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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: 1069644-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Carla Harvieux 651-431-3970 / 651-431-6616 Suspected Maltreatment Reported: It was reported that on August 9, 2024, a vulnerable adult (VA) hit a resident (R1) and a staff person (SP) redirected the VA. The VA threw an open bottle of juice at residents, and the SP redirected him/her again, but the VA grabbed the SP’s hair, and the SP was overheard yelling at the VA. After the incident, the VA had a baseball sized mark on the left side of his/her face and said that the SP slapped him/her. Date of Incident(s): August 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 (1); and subdivision 17, paragraph (a): 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 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 21, 2024; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, P3, and the SP), a facility resident (R1), and the VA’s guardian (G). The VA provided information in the facility’s Internal Review, and it was included below. Facility documentation showed that the VA was diagnosed with a mild developmental disability, down syndrome, hypothyroidism, leukemia (in remission), and generalized anxiety disorder. The VA weighed more than was recommended by his/her physician and was blind in his/her right eye. According to the VA’s Individual Abuse Prevention Plan (IAPP), the VA had a history of engaging in self-injurious behavior and was vulnerable to physical abuse since s/he might not identify potentially dangerous situations. The Notes for the VA showed that s/he might threaten to hit staff persons and raise his/her voice to them or say that s/he was going to tell his/her family members (FMs) that staff persons were mean to him/her, when staff persons did not give the VA his/her preferred food items. However, the VA usually apologized for his/her actions, and was redirected by staff persons. The VA’s Coordinated Services and Support Plan (CSSP) showed that s/he might avoid confrontation but responded to suggestions and redirections when given enough time to process them. The VA might become frustrated if s/he felt s/he was being told what to do or if s/he thought that staff persons did not listen to him/her. If the VA was upset, staff persons were to suggest that they talk again later, or offer the VA a relaxing activity including drawing, coloring, or playing a game. No information showed what types of self-injurious behaviors the VA might have or whether s/he had a history of providing inaccurate information. The VA knew how to swim and enjoyed going shopping. Interviews with a DHS investigator, facility documentation, and the facility’s Internal Review, provided the following: · The VA provided information to P1 and P2, who were supervisory staff persons, in the facility’s Internal Review, showing that on the date of the incident, the VA had a pop and a snack, but the SP called the VA’s name several times which bothered him/her. The VA was sitting at the dining room table with R1, and the SP was in the kitchen. R1 told the VA that s/he did not like the VA and the VA threw R1’s juice but did not hit anyone with it. The VA became upset and hit the SP on the back of his/her head, then the SP hit the VA’s face on the left side with an open hand and grabbed the VA’s wrists. The SP released the VA, and s/he called the G. The VA knew it was wrong to hit the SP and was working with a mental health care professional for anger management issues. The G came to the facility to check on the VA and calm him/her. No information showed that the VA had marks or injuries to his/her wrists. · In the Internal Review, R1 told P1 and P2, that on the date of the incident, s/he and the VA were sitting at the dining table. The VA was upset and s/he asked the VA why s/he was upset, but the VA told him/her that it was, “None of [his/her] damn business.” The VA hit the right side of R1’s head and threw R1’s juice and the SP told the VA to stop, but the VA went to the kitchen where the SP was and slapped the SP’s head. The Ps asked R1 what happened next and s/he answered that the VA went home, meaning that s/he left the facility with the G. R1 denied that the SP hit the VA and no information showed that R1 was injured during the incident. · The G said that on the date of the incident, s/he was on the way to pick up the VA for a visit, when the VA called him/her and said that s/he and the SP were “fighting.” When the G arrived at the facility, the VA was standing outside the facility and his/her face was “red.” The VA told the G that the SP slapped him/her after the SP called P1. The G entered the facility to talk with the SP, but the SP did not discuss the incident with the G. The G thought that one of the residents routinely made upsetting comments to the VA using a low voice to prevent staff persons from hearing them, and thought