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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: 1081633-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP), called a vulnerable adult (VA) a “fucking retard” (referred to as r-word throughout the remainder of the report) after telling the VA s/he could not smoke “this early in the morning.” Date of Incident(s): September 2, 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 September 19, 2024; from documentation at the facility; and through six interviews conducted with two facility supervisory staff persons (P1 and P2), one facility staff person (P3), the VA’s guardian (G), the VA, and the SP. Another facility staff person (P4), declined to provide information for this report. The facility was a one-story home with a finished basement. On the main level there was an open kitchen, dining, and living room. The VA’s bedroom was down a hallway from the kitchen/dining/living area. The VA’s ISSA Assessment Detail stated, the VA liked birds and walking in the community. A few of the VA’s favorite foods included: cereal, macaroni and cheese with hot dogs, oatmeal, and baked potatoes. The VA’s Person Summary stated the VA was diagnosed with mild intellectual disabilities. Due to the VA’s diagnoses, the VA was “very difficult to understand” if someone did not know him/her “well.” The VA’s Risk Assessment Detail stated the VA was at risk for verbal/emotional abuse and may not defend him/herself against it. The VA may not know that a situation was considered abusive. The facility’s Internal Review, P1-P3, and the VA provided the following information: · On September 2, 2024, at 10:22 p.m. P4 sent P1 a text message that stated: . . . When [the VA] woke up this morning, I took [him/her] to the living room. [The SP] was sitting on the couch. [The VA] asked if [s/he] could smoke, and I suggested [s/he] have breakfast first and then a smoke as a reward. After finishing [his/her] breakfast, [s/he] headed to the backyard. [The SP], still on the couch, shouted, ‘You can’t have a smoke this early in the morning. You should go back to bed. [The VA] stopped moving [his/her] wheelchair for a while and then said, ‘Fuck it, fuck it, fuck it,’ as [the VA] made [his/her] way back to [his/her] room. [The SP] then asked, ‘Who’re you talking to?’ Just as [the VA] was about to enter the corridor, [the SP] called [the VA] a ‘fucking r-word.’ . . . this was incredibly cruel to say to a disabled person. · P4 provided information in the Internal Review that was consistent with the information P4 text to P1. P4 also stated that the VA did not “respond or react” to the SP’s comment; however, when the VA got to his/her room s/he told P4, “I am scared of [the SP].” P4 said that neither s/he nor the VA discussed what the SP said further because the SP was in the living room. P4 “had not seen this before,” but did not work with the SP frequently. Additionally, P4 said the VA had “no restrictions” for his/her smoking. · The VA provided consistent information in the Internal Review and to this investigator. (Note: Due to the VA’s diagnoses, s/he was difficult to understand during his/her interview.) The VA denied that the SP or any other staff persons called him/her names or yelled at him/her and staff persons were “nice” and “kind” to him/her. There were some “good” days and some “bad” days, but the VA did not provide additional details. The VA liked all the staff persons. · P1 stated that s/he thought that if the VA heard what the SP said, the VA would have said so. On September 5, 2024, the VA told P2 that the SP (described by gender and race) “was mean” to him/her but did not provide additional information and said s/he “didn’t know” when P2 asked for more information as to why. · The VA provided conflicting information regarding his/her freedom to smoke. In the Internal Review, the VA stated that the SP restricted his/her smoking, but when this investigator asked if the staff persons let him/her smoke whenever s/he wanted to, the VA said, “Yes.” · About one month prior to the incident, P2 heard the SP tell the VA s/he could not smoke after s/he just had a cigarette and talked to the SP about it that day. Since then, P2 had not heard the SP tell the VA s/he could not smoke. P3 said that the VA really liked to smoke and that at some point, P2 told him/her that the VA was allowed to smoke if s/he wanted to and that it was his/her choice. · P1 said that prior to the incident, P1 was not aware of any concerns about the SP’s interactions with clients. P1 had no concerns regarding P4 and was unsure if there was any interpersonal conflict between P4 and the SP. P2 heard about the incident from P1 and said that there was some interpersonal conflict between the SP and P4 either the day before or the day of the incident when the SP “didn’t really speak to [P4] in a friendly manner” regarding the VA’s shower schedule. However, P2 had no reason not to believe P4’s information. · P3 stated, “Everyone is nice to everyone” and s/he did not have any information regarding the incident. The SP provided information that was consistent with the information s/he provided in the Internal Review. The SP denied telling the VA s/he could not go outside to smoke after eating breakfast, and denied swearing at the VA, and/or calling the VA a “fucking [r-word].” The SP said s/he was trained to encourage the VA to take breaks between smoking because the VA “coughed a lot.” The SP said that the VA sometimes called him/herself a “fucking [r-word]” and s/he redirected the VA. The SP did not remember the VA saying that on the date of the incident. The SP told this investigator that on September 2, 2024, s/he and P4 had conflict over who would shower the VA, when the SP was already clocked out of his/her shift for the day. The G said s/he was aware of the incident, but not all of the details. The G did “not really” have any concerns with the facility but said that sometimes the VA got “upset” with some of the staff “every now and then” when they were on their phones. The G said due to the VA’s diagnoses, it might be hard for the VA to remember information but thought the VA would understand if disrespectful language was used. All staff persons, including the SP, were trained on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rule and/or Statute: Minnesota Statutes 245D.04, subdivision 3, paragraph (a), clause (6) and (8), state that the servant recipient has the right to be treated with courtesy and respect and be free from bias and harassment regarding race, gender, age, disability, spirituality, and sexual orientation. Conclusion: Although P4 did not provide information for this report, P4 provided consistent information to P1 and in the Internal Review, that on the morning on September 2, 2024, the SP told the VA s/he should not smoke and to go back to bed, and then told the VA s/he was a “fucking r-word” as the VA went to his/her room. The SP denied having said it and the VA denied that staff persons called him/her names or yelled at him/her. While it was possible that the SP called the VA a “fucking r-word,” which would be inconsistent with the standards of a professional caregiver in a facility license by the Department of Human Services; a violation of Minnesota Statutes 245D.04, subdivision 3, paragraph (8), clause (6) and (8); and derogatory as an insult when used toward any person especially towards a person who lived in a residential setting, given the conflicting information provided by the SP and P4 and that the VA said that no staff persons called him/her names, there was not a preponderance of evidence whether the SP used language that was malicious and 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). Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were adequate but not implemented as applicable by the SP. The SP 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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