persons witnessed the SP yell at the VA on two occasions, tell the VA, “You stink,” tell the VA to “shut up,” “mock” the VA, call the VA a “baby,” and tell the VA that s/he “intentionally pooped,” and that the SP held the door shut when the VA was in the bathroom causing the VA to be agitated, there was a preponderance of the evidence that the SP used repeated oral and gestured language toward the VA that would be considered by a reasonable person to be derogatory, humiliating, and harassing and be expected to cause emotional distress. 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 trained 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 abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because the SP’s behavior was considered a single pattern of behavior, and the VA did not sustain an injury. However, information obtained by the Department of Human Services, in combination with this report, resulted in the SP being disqualified for recurring maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review Conclusion and Evaluation and determined that policies and procedures were adequate, followed and that even though there were “multiple reports where similar events have occurred” regarding the SP making “negative verbal comments towards individuals,” “no corrective actions is needed as [the SP] is usually scheduled with multiple coworkers during [his/her] scheduled shifts.” 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. On October 2, 2024, the facility was issued a Correction Order for the violation outlined in this report.
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