the resident made comments to upset the VA on the date of the incident. The G was certain that the VA did not hit him/herself, but the VA might have pulled the SP’s hair, because s/he was extremely frustrated with R1 when the incident occurred. · The SP said that shortly after 3 p.m. on August 9, 2024, s/he gave the VA a snack and a pop, then gave snacks and pops to all the residents (Rs). The SP then went to the kitchen to prepare medications for one of the Rs, while the VA and the Rs sat at the dining table eating snacks and drinking beverages. The VA finished his/her snack first and said that s/he loved being hugged, then began saying how “annoying” the Rs were and at some point, said that s/he was leaving the facility with the G because the VA did not get along with R1. The SP asked the VA to let the Rs “be,” but the VA said, “Knock it off, I’m not talking to you,” and told R1 to shut up. The VA suddenly became very upset and raised his/her voice, and R1 covered his/her ears. The VA then hit R1 on the right side of his/her head and pushed R1’s beverage from the table onto R1 and the floor. · The SP went to the dining room to check on R1 and comfort him/her. R1 was upset and crying, and the SP asked the VA to go to his/her bedroom until the G arrived, but s/he did not. The SP called P1, and they talked on speaker phone. The VA “yelled and screamed” during the SP’s conversation with P1, then asked the SP to let him/her call the G. When the SP’s call with P1 ended, the VA yelled at the SP to give him/her the phone, then slapped the SP on his/her left ear and said that s/he could slap the SP again. The SP started crying and the VA told him/her that s/he was going to “make sure” that the SP lost his/her job because s/he was going to hurt him/herself then contact a law enforcement agency and say that the SP harmed the VA which was consistent with the VA’s past statements according to the SP. The SP then grabbed the VA’s wrists and the VA said, “Oh, are you going to hit me?” but the SP told the VA that s/he would not hit him/her. The SP did not recall how long s/he held the VA’s wrists, but it was less than a minute. · When the SP released the VA, the VA slapped the SP on his/her back and took the telephone then left the kitchen to call the G. When the VA and the G talked, the VA asked him/her to come get him/her. The SP told the VA that if s/he slapped the SP again, the SP was going to call a law enforcement agency and P1. R1 told the VA to stop hitting staff persons, but the VA hit R1 again, then walked outside to wait on the G. When the G arrived, s/he told the SP that s/he needed to find different ways to approach the VA. The SP was aware that the VA had a red mark on his/her face, but denied that s/he hit the VA. The SP was very upset and felt that s/he was not respected. · P1 stated that at about 3:45 p.m., the SP called him/her and P1 heard the VA speaking with a raised voice in the background of the call. The SP yelled that the VA had his/her hair, and the SP told the VA to let go of his/her hair. P1 said that s/he would immediately come to the facility, then disconnected the call and began driving there. · When P1 arrived at the facility, the G was there and said that the SP slapped the VA, but no one had mentioned the SP slapping the VA until P1 talked with the G. The VA told P1 that s/he pulled the SP’s hair, and then the G prompted the VA by saying, “What happened next, [the SP] slapped you, didn’t [s/he]?” The VA replied that the SP had hit him/her, but when P1 asked whether the SP hit him/her with a closed or open fist, the VA did not reply. · P1 thought that the VA could remember events well, but s/he made prior statements that were inaccurate, including telling others that P1 “fired” the SP, which was not true. However, the VA had not previously stated that a staff person hit him/her but s/he had threatened to call the G and say that staff persons called him/her names. In addition, the VA had previously threatened to hit another staff person. When the incident occurred, there were no other staff persons at the facility and P1 had no concerns with the SP’s work at the facility. The SP spoke well of the VA and the Rs and P1 thought that the SP did not slap the VA. · Information was consistent from P2 and P3 that the VA was newer to the facility and there had been some minor disagreements with the Rs. The VA’s verbal aggression increased but prior to this incident, s/he did not have physically aggressive behavior. R2 and R3 had memory issues and did not provide information regarding the incident. Photographs of the VA obtained by a DHS investigator showed that shortly after the incident, the VA had a large red area on the left side of his/her face, that covered his/her left cheek, the side of his/her nose, and his/her left eye. The photograph did not show handprints or fingers that might be consistent with being slapped. P1 said that when s/he saw the VA on the date of the incident at about 3:45 p.m., the VA’s face was not as red as it was in the photograph and no information indicated that the VA cried or was crying because of the incident. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: The VA was diagnosed with a mild developmental disability, down syndrome, hypothyroidism, leukemia, and generalized anxiety disorder, and the IAPP showed that the VA might engage in self-injurious behavior and was vulnerable to physical abuse. The Notes for the VA indicated that s/he might threaten to hit staff persons, raise his/her voice to them, or say that s/he would tell the FMs that staff persons were mean to him/her. The VA responded to redirections with time to process them but might become frustrated if s/he felt s/he was being told what to do or felt that others did not listen to him/her. No documentation showed what types of self-injurious behaviors the VA might have or whether s/he had a history of providing inaccurate information. On August 9, 2024, there was an incident involving the VA, R1, and the SP. In the Internal Review, the VA said when the incident occurred, s/he and R1 were having a snack at the dining table. R1 said s/he did not like the VA, and the VA threw R1’s juice, and hit the SP. The SP then hit the VA’s face and grabbed his/her wrists but released him/her according to the VA. No injuries were noted to the VA’s wrists. The VA called the G who was on the way to pick up the VA and said that s/he and the SP were fighting. When the G arrived, the VA had a red mark on his/her face that s/he said s/he sustained when the SP slapped him/her. The G thought that the VA might have pulled the SP’s hair but did not think that the VA hit him/herself. R1 said that the VA hit R1’s head and threw R1’s juice, then slapped the SP’s head when the SP told the VA to stop. However, the SP did not hit the VA. The SP said that the VA and the Rs were having snacks, when the VA said that the Rs were annoying and that s/he was leaving the facility because of it. The SP redirected the VA, but the VA raised his/her voice then hit the right side of R1’s head and threw his/her beverage. R1 cried and the SP checked on him/her, then asked the VA to wait for the G in his/her bedroom, but s/he declined. The SP called P1, and the VA slapped the SP and said that s/he was going to hurt him/herself but tell the law enforcement agency that the SP harmed him/her. The SP grabbed the VA’s wrists for less than a minute then released him/her and when s/he did, the VA slapped the SP’s back, took the telephone, and called the G. The SP told the VA that if s/he hit him/her again, s/he would call the law enforcement agency and P1. The SP knew that the VA had a red mark on his/her face, but denied hitting the VA. P1 stated that when the SP called him/her, s/he heard the VA using a raised voice in the background, and the SP said that the VA had his/her hair. P1 immediately went to the facility, and when s/he arrived, the G was at the facility and said that the SP slapped the VA. However, prior to this, no one mentioned the SP slapping the VA. The VA told P1 that s/he pulled the SP’s hair, and then the G prompted the VA, saying, “What happened next, [the SP] slapped you, didn’t [s/he]?” The VA replied that the SP hit him/her, but P1 asked whether the SP hit him/her with a closed or open fist and the VA did not answer. According to P1, the VA had a good memory, but s/he made prior statements that were inaccurate, including telling others that the SP was no longer employed at the facility. The VA did not have a history of saying that staff persons hit him/her, but s/he had threatened to tell the G and that staff persons called him/her names and previously threatened to hit another staff person. Although the VA had a red mark on his/her face and said that the SP slapped him/her, and the SP grabbed the VA’s wrists, given that R1 witnessed the incident and said that the SP did not slap the VA, that the VA had a history of self-injurious behaviors and had previously said that s/he would harm him/herself and tell others that staff persons harmed him/her, that no information showed that the VA sustained injuries to his/her wrists, that P1 said the VA had a history of providing inaccurate information, and that the SP denied that s/he slapped the VA, there was not a preponderance of the evidence whether the SP caused the red mark to the VA’s face or whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or maintain the VA’s health or safety. It was not determined whether neglect or 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; or 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 which determined that their policies and procedures were adequate and were followed. After the incident, the SP began working at another service location owned by the same program. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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