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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: 1070393-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) pushed a vulnerable adult (VA) down a hallway and into the VA’s bedroom after the VA asked for food. Date of Incident(s): July 21, 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 August 9, 2023; from documentation at the facility; and through nine interviews conducted with the VA, the VA’s family member (FM), the VA’s case manager (CM), a community person (CP), a facility resident (R), a supervisory staff person (P1), and three facility staff persons (the SP, P2, and P3). Two additional residents were at the facility at the time of the incident. However, neither was interviewed because one resident did not witness the incident, and the other was unlikely to communicate information about the incident due to his/her disabilities. The VA’s diagnoses included hypothyroidism, hemochromatosis, major depressive disorder recurrent, anxiety disorder, posttraumatic stress disorder, autistic disorder, legal blindness, heart failure, and liver transplant. The VA enjoyed building with Legos, reading fantasy books, computer games, and watching TV. The VA’s Behavior Support Plan stated that staff persons were to record instances of the VA’s anxiety that included withdrawal from a situation, increased stuttering and fidgeting, an upset stomach, and avoidance. Staff persons were to ask the VA about to the source of his/her anxiety in a friendly tone, give the VA time to respond or not respond, and respect his/her wishes and decisions. The VA may need time alone in his/her room with calming activities, request his/her PRN medication, or want to call a support person on the phone. The VA had no rights restrictions on food and portion sizes. The VA was ordered by his/her medical professional to walk 12 laps around a circular area inside the facility each day for the VA’s edema. The facility’s Emergency Use of Manual Restraint policy stated “’emergency use of manual restraint’” means “using a manual restraint when a person poses an imminent risk of physical harm to self or others and it is the least restrictive intervention that would achieve safety.” Property damage that would not result in injury, verbal aggression, or a person’s refusal to receive or participate in treatment or programming on their own, did not constitute an emergency. The facility was a single level home. The facility’s living room, dining room, and kitchen were interconnected. The VA’s bedroom was at the end of a hallway that led from the living room. During his/her interview, P1 said the VA did not typically have any behavioral concerns and was usually “quiet and well manner[ed].” If the VA was to get upset, staff persons were to encourage the VA to take time in his/her room to calm and after five minutes ask if the VA wanted to talk. The VA had a PRN (taken on an as needed basis) medication for anxiety. Staff persons were not supposed to suggest that the VA take the PRN, but if the VA requested the PRN unprompted, staff persons were to administer it to the VA. P1 said the VA “rarely” requested the PRN. P1 said the staff persons were “not supposed to put hands on [the VA] unless [s/he] cause[d] harm to self or a resident.” The CP said that on July 28, 2023, the FM told the CP about how a week prior the VA called the FM while upset. The VA cried to the FM and asked the FM to get him/her out of the facility. The FM said the VA was “screaming in [his/her] ear,” that the SP pushed him/her down the hallway, grabbed him/her by the ear, and locked him/her in the bedroom. The FM went to the facility and “confronted” the SP, told him/her that the FM could have him/her fired, and the SP apologized. The FM said, “You cannot treat my [child] that way.” The FM and the VA then left the facility and went to the FM’s home. (Note: during their interviews, the VA and FM made no mention that the SP grabbed the VA’s ear or locked him/her in the bedroom.) The following is a summary of information provided by the VA, the FM, P2 and P3 about a July 19, 2023, incident: · Information was consistent that on July 19, 2023, the FM spent time with the VA earlier in the day and there were no issues. That evening the SP, P2, and P3 worked at the facility. · The VA, P2, and P3 each said the staff persons made a dinner of burritos for the VA, the R, and other residents. The VA, the SP, the R, and other residents sat at the table to eat. P3 sat in the living room while P2 went back and forth between the kitchen and dining room and got various items for others. The VA had a choking risk and started to eat his/her food quickly. P2 asked the VA to “just slow down, enjoy your food.” · The VA finished his/her dinner “pretty quickly” and asked for a dessert s/he got from the store with the FM earlier that day. P2 told the VA the staff persons needed to assist with dinner now and