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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: 1112474-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071801-HCBS (Home and Community-Based Services) 1112473-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071801-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: Allegation One: It was reported that two staff persons (SP1 and SP2) called five vulnerable adults (VA1-VA5) names including “idiots” when they did not cooperate during personal cares, made fun of VA5 for talking to his/her deceased parents, and made negative comments about VA5 having a sexually transmitted disease. Allegation Two: It was reported that SP1 and SP2 locked VA1-VA5 in their bedrooms, and placed items in front of VA5’s door so s/he could not have access to the Meadows facility. Allegation Three: It was reported that SP1 and SP2 did not provide personal cares to VA1-VA5 in a timely manner, and VA1-VA5 were found soaked in urine and feces. Additionally, it was reported VA1-VA5 were not provided meals. Allegation Four: It was reported that SP2 held VA1’s and VA2’s hands and arms down with “aggression” while completing personal cares, and VA2 had bruise the size of a soccer ball on his/her stomach. Allegation Five: It was reported that SP1 and SP2 did not complete VA3’s programmed exercises. Allegation Six: It was reported that VA4 did not have a seizure protocol, and did not have seizure medication at the facility. Allegation Seven: It was reported that VA4’s feet were “run into doors” which resulted in VA4 requiring bandages. Date of Incident(s): Unknown dates for all alleged incidents. Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b); and Minnesota Statutes, section 626.5572, subdivision 15; subdivision 2, paragraph (b), clauses (1-3); and subdivision 17, paragraph (b): 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. · 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. · Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544.
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 August 22, 2023; from documentation at the facility; and through six interviews conducted with VA5, a facility staff person (P1), a facility supervisor (P2), a community person (CP) who was a former staff person, and SP1 and SP2. VA1 and VA2 were unable to be complete an interview due their communication, VA3 did not engage in an attempted interview, and VA4 moved from the facility and was not interviewed during the investigation. Meadows and Hope Studio were adjoined residential facilities. VA1-VA4 lived at Meadows, which was a single level home with four bedrooms, and a staff office. VA5 lived at Hope Studio, a one-bedroom unit. An adjoining door connected the Hope Studie kitchen to a hallway which led to the Meadows kitchen. Report #202305197 pertained to allegations involving VA1 – VA4 at Meadows, and report #202305825 pertained to allegations involving VA5 at Hope Studio. SP1 and SP2 had supervisory roles at both facilities. Information from the CP, P1, SP1 and SP2 was consistent that there was significant interpersonal conflict between the CP, SP1, SP2, and other staff persons. Facility documentation showed VA1 required staff assistance for all tasks including transfers. VA1 liked sports, swimming and other water activities. VA1’s diagnoses included developmental disabilities, spastic quadriplegia, cerebral palsy, insomnia, osteoporosis, and agitation. VA1 was unable to defend him/herself from emotional abuse as s/he might not recognize that s/he was being abused. Facility documentation showed VA2 liked to go on car rides, watch the television show Impractical Jokers, and dreamed to be surrounded by his/her family. VA2’s speech was not understood by others. VA2 was diagnosed with an anoxic brain injury due to a heart attack, and a neurogenic bladder. VA2 had difficulty standing and walking, including maintaining upright posture when attempting to stand and walk. VA2 was unsteady during transfers and staff persons used a gait belt for transfers due to risk of falling. VA2 swung his/her arms when s/he was anxious, and staff persons should attempt to announce the steps of the task to VA2 to reduce his/her anxiety. VA2 was unable to defend him/herself from physical and emotional abuse due to his/her physical limitations and limited communication. Facility documentation showed VA3 was a “happy” person who enjoyed fishing, bowling, and going to church. VA3’s diagnoses included developmental disabilities, intermittent explosive disorder, nocturia, diabetes, and high blood pressure. VA3 was not consistently able to defend him/herself from all forms of abuse. Facility documentation showed VA4 was “happy” and liked animals. VA4 was able to communicate his/her preferences, and enjoyed singing. VA4’s