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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: 1114368-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 staff person (SP) filled a spray bottle with paprika and sprayed it into/near a vulnerable adult’s (VA’s) eyes and genital area. Date of Incident(s): July 9, 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 August 8, 2024; from documentation at the facility; and through six interviews conducted with two facility supervisory staff persons (P1 and P2), three facility staff persons (P3, P4 and the SP), and the VA’s guardian (G). Due to the VA’s diagnoses, s/he was unable to provide information to this investigator related to this investigation. The VA provided information to the G which is included below. The VA was diagnosed with autism spectrum disorder. The VA enjoyed listening to music and dancing. According to the VA’s Coordinated Services and Supports Plan (CSSP), “[The VA] required 2 staff to be with [him/her] during awake hours both at home and in the community. [The VA] can be alone in the bathroom and bedroom at home but requires two staff when accessing a public bathroom.” The VA’s CSSP also stated, “When [the VA] is experiencing anxiety, [s/he] isn’t able to fully express him/herself verbally,” and “[S/he] will cry, isolate [him/herself] and remove [his/her] clothing.” The VA’s Individual Abuse Prevention Plan stated, “The VA was susceptible to physical abuse due to his/her inability to identify potentially dangerous situations, lack of community orientation skills, inappropriate interactions with others, inability to deal with verbally/physically aggressive persons and verbal/physical aggression to others,” and “If [the VA] becomes physically aggressive toward another, individual staff will attempt to redirect [him/her].” P3 provided the following information, · “The first day” that P3 worked at the facility, the SP spoke in a “threatening” way and was “against everybody,” which P3 described as the SP “abusing” P3 and the VA. P3 told the SP that they had to “work together,” and “Let’s have a good day.” · On an unknown Tuesday night (later determined to be July 9, 2024), P3 saw the SP mix paprika with water and spray the VA in the eyes and genital area. After the SP sprayed the VA, the VA tried to “run away.” P3 said s/he “could tell” that the VA “understood who was treating [him/her] wrong.” P3 told the SP, “That is wrong,” and the SP said, “Don’t tell anyone,” and threatened P3 and said, “I have my [partner] and [child] go after you if you tell anyone.” That night P3 finished his/her shift and the next morning, emailed P1 and P2 with his/her concerns and called P2 and said that s/he had concerns about the SP’s interactions with the VA and wanted to meet in person with P1, P2, and a representative from HR. At the meeting, P3 told P1, P2 and HR personnel that on one overnight shift earlier that week, s/he saw the SP spray the VA with water and paprika “three times” and on another overnight shift earlier that week, the SP prevented the VA from using the bathroom by locking the bathroom door and standing in front of it. P3 heard VA wake up and go towards the bathroom, and then heard the SP tell the VA that s/he could not use the bathroom until 6 a.m. · Since the SP no longer worked at the facility, the VA was doing “so much better.” P3 described the SP as “a bully” and stated that the SP “felt like [s/he] had power over everybody.” P1 and P2 provided the following information: · “About a month ago,” P3 emailed P1 and P2 stating that s/he wanted to meet with P1, P2, and someone from human resources (HR) regarding “concerning behaviors” between the SP and VA. On July 12, 2024, P1, P2, P3 and HR personnel met for a meeting to discuss P3’s concerns. · P3 told P1, P2, and HR personnel that the SP prevented the VA from using the bathroom overnight by locking the door and removed all the blankets from the VA’s bed. P1 stated, “The biggest thing” was that there was a spray bottle at the facility that P3 saw the SP remove from the cabinet, fill with water, and then a spice from the spice rack that P3 believed was paprika. The SP then used the spray bottle to spray the VA in the face and genital area. P2 stated that P3 told them that s/he saw the SP spray the VA in the eyes and genital area with water and “some type of cayenne pepper mix.” and that the SP stated, “It will make [the VA] go to sleep because [s/he] won’t be able to open [his/her] eyes.” · P1 stated that P3 also told P1 and P2 that the SP made “threats” to P2 including, “I get people fired here. I don’t get in trouble,” and that s/he would have his/her partner and child “come after” P3 if s/he told anyone what s/he saw the SP do. P1 stated that s/he never heard about concerns with the SP from other staff persons, but believed that because P3 was “newer staff,” the dynamic between the SP and P3 was “different” and P3 recently started working overnight shifts with the VA and SP. · P1 stated that P3 told him/her the VA did not show any signs of “rash” or “discomfort” after the incident and did not require medical treatment. · Following the meeting, P1 notified the G of the incident. The G then went to the house and asked the VA, “Is [the SP] spraying something on you?” The VA did not verbally respond but went to a cabinet at the facility and took out a bottle of “Clorox spray.” · P2 stated that s/he called the SP to inform him/her that s/he was suspended from working. The SP asked, “for what” and P2 informed him/her that HR would be calling to follow up. The SP “kept saying” s/he needed to know what the allegation was so that s/he could obtain an attorney. P2 did not have any further communication with the SP related to the incident. · P1 scheduled multiple meetings with the SP, but the SP “refused” to meet with P1 and P2 and did not show for the meetings. · P1 and P2 each stated that the SP’s actions were not consistent with his/her training related to de-escalation or the VA’s support plans. P4 provided the following information: · P4 worked overnight shifts with the SP. The SP’s language towards the VA did not “sound good” and the SP used an “aggressive tone” with the VA. P4 heard the SP tell the VA, “I will beat you.” It was also “common” for the SP to “yell” at the VA and P4 stated that “yelling was one of [the SP’s] attributes.” P4 also