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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: 1068335-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) pointed his/her finger in a vulnerable adult’s (VA’s) face and then slapped the VA’s face. Date of Incident(s): October 18, 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 17, 2023; from documentation at the facility and law enforcement records; and through five interviews conducted with a facility administrative staff person (P1), the SP, the VA, and two residents (R1 and R2). The VA enjoyed going on community outings, playing video games, creating art, going to the movies. Shopping, and spending time with his/her friends and family members. The VA’s diagnoses included mild intellectual disabilities, pervasive developmental disorder, depression, personality disorder, and a history of seizure disorder. According to the VA’s Individual Abuse Prevention Plan (IAPP), the VA was unable to identify potentially dangerous situations and was unable to deal with verbally or physically aggressive persons. If the VA began to provoke others, the staff persons were to verbally redirect the VA and to physically remove him/her from abusive situations. The VA had a history of being aggressive toward others when s/he was upset. The VA stated that at the time of the incident, s/he was on a video call with a church group s/he frequently met with. The SP “made me mad for no damn reason” and the VA told the SP to go away because the SP was irritating him/her. The SP asked the VA if s/he “was insane or do you have a death wish.” The VA pushed a plate of chips onto the SP’s shirt and the SP hit the VA’s head with a spray can of Lysol “a couple of times.” The VA attempted to cover his/her head and received scratches on his/her arms. The SP then threw the can on the floor. The VA stated that s/he did not threaten the SP during the incident. A short time later a law enforcement officer (LEO) arrived at the facility. One of the community people (CP) on the video call saw the incident. P1, R1, and R2, and the facility’s documentation provided the following information: · P1 stated that on October 18, 2023, the SP and another staff person (P2) worked at the facility, but prior to the incident, P2 left the facility to shop for the facility’s groceries. P2 returned to the facility at approximately the same time as when the LEO arrived at the facility. · R1 stated that s/he was sleeping on the lower level of the facility when s/he heard “fighting” upstairs and went upstairs. When R1 entered the dining room, the VA was throwing things, making “racial slurs” to the SP, and calling the SP “a piece of shit.” When the VA began to spit on the SP, the SP picked up a can of Lysol, “smacked” it on the table, and asked the VA if s/he was going to hit the SP. The VA threw something at the SP and the SP threw something at the VA, but did not hit the VA with anything. R1 stated that the SP “did not make contact with the VA.” The VA was holding a fork, which R1 took, so that the VA did not hurt the SP. R1 stated that s/he typically tried to “de-escalate” situations. R1 saw a scratch on the VA’s arm, but did not know the cause of the scratch. · R2 stated that on the day of the incident, the VA and the SP “argued.” The VA “dumped” food on the SP and spit on the SP. The SP then banged a can of Lysol on the table and told the VA not to throw food. The VA grabbed the can and “got scratched.” R2 did not see the SP hit the VA, but the VA “tried to swing at” the SP. · P1 stated that s/he received a telephone call from the CP, who told P1 that during the video call, s/he saw the SP approach the VA and “swing” at the VA “a few times.” The CP told P1 that s/he “swatted” the VA and “slapped” the VA two or three times. The CP told P1 that the sound was muted during the call and the CP was only able to see what happened, but did not hear the conversation between the VA and the SP. P1 stated that the SP denied hitting the VA and was trying to “block” the VA from hitting him/her. After the incident, the SP called the LEO, who then arrived at the facility. No information was provided that there were any marks on the VA’s face. The SP provided the following information: · On the day of the incident, the VA was upset because s/he could not find his/her cell phone and accused the SP of taking the cell phone. At dinnertime, the VA sat at the dining room table with his/her laptop because s/he was participating in a video call with a church group. The SP brought the VA’s medications to the VA and the VA knocked the medications out of the SP’s hand and onto the floor. The SP asked the VA why s/he knocked the medications onto the floor and the VA “said an insulting word” about the SP. The VA flipped his/her plate of food onto the SP as the SP picked up the medications from the floor. When the SP looked up, the VA had pointed a can of Lysol, which s/he pointed at the SP. The SP covered his/her face in case the VA sprayed Lysol on the SP and then took the can from the VA. · The VA continued to be “aggressive,” picked up a fork, which s/he “slammed” into the table, and then attempted to stab the SP with the fork, so the SP called the LEO. The VA unmuted his/her computer and asked the people on the video call if they saw the SP hit the VA. The SP told them that s/he did not hit the VA. The LEO arrived at the facility and talked to everyone involved. The LEO later told the SP that R1 and R2 told the LEO that the SP did not hit the VA. · The SP stated that when the VA became upset, s/he frequently threw items, broke things in the facility, and took food from the refrigerator. The SP stated that s/he believed the VA might have scratched him/herself when s/he slammed the fork onto the table. The SP stated that s/he did not hit the VA or cause the scratches on the VA’s arm and hand. The VA was frequently aggressive toward the staff persons. According to the LEO’s Summary, on October 18, 2023, at approximately 8:25 p.m., the LEO responded to a call at the facility regarding the VA attempting to stab the SP with a fork. The VA told the LEO that s/he did not want to take his/her medications and threw them away along with his/her food and that the SP then asked the VA if s/he “wanted to die.” The SP hit the VA on the head with a cap and scratched the VA’s elbow while the VA attempted to protect his/her head from being hit. The LEO saw scratches on the VA’s right elbow and on the knuckles of his/her right hand. The CP told the LEO that s/he saw the SP slap the VA’s face. The SP told the LEO that the VA “charged” at the SP with a fork, but that R1 and R2 “separated” the VA and the SP. R1 and R2 told the LEO that they saw the VA “come at” the SP with an object, so they separated the two. Facility documentation showed that the SP and P1 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: On the evening of October 18, 2023, the VA became upset and threw his/her medications on the floor and dumped his/her food on the SP. The VA stated that the SP then hit the VA’s head with a spray can of Lysol “a couple of times.” When the VA attempted to cover his/her head, s/he received scratches on his/her arm. The CP told P1 that s/he saw the incident occur while on a video call with the VA and saw the SP “swat” and “slap” the VA two or three times. R1 stated that the SP “smacked” the can of Lysol on the table and threw something at the VA, but did not hit the VA or make contact with the VA. R2 stated that the VA took the can of Lysol from the SP and “got scratched,” but that the SP did not hit the VA even though the VA attempted to hit the SP. The SP stated that s/he did not hit the VA at any time and only blocked the VA from hitting him/her. Although the VA had scratches on his/her arm and hand after the incident, given the conflicting information provided by the VA, the SP, the CP, R1, and R2 about the incident; that the CP viewed the incident during a video call while R1 and R2 were present at the time of the incident; and that it was unclear whether the scratches were caused by the SP or by the VA’s actions, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or whether the VA sustained the bruise by any means other than accidental. 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 the facility’s policies were adequate, but were not followed by the SP. After the incident, the SP received retraining on the facility’s policies and no longer worked with the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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