diagnoses included multiple sclerosis, epilepsy, neurogenic bladder, and memory loss. Due to VA4’s memory loss, s/he might not remember new events or be able recall memories of the past. VA4’s mobility was limited due to multiple sclerosis, and s/he required staff assistance for personal cares. Facility documentation showed VA5 enjoyed watching television, going shopping, going out to eat, and spending time with VA1-VA4. VA5 used a wheelchair and needed physical assistance to leave abusive situations. VA5 might not recognize dangerous situations, including emotional abuse. VA5 was able to communicate his/her preferences and advocated for him/herself. VA5’s diagnoses included developmental disabilities, depression, anxiety, and urinary urgency. VA5 had difficulty with impulse control, spoke loudly, interrupted conversations, and invaded others’ personal space. P1, P2, SP1 and SP2 completed training on Reporting of Maltreatment of Vulnerable Adults Act, and P2 and SP1 completed training on VA1-VA5’s client specific programming for VA1-VA5. However, P1 and SP2 had not fully completed the required trainings related to VA1-VA5’s client specific programming. Allegation One: It was reported that SP1 and SP2 called VA1-VA5 names including “idiots” when they did not cooperate during personal cares, made fun of VA5 for talking to his/her deceased parents, and made negative comments about VA5 having a sexually transmitted disease. The CP said SP2 called VA1-VA5 names “every day,” however s/he was only able to provide one example. The CP said SP2 called VA2 a “piece of shit,” after VA2 hit SP2 in the face while SP2 was completing personal cares. The CP said no other staff persons were present when SP2 called VA1-VA5 names. The CP said s/he witnessed SP1 “cussing” at VA2 and SP1 told VA2 that “no one loves [him/her].” The CP also said SP1 made fun of VA5 coughing, but did not provide specific details to what was said. The CP said s/he could tell VA5 was “depressed" by SP1 and SP2’s treatment of VA5. The CP said SP1 and SP2 made fun of VA5 for thinking s/he could talk with his/her deceased parents. The CP said SP2 made fun of VA5 because of a sexually transmitted disease, saying SP2 did not want to touch VA5 and, “I don't want to get that!" The CP said there were other “awful” things that were said in an employee group text message, and provided the text messages to the DHS investigator. However, the text messages provided did not include any information related to VA1-VA5 being called names. P2 did not witness SP1 and SP2 calling VA1-VA5 any names. P1 said on an unknown date s/he heard SP2 say, “Shut up,” to VA5, and on a different unknown date, SP1 made a comment that VA5 had “peed [his/her] pants,” so s/he could not go to a store. P1 said SP1 did not take the correct approach with VA5, and described SP2’s interactions with VA1-VA5 as “short.” During his/her interview, VA5 provided very short answers, mostly saying, “Yes,” or, “No,” without further elaboration. VA5 said s/he liked living at the facility, but that “all” of the staff persons called him/her an idiot. VA5 was unable to provide any additional information, and was unable to say how it affected him/her. VA5 said s/he specifically liked SP2 and P2, and did not name any specific persons that s/he disliked at the facility. SP1 and SP2 denied calling VA1-VA5 any names or using any derogatory statements, and denied awareness of anyone else calling VA1-VA5 names. SP2 said s/he and VA5 had dialog when they told each other to, “Shut up,” but they were “joking around” and VA5 was not emotionally affected by the interaction. SP2 denied that s/he did not allow VA5 to complete a community activity because of VA5’s behavior. SP2 said there were times VA5 was unable to complete community outings because the facility did not have enough staff. There was no information that any other staff persons witnessed the name calling described by the CP. No one interviewed witnessed VA5 being made fun of about talking to his/her deceased parents, nor anyone making comments about VA5 having a sexually transmitted disease. Conclusion for Allegation One: The CP, P1, SP1, and SP2 provided conflicting information related to VA1-VA5 being called names, and the use of derogatory statements. The CP said there were “awful” statements in a group text message, however the text messages provided did not include any information related to VA1-VA5 being called names. Although VA5 said all staff persons called him/her an “idiot,” s/he did not provide specific details related to the name calling, and stated s/he liked SP2 and living at the facility. Furthermore, there was no information obtained that any alleged conduct by SP1 and/or SP2 caused VA1-VA5 emotional distress. Therefore, there was not a preponderance of