asked the VA to do his/her laps first before s/he got the dessert. The SP said s/he “didn’t want to spoil [the VA’s] digestion” and that the VA “should wait until [his/her] stomach settled.” · The VA did not like what P2 said, called the FM on the facility phone, and the FM asked to talk with P2. P2 told the FM the staff persons did not deny the VA the dessert, they asked the VA to wait as they needed to do other tasks first before they could get the VA’s dessert for the VA. The FM told P2 that was “fine,” and the FM talked again with the VA. The call ended and the VA went back to the table and sat with the others. · The VA began to cry due to not getting his/her dessert. The staff persons encouraged the VA to do his/her laps and the VA got up and began them. The VA walked down the hallway, around the kitchen and through the dining room to complete the laps while P2 and the SP assisted another resident to use the bathroom and P3 stayed in the living room and was not able to see into kitchen. The VA told the DHS investigator that s/he completed 12 laps. P3 told the DHS investigator that s/he thought the VA did around seven laps. Then they all went back to the dining room table. · The VA sat at the table with a bowl and spoon and said s/he completed his/her laps. P2 went down to the basement to get the VA’s dessert and brought it up to the kitchen. · The VA told the DHS investigator that when s/he was at the table, the SP told the VA s/he “doubted” the VA completed his/her laps, then the SP told the VA that the VA should go to his/her room. The VA asked if s/he was able to have the dessert first and then go to his/her room and the SP said no. · P3 said s/he heard the VA “raise [his/her] voice” at the SP, saying s/he “finished [his/her] laps,” and, “I can eat what I want.” P3 heard the SP “raise [his/her] voice back” and tell the VA to “finish [his/her] laps” before s/he got the snack. The SP’s voice was “elevated” to the “same level as [the VA].” · P2 said s/he entered the kitchen and saw the SP and VA at the kitchen table in a “yelling match” about whether the VA finished his/her laps. The VA swore at the SP, but the SP did not swear at the VA. The SP said the VA did not finish his/her laps and they needed to be done before s/he got the dessert. P2 did not remember the SP swearing or insulting the VA, only that it was “kind of loud.” The VA wanted to call the FM and grabbed the facility phone. The SP told the VA something like, “Good, maybe call [the FM].” · P2 and the VA each said the SP and VA both stood up and the SP got in front of the VA, then the SP “grabbed” the VA’s right arm at the bicep and triceps area. · The VA said the SP “grabbed [him/her] by the arm and pushed [him/her] down the hallway into my room.” The VA said the SP “firmly and gently” pushed him/her down the hallway. The SP walked “sideways like a crab down the hall.” The VA grabbed the house phone as they walked towards the VA’s room. The SP said, “Stay in your room and think about what you’ve done.” The VA said the SP’s voice was “loud, but I would not call it yelling.” The VA denied the SP ever grabbed his/her ear. · P2 did not recall if the SP used one or two hands to grab the VA’s arm. P2 recalled the SP walked backwards facing the VA and told the VA something like, “Go to your room and think about it.” The SP moved to the VA’s right side, kept his/her hand on the VA’s right arm, and walked with the VA towards the VA’s bedroom with their backs to P2. The SP might have been slightly behind the VA due to the narrow hallway. P2 did not recall what was said between the SP and the VA, only that “they were yelling.” · P3 said s/he got up from the living room and stood by P2 at the end of the hallway to see what had occurred. P3 saw the back of the SP’s head as the VA and SP went into the hallway. P3 heard the VA say s/he wanted to call the FM, and the SP say the VA “should do that… to calm down… and cool off in your room.” P3 did not see the SP’s hands on the VA at any time. The VA entered his/her bedroom and slammed the door. · The SP turned around and walked back towards the kitchen. P2 saw that the SP appeared “pretty heated,” and P2 and P3 did not remember if the SP said anything as s/he passed P2 and P3. P2 said s/he told P3, “I think [the SP] went too far,” and P3 “shook [his/her] head or nodded.” · The VA got into his/her bedroom and locked the bedroom door. Around 6:30 p.m., the VA called the FM and told him/her what happened. The FM said the VA was “screaming” to get him/her of the facility. The VA said, “I have been man-handled down the hall, grabbed, and told me to sit in my room until I behaved.” The VA told the DHS investigator, “I couldn’t say here and rest, I was too upset, too fed up.” The VA asked to go to the FM’s home for the night and the FM agreed. The VA began to pack items for the overnight. · Between five to ten minutes after the VA entered the bedroom, P2 brought the bowl with