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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: 1080227-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that during an argument between a staff person (SP) and a vulnerable adult (VA), the SP called the VA the “retarded” and said that was why the VA lived in a facility and the SP did not. (“Retarded” will be referred to as the “R word” throughout the remainder of this report.) Date of Incident(s): February 20, 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 March 26, 2024; from documentation at the facility; and through six interviews conducted with the VA, four facility staff persons (the SP and P1-P3), and a guardian (G). The VA’s diagnoses included Klinefelter’s syndrome, mood disorder not otherwise specified, antisocial personality disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, and moderate intellectual disability. The VA enjoyed fishing, playing basketball and video games, and camping. The VA also liked cooking spaghetti and tacos. The VA resided alone on the third floor at a residential apartment complex with staff persons present 24 hours per day. The VA’s Alone Time Protocol stated that s/he was allowed 12 hours of unsupervised time. The unsupervised time started at the VA’s request or when staff persons needed to “avoid conflict with [the VA’s] behavior or straining their relationship with [the VA].” When staff persons left the VA’s apartment, they kept the facility cell phone with them at all times in case they received a call for assistance from the VA. The VA’s Individual Abuse Prevention Plan (IAPP) stated in September 2021, the VA obtained “a boxcutter or razor blades” and made “superficial cuts on both of [his/her] arms approximately 50-100 times.” The plan to address that issue was to monitor the VA’s behavior and report noticeable changes to team members through internal email. The VA’s Self-Management Assessment (SMA) stated that staff persons locked and secured knives and other sharps at all times, “except when in direct use.” If the VA needed “knives or sharps while cooking,” staff persons provided the item and returned it to the locked area when done. The VA’s Progress Notes showed the following: · On February 20, 2024, documentation from the SP for the 3-11 p.m. shift, stated that the VA called the SP names and made racial comments. The VA said, “You are [R word],” “You are so stupid,” and called the SP a “[racially descriptive] stinky bitch,” and a “dummy.” The VA then left the facility and used “[unsupervised] time” until the SP’s shift ended. · On February 20, 2024, a staff person (P5) documented that the VA returned to the facility around 11 p.m. and was “upset” with the SP because the SP called the VA the “R word.” The VA told P5 that s/he planned to make the SP “miserable” when the SP worked the next day. The VA appeared “stable” and went to bed and slept. · On February 21, 2024, P3 documented that the VA woke up around 10 a.m. and was “upset” that the SP called the VA the “R word” yesterday. The VA said that s/he was going to send the SP “downstairs until they apologize.” (Staff persons generally went downstairs to a conference room or to their car when there was conflict and the VA wanted to be alone in his/her apartment.) · On February 21, 2024, the SP documented that when s/he arrived at the facility that afternoon, the VA called the SP names such as “bitch” and “stinky.” The VA said that the SP called the VA the “R word” and asked the SP to leave the VA’s apartment. · On February 21, 2024, a staff person (P4) worked the overnight shift. From 10 p.m. until 11 p.m., the SP and P4 worked together. During that one-hour period of time, the VA was verbally “attacking” the SP. The VA said that the SP called the VA the “R word.” The VA said that s/he “will make [the] workplace hard” for the SP and will cause the SP to “get fired.” The VA called the SP names such as “[racially descriptive] stinky bitch, prostitute, dummy, and stinky.” After the SP left the facility the VA “calmed to baseline behavior.” · On February 22, 2024, P4 documented that the VA “appeared fixated” and stated the SP called the VA the “R word.” The VA called his/her family members to “complain that [the VA] is being mistreated” and was called the “R word.” The VA wanted the SP “fired.” · On February 23, 2024, P4 documented that the VA was “minimally fixated” about the SP calling the VA the “R word.” The VA said that the SP called the VA the “R word” in the apartment and on a car ride. The VA provided the following information when interviewed by this investigator: · On an unidentified date, the VA asked for an as needed (PRN) medication and scissors to open it. The SP told the VA that it was “policy” that the VA was not allowed to have scissors. The VA told the SP, “You sound dumb right now.” The SP replied, “You’re the one who lives in a group home, you are the one who take meds, who’s [the R word]?” The VA was “caught off guard” by the