the evidence as to whether VA1-VA5 were subject to conduct which produced or could reasonably be 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). Allegation Two: It was reported that SP1 and SP2 locked VA1-VA5 in their bedrooms and placed items in front of VA5’s door so s/he could not access the Meadows facility. The CP said that on an unknown date SP1 and SP2 put tote bins in front of the adjoining door between Meadows and Hope Studio, and “locked” VA5 in his/her unit because VA5 “likes to talk.” The CP said the totes were in front of the adjoining door from 8 a.m., to 6:30 p.m., and the CP moved the totes, but SP1 and SP2 moved the totes back in front of the door. The CP was not aware of any other incidents where the adjoining door was blocked. VA5 did not share any information related to being locked in his/her unit or bedroom, and was not aware of any items being put in front of the adjoining door. P1 and P2 did not provide any information related to VA1-VA5 being locked inside their bedrooms. SP1 said there was an incident where a previous staff person placed water jugs in front of the adjoining door after VA5 had physically aggressed, but there was no information VA1-VA4 were locked in their bedrooms at any time. SP2 said VA1-VA5 were not locked in their rooms, and VA5 liked being on the Meadows side of the building. SP2 said a previous staff person, prior to this investigation, placed items in front of VA5’s door after VA5 physically aggressed, but the items were removed afterward. Conclusion for Allegation Two: No information was provided to the DHS investigator that VA1-VA5 were locked in their bedrooms. There was conflicting information from the CP, P1, SP1, and SP2 regarding items being placed in front of the door that adjoined Meadows and Hope Studio and/or VA5’s bedroom door, and VA5 was not aware of anything being placed in front of the adjoining door. However, given that VA5 lived in a separate living unit than VA1 – VA4, preventing VA5 from entering Meadows through the adjoining door may have been appropriate if doing so aligned with VA1-VA4’s wishes. Further, no information was provided to the DHS investigator that VA5 experienced physical pain, injury or emotional distress due to being prevented from accessing Meadows through the adjoining door. Therefore, there was not a preponderance of the evidence as to whether VA5 was unreasonably confined. It was not determined whether 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: use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825). Allegation Three: It was reported that SP1 and SP2 did not provide personal cares such as showering and changing clothing in a timely manner as VA1-VA5 were found soaked in urine and feces; and VA1-VA5 were not provided meals. The CP said s/he observed VA1-VA5 soaked in urine and feces due to their incontinence, and personal cares and showers were not completed resulting in rashes for VA1-VA5. The CP tried to “speak up,” but was treated like “the bad guy.” The CP said none of the other staff persons cared, and that when s/he worked at the facility, the CP was the only staff person that would complete cares for VA1-VA5. The CP was unable to provide any specific dates regarding his/her observed concerns. P1 said VA5 was not treated with dignity and respect by SP1 and SP2 as they did not ensure care and services were completed by other staff persons. P1 describe an incident in which s/he arrived at the facility and VA5 was in dried feces, and VA1-VA4 were soaked with urine. P1 said SP2 was not working during the alleged incident, but P1 told SP2 s/he thought the overnight staff were sleeping and VA1-VA5’s personal cares were not completed. P1 believed as a supervisor SP2 should have addressed the concerns with the staff persons involved, but SP2 did not sufficiently address the concerns. P1 said VA1-VA5 did not have any rashes or health issues as a result of a lack of personal cares. VA5 did not provide specific information about whether or not personal cares were competed in a timely manner. VA5 said s/he was not worried or scared about living at the facility. SP2 said other staff persons did not complete VA2’s exercises or showers, and SP2 completed VA2’s showers when s/he was at the facility. SP2 said VA1-VA5 each experienced incontinence, however only VA2 had any skin breakdown. SP2 said VA2’s skin breakdown did not require any medical treatment. SP2 said there was an incident where a previous overnight employee did not complete personal cares, but SP2 was not present during the shift. SP2 said VA5 had a history of incontinence, and VA5 had refused cares from staff persons in the past. SP1 did not express any concerns with VA1-VA5’s personal cares not being completed in a timely manner. SP1 said VA3 had a “little” skin