the VA’s dessert to the VA’s bedroom. Through the door, P2 heard the VA talking on the phone with the FM. The VA said s/he was “manhandled” by the SP. P2 asked the VA if s/he wanted the dessert and the VA said in an “elevated voice” something like, “Go away.” P2 brought the bowl back to the kitchen. About five to ten minutes after that, P3 went to the VA’s bedroom to check on him/her. The VA sounded “agitated” and told P3 in a “raised voice” that s/he called the FM. P3 said that was “okay” and left went back to the living room. · Around 6:15 p.m., P2 left the house with another resident to go bowl. At the bowling alley, P2 told P1 about the incident in a phone call. P1 said, “Oh man, [the SP] can’t put [his/her] hands on [the VA],” and said s/he planned to talk to the SP the next day. · Around 7:30 p.m., the FM arrived at the facility and went into the VA’s bedroom where the VA appeared “panicked” and “distraught.” The VA told the FM the SP “grabbed [the VA’s] arm,” told the VA to stay in the VA’s room “until [s/he] could behave calmly,” and “pushed [the VA] down the hall.” · The FM said s/he talked with the SP about what happened and the SP told the FM s/he grabbed the VA’s arm and pushed the VA down the hallway to the VA’s bedroom. According to the FM, the SP said s/he told the VA, “Go in there until you can behave.” The SP then yelled at the FM, “I know best,” and “I am being a [parent], yelling like a [parent],” and said his/her actions were intended to “protect” the VA for the VA’s “own good.” When talking with the FM, the SP also contradicted him/herself by denying s/he touched the VA. The FM said P3 heard the FM tell the SP, “Yeah, you're right about the portion sizes,” and the VA “shouldn't be eating that much.” · The FM went back into the VA’s room. About five to ten minutes later, the VA appeared “more calm.” The FM left P1 a voicemail about what happened and helped the VA prepare for an overnight at the FM’s home. · When P2 returned to the facility, P2 saw the VA and FM were inside the VA’s bedroom. The VA appeared calm and in a good mood. P2 asked the VA if s/he got the dessert and was told no. P2 prepared the dessert and brought it to the VA’s bedroom. · The FM and VA left the facility around 8:30 p.m. · P3 later talked with the SP about what occurred. The SP said that the VA asked for the dessert and the SP asked if s/he finished his/her laps. The VA said they were done. The SP said the VA only did seven and once they were finished the VA could have the snack, then the VA started to yell at the SP. P3 denied the SP said s/he put his/her hands on the VA. · On July 20, 2023, P2 worked the morning shift and the VA returned to the facility between 10 a.m. and noon. The VA appeared in “a lot better mood.” The VA greeted everyone at the facility and went to his/her room until lunch. The VA did not discuss what happened the previous night. P2 believed that day s/he checked the VA’s blood pressure and looked at both arms and did not recall seeing any marks. The VA did not report any injuries to others. · P1 also spoke with the SP about the incident. The SP told P1 that s/he and the VA “got into an argument” during which the VA “started swearing” as the VA wanted the dessert and the SP told him/her to wait. The SP “grabbed [the VA] a little bit at first” by the upper arm to “nudge” the VA and guided [him/her] to the bedroom. When P1 talked with the FM about what happened s/he told P1 that the SP “dragged [the VA] down the halls.” P1 told the FM that s/he was at the facility with the VA and that the VA appeared “fine.” P1 asked the VA if s/he was okay and s/he said s/he was. The R said that s/he got along with “all” of the staff persons at the facility and the SP was “nice.” The SP might be loud with the VA as s/he “don’t listen” about items like not washing his/her hands and eating too quickly. The R denied s/he ever saw the SP grab or touch the VA. The CM did not have any concerns about the facility and thought the staff persons did a “good job” and “worked well” with the VA. The CM said there was “tension” between the FM and the facility such as when the FM brought certain food items to the facility and when the FM encouraged the VA to disregard staff persons’ suggestions regarding healthy food choices. The VA did not contact the CM with concerns about the staff persons or facility. The VA was “very intelligent” and “not the type to make up something” unless it involved an amount of food. The CM was not aware of the allegations that the SP physically abused the VA. The SP provided the following information: · The SP worked with the VA for “a few years” and was aware of his/her health issues, “high anxiety,” and tendency to “overeat” until s/he became unwell. The SP was aware the VA did not have any dietary restrictions from a medical professional and staff persons were to encourage the VA to make healthy choices. The SP and VA got along “well.” · The VA’s maladaptive