stated that the SP slept during his/her shifts “many times.” P4 did not have additional concerns regarding the SP’s interactions with the VA and never saw the SP redirecting the VA in a way that was “not part of procedure.” · P4 no longer worked at the facility “because of [the SP].” P4 “could not get along” with the SP because the SP was “disrespectful” towards P4, however, P4 did not wish to provide further information about “personal issues” between him/herself and the SP. The G provided the following information: · The G had “issues” with the SP “for quite a while” including multiple times that the VA left the facility without supervision while the SP was sleeping. · P1 told the G that a staff person saw the SP spray the VA with a spray bottle. Afterwards, the G went to the facility and asked the VA to show the G what the SP sprayed at him/her. The VA took the G to a locked cabinet, and the G asked the staff person working to open it. The staff person opened the cabinet and the VA took out a bottle of Clorox brand spray cleaner. The G then sent an email to P1 informing him/her of what the VA showed him/her. · The G stated that the VA’s behaviors had escalated recently, and when this typically occurred, the VA was “on the defense” and that “something” was happening to the VA that staff persons “were not paying attention to.” The G also stated that information provided by the facility showed that “every time” the VA behaved negatively, it was when the SP worked. The SP provided the following information: · The SP worked awake-overnight 2:1 shifts with the VA. There was always one other staff person working the overnight shifts with the SP. · The SP stated s/he “would never” spray the VA with a spray bottle, and asked, “If I did that, why did no one call the police?” The SP also stated, “Never in my life did I abuse a client.” · The SP stated that s/he never locked the bathroom door or prevented the VA from using the bathroom except for when s/he was using it. The SP also stated that s/he never slept during his/her overnight shifts. · The SP believed that other staff persons were “retaliating” and “trying to intimidate [the SP] because of [his/her] age” and they thought the SP was “too old to do [his/her] job.” The SP said that P2 did not “like” the SP because of the SP’s age. · The SP denied taking and/or withholding the VA’s blankets and stated that s/he only took the VA’s blankets after the VA urinated or defecated on them. · The SP stated that if the VA engaged in negative behaviors, staff persons were trained to redirect the VA. The SP added that the VA “wants to do stuff overnight” and does not sleep. Facility documentation showed that P2, P3 and the SP were trained on the Reporting of Maltreatment of Vulnerable Adults Act. The facility did not provide documentation that the SP, P2, P3, and P4 were trained on the VA’s plans or that P4 was trained on the Reporting of Maltreatment of Vulnerable Adults Act. These were violations of Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a), clause (2) which states in part that the license holder must maintain a personnel record of each employee to document and verify orientation and annual training to individual service recipients needs; and Minnesota Statutes, section 245D.09, subdivision 4, clause (5), which states in part that within 72 hours of first providing direct contact services and annually thereafter, the license holder must provide an ensure direct support staff are trained on the reporting requirements governing maltreatment. Relevant Rules and/or Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states in part that a persons protection-related rights include the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: P3 provided consistent information to this investigator and facility administrative staff that on one occasion s/he saw the SP use a spray bottle filled with water and paprika to spray the VA in the eyes and genital area three times that evening. The VA was unable to provide information to this investigator but showed the G a spray bottle that was located in the facility when the G asked the VA if the SP was spraying him/her with something. The SP denied spraying the VA with anything. P3 also stated that the SP treated the VA in a “threatening” way and denied the VA access to the bathroom, and P4 said the SP treat the VA in an “aggressive” way and “yelled” at the VA. Although the SP denied the allegations including spraying the VA with a spray bottle and preventing the VA from using the bathroom, given that P3 provided consistent information about what s/he witnessed to P1, P2, and this investigator; that the VA showed the G a spray bottle when asked what the SP sprayed the VA with; and that the SP had reason to minimize his/her actions for fear of repercussions, it was more likely that the incidents occurred as described by P3. Spraying someone with a spray bottle that included paprika, preventing them from using the bathroom when needed, and yelling at and/or treating them in a “threatening” and/or “aggressive” manner was not accidental or therapeutic conduct, inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Therefore, there was a preponderance of the evidence that the SP’s interactions and treatment towards the VA would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be expected to produce emotional distress. It was determined that 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.) 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. Although there was no documentation to show that the SP was trained on the VA’s plans, this does not mitigate the SP’s responsibility to treat the VA with courtesy and respect. In addition, 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 emotional abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because the SP’s pattern of behavior was considered a single incident and it did not meet the definition of serious maltreatment. Action Taken by Facility: The facility completed an internal review and found that policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of 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 the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On December 6, 2024, the facility was issued a correction order for the violations outlined in this report.
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