breakdown, but it did not require medical treatment. There was no information provided that VA1-VA5 did not receive meals, however there were times staff persons did not follow the facility’s menu or a menu was not created. Conclusion for Allegation Three: There was consistent information that there was at least one incident where VA1-VA5 were found soaked in urine or feces, and SP1 and SP2 each provided information that VA2 and/or VA3 experienced minor skin breakdown from incontinence. However, there was conflicting information from the CP, P1, P2, SP1 and SP2 regarding whether VA1-VA5’s personal cares were completed in a timely manner. Moreover, SP1 and SP2 were not the staff persons directly responsible for the care and well-being of VA1-VA5 during the alleged incident. There was no information obtained during the investigation which showed VA1-VA5 were not provided meals. Without additional witnesses or information to suggest otherwise, there was not a preponderance of the evidence whether there was a failure to supply VA1-VA5 with care or services, which were reasonable and necessary to maintain VA1’s-VA5’s health or safety. It was not determined whether 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). Allegation Four: It was reported that SP2 held VA1’s and VA2’s hands and arms down with “aggression” while completing personal cares, and VA2 had bruise the size of a soccer ball on his/her stomach. The CP said s/he witnessed an incident where VA2 “flapped” his/her arms and SP2 held down VA2’s arms for approximately two minutes. VA2 was not injured during the incident. The CP said no one else observed the incident. The CP said s/he observed a bruise on VA2’s chest, which SP1 and SP2 told the CP was from “a strap or something,” however the CP did not believe that was true. The CP did not provide any further explanation to the type of strap that allegedly caused the bruise, nor any additional information about the bruise. P1 did not provide any information that SP2 had aggressive or restrictive physical contact with VA2. SP2 said s/he held VA2’s hands down while assisting VA2 with his/her g-tube to prevent him/her from moving it and causing the g-tube to “pop” out. SP2 denied harming VA2 while assisting him/her. An Incident Report from June 15, 2023, showed VA2 had an accident with his/her g-tube which included the balloon and tube coming out of VA2’s stomach. VA2 was treated at an emergency room and discharged back to the facility. There was no information that any form of maltreatment occurred during the June 15, 2023, incident. Documentation of this incident did not state whether or not VA2 sustained a bruise. There was no information obtained during the investigation that VA2 had a bruise the size of a soccer ball on his/her stomach. There was no information obtained during the investigation that VA1 had his/her hands held down by any staff person. Conclusion for Allegation Four: The CP said s/he observed SP2 hold VA2’s arms down for two minutes. However, SP2 denied harming VA2 and said s/he held VA2’s arm to prevent VA2 from harming him/herself during cares. There was an incident which provided a plausible explanation of a bruise on VA2’s stomach, however there was no information which showed that incident caused a bruise on VA2’s stomach. Furthermore, there was no other documentation which showed VA2 had a bruise the size of a soccer ball on his/her stomach. There were no other witnesses to SP2’s alleged behavior, and no other information that corroborated the CP’s statements. Given that SP2 said s/he held VA2’s arms for therapeutic reasons, and that there was no supporting evidence of VA2’s stomach having a bruise, there was not a preponderance of the evidence whether SP2 engaged in conduct which produced or could reasonably be expected to produce physical pain or injury. 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). Allegation Five: It was reported that SP1 and SP2 did not complete VA3’s programmed exercises. The CP said SP1 and SP2 did not assist VA3 with completing programmed exercises, but did not provide any additional information related to the allegation. Facility documentation showed that VA3’s programmed exercises were part of VA3’s Action Plan, and there was no information the exercises were ordered by a doctor. Neither P1, P2, SP1, and/or SP2 had concerns regarding VA3 not receiving programmed exercises. There was no information VA3 was negatively affected by not completing the exercises. Conclusion for Allegation Five: The CP, SP1 and SP2 provided conflicting information about whether or not SP1 and SP2 completed VA3’s programmed exercises. However, no information was provided to the DHS investigator that VA3 experienced any ill effect due to not completing exercises. There was not a