behaviors were mostly related to food and at times the VA might “snap” and be “angry.” As the VA might “insist on overeating,” the SP said it was “necessary to be a lot firmer with [him/her].” The SP said the “message wasn’t getting through” to the VA that the overeating was “self-harming” and led to hospitalizations. · The evening of the incident, the VA finished dinner and asked about his/her dessert. P2 went to get the dessert package, which contained eight servings. P2 went to get a bowl and the VA said s/he “wanted the whole bag.” Both the SP and P2 said they would serve the VA. The SP told the VA s/he “cannot give that much.” The VA “stomped off… started fussing… crying… a tantrum.” The SP told the VA s/he was “not making a good choice,” that the snack was “bad for you,” and the SP had to “put [his/her] foot down.” · The SP asked the VA to do his/her laps, which was “pretty standard” and “more [of a] recommendation” that the VA was “supposed” to do instead of a requirement. The SP again told the VA s/he “cannot have that much” of the dessert and the VA became “upset.” The SP told the VA, “If you are going to be like this you can go back to your room and think about this, just calm down.” The SP meant this as a “suggestion.” The VA was “in tears” and “wasn’t listening and wasn’t cooperating.” · The SP walked down the hallway. The SP denied grabbing the VA but acknowledged s/he put his/her hand on the VA’s shoulder “briefly” to “encourage [the VA] to calm” as they walked down the hall and as the VA entered his/her bedroom. The SP denied that s/he in any way restricted the VA’s movement. The SP denied grabbing the VA by the ear at any time. · The VA remained in his/her bedroom until the FM arrived about 30 minutes later. The SP discussed the situation with the FM and the FM told the SP s/he agreed that the VA should not be offered all eight servings. The SP said the conversation with the FM “wasn’t confrontational” and s/he acted that way for the VA’s “own good.” The SP did not recall saying s/he “acted like a [parent]” to the FM. The FM and VA left the facility “not more than 20 minutes” after the FM arrived. When they left the VA did not appear to be upset or agitated. · The SP denied s/he was trained to interact with the VA in this manner and said it was “a choice I made on the spot” and s/he “needed to get through to [the VA].” The SP “[did not] regret doing it” as the VA had an “attitude adjustment” afterwards. The SP said it resulted in “some positive effects” as “it needed to upset [the VA]” because “nothing else was getting through to [the VA].” Facility documentation showed that the SP and P1 – P3 were trained on the VA’s support plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states in part that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: Information from all sources was consistent that on July 19, 2023, in the evening, the VA finished his/her dinner and asked for a dessert s/he got earlier that day with the FM. The VA was asked to wait and staff persons suggested the VA complete his/her laps while they assisted another resident in the bathroom. When the SP and P2 returned to the dining room the VA said the laps were completed and asked for the dessert. P2 went to get the dessert from the basement freezer. The SP told the VA s/he did not believe the laps were completed and that s/he could not eat his/her dessert until s/he completed his/her laps. While there were differing accounts of what was said between the VA and the SP and their tone of voice, all sources provided consistent information that the VA became upset and the SP asked or told the VA to take time in his/her room to calm. Information was also consistent that while the VA walked from the kitchen to his/her bedroom, the SP placed his/her hand on the VA’s arm or shoulder area. The SP’s treatment of the VA was disrespectful and violated the VA’s rights according to Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, information was inconsistent as to what manner of physical contact the SP had with the VA during the incident. In addition, there was no information that the VA experienced pain, nor that the VA sustained any injury, as a result of the SP’s actions. Therefore, there was not a preponderance of evidence as to whether the SP engaged in conduct which produced or could reasonably be expected to produce physical pain or injury or emotional distress. 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 not followed. The facility retrained the SP on the VA’s behavior plan and rights and prevention. Action Taken by Department of Human Services, Office of Inspector General: The SP’s treatment of the VA violated the VA’s rights according to Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, because the facility identified and self-corrected this violation, a Correction Order was not issued. No further action taken.
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