preponderance of the evidence whether there was a failure to supply VA3 with care or services, which were reasonable and necessary to maintain VA3’s health or safety. It was not determined whether 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). Allegation Six: It was reported that VA4 did not have a seizure protocol, and did not have seizure medication at the facility: P1 said VA4 did not have a seizure protocol, and did not have a seizure medication at the facility from April 18, through May 9, 2023. P1 added that VA4 did not have a seizure while at the facility, and moved out of the facility before a seizure protocol was completed. VA4’s client specific documentation dated July 7, 2022, showed if VA4 had a seizure staff persons should place VA4 on his/her side, and nothing should be put in VA4’s mouth if it is a generalized tonic-clonic seizure. Staff persons should call 9-1-1 if the seizure lasted greater than five minutes, repetitive seizures without regaining awareness, or if VA4 was cardiorespiratory compromised. VA4 should not eat until s/he returned to baseline level of functioning. Additionally, VA4 should be seen at an emergency room if there were any new changes to VA4’s behavior. Staff persons would monitor VA4 and encourage him/her to report if s/he was not feeling well. SP2 said VA4 had an as needed (PRN) seizure medication, however, did not have any seizures while at the facility. SP1 said s/he worked with the facility nurse to get a seizure protocol for VA4, and did not recall anyone raising concerns with VA4’s PRN medications. P2 said VA4 had a seizure protocol, but had not had a seizure in a “few years.” The CP did not share any concerns related to VA4’s seizure protocol or PRN seizure medication. Conclusion for Allegation Six: There was client specific documentation for VA4 which outlined how staff persons should respond to potential seizures. There was no information, beyond P1’s statements, that showed VA4 did not have a seizure protocol, or that VA4’s seizure medications were not at the facility. Furthermore, VA4 did not have a seizure while at the facility, and there was no ill effect or harm to VA4. There was a preponderance of the evidence that there was not a failure to supply VA4 with care or services which were reasonable and necessary to maintain VA4’s health or safety. It was determined that neglect did not occur (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). Allegation Seven: It was reported that VA4’s feet were “run into doors” which resulted in VA4 requiring bandages. The CP said there were “plenty” of staff and managers that had “run” VA4’s feet into a door. The CP said “hospice” had to come to the facility and put cream on VA4’s feet, and also bandaged VA4’s feet. The CP said s/he never “ran” VA4’s feet into anything, but other staff persons did because they were not paying attention. SP2 said VA4 used an electric wheelchair and ran into doors and walls with it, but SP2 was not aware of anyone VA4’s feet being injured when a staff person was pushing VA4’s wheelchair. P1, P2, and SP1 did not share any concerns related to VA4’s feet. VA4’s daily documentation dated April 15 through May 8, 2023, included no information about injuries to VA4’s feet. At the time of the investigation the CP, P1, SP1 and SP2 were no longer employed at the facility. Conclusion for Allegation Seven: The CP said multiple staff persons ran VA4’s feet into doors and that VA4’s feet needed cream and bandages as a result. SP2 said VA4 ran into doors and walls while s/he used his/her electric wheelchair independently, but s/he was not aware of VA4’s feet being injured when a staff person was pushing VA4’s wheelchair; and VA4’s daily documentation dated April 15 through May 8, 2023, included no information about injuries to VA4’s feet. Furthermore, P1, P2, and SP1 did not share any concerns related to VA4’s feet. There was not a preponderance of the evidence whether there was a failure to supply VA4 with care or services which were reasonable and necessary to maintain VA4’s health or safety. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate and followed. The facility updated client specific programming, completed training with staff persons, and developed a plan to ensure all client specific trainings were completed in the future. The facility did not identify a need for additional corrective action. Action Taken by Department of Human Services, Office of Inspector General: A review of personnel records showed P1 and SP2 had not fully completed required training related to VA1-VA5’s client specific programming. However, given that the facility took corrective action to address this concern, a Correction Order was not issued. No further action was taken.
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