SP’s words and attempted to call P1 multiple times. The VA also asked the SP to call P2 or P4 to ask about the scissors; however, the SP refused. The VA continued to call P1 until s/he finally answered the phone. The VA said that was the only time the SP called the VA the “R word.” · The VA said that prior to the incident s/he got along “pretty good” with the SP but voiced irritation with the SP’s hygiene, especially when riding in a car. P1 said that on the day of the incident, the VA called P1 around 4 p.m. and sounded “upset.” The VA said that s/he wanted to use scissors to cut open his/her PRN medication and the SP did not allow the VA to use scissors. P1 believed that the VA was okay to use scissors or “sharps” as long as s/he returned it when done. The VA said that the SP called the VA the “R word.” P1 described the SP as “mild mannered” and “did not speak a lot;” however, that day, the SP raised his/her voice over the VA’s to tell P1 that the SP “did not say that” and said [the VA] was the one calling me names.” P1 then talked to the SP who said s/he attempted to call P2 and P4, but by the time P4 called back, it was “too late”, and the argument had already occurred. The SP denied calling the VA the “R word” and said the VA called the SP names. Prior to the incident, P1 was aware that the VA did not like the SP’s hygiene and called the SP “stinky.” The VA had a “history of racially targeting” some staff persons and a history of “false reporting.” P2 provided the following information: · P2 heard about the incident from P5 who worked the overnight on February 20 until the morning of February 21, 2024. P5 told P2 that s/he read about the incident in an email communication. When the VA woke up on the morning of February 21, 2024, s/he “immediately” told P2 that the SP did not allow the VA to use scissors to open his/her medication and called the VA the “R word.” The VA admitted s/he called the SP names. · The VA was allowed to use “sharps” unless s/he was noncompliant with taking his/her medications or displaying mental health symptoms. P2 said that the SP attempted to call P2 on February 20, 2024; however, P2 did not have the SP’s phone number in his/her phone so thought it was “spam” and did not answer. P4 told P2 that the SP also contacted P4 on February 20, 2024, regarding the VA’s request for scissors. · Prior to the incident, the VA complained about the SP stating s/he had body odor and the VA called the SP “stinky” and “bitch.” The VA “liked to cause fear and intimidation” with new staff persons, in particular, staff persons of the opposite gender or other nationalities than the VA. P3 said that the VA “made sure everyone was aware of what [the VA] perceived happened” between the SP and VA on February 20, 2024, specifically, that the SP did not allow the VA to use scissors and called the VA the “R word” one time. The VA “said stuff in the past that has not been true;” however, P3 also did not want to “not trust [the VA’s] word.” P3 was not present for the incident but observed the VA was upset, so P3 listened and validated the VA’s feelings. Prior to the incident, there were times when the VA “targeted” the SP and called his/her family and friends to talk disparagingly about the SP. The SP provided the following information regarding February 20, 2024: · The VA was in his/her room talking on the telephone to a relative and was “insulting” the SP by calling the SP names like “stinky.” The SP did not respond to the VA’s comments. · The SP was in the office when the VA requested a PRN medication for diarrhea. The SP initially had difficulty locating the medication and called P2 and P4; however, neither of them answered their phones. The SP then found the PRN and told the VA that s/he needed to “pop it and give it to” the VA. The VA said the SP should give it to the VA along with scissors. The SP was “skeptical” about giving the VA scissors and attempted to call P4 again to ask if that was allowed, and again was not successful in reaching P4. At that point the VA was “yelling and shouting and going off” on the SP. The SP said that s/he had never administered the PRN before nor had s/he seen anyone give the VA scissors. The SP opened the PRN package and gave the medication to the VA. · When the SP finally reached P4 via telephone, P4 said that the VA “has rights” and the SP could give the VA scissors. While the SP was talking to P4, the VA called P1 and told P1 that the SP called the VA the “R word.” The SP attempted to tell P1 that was not true, and that the VA called the SP the “R word.” The SP told the VA that s/he should “stop being mean” to the SP and stop calling the SP names. The VA said that s/he would make the SP’s life “miserable.” The SP denied ever calling the VA the “R word.” The G worked with the VA for about five years and said that there were concerns about the VA’s ability to accurately report events, especially if it concerned a staff person that the VA did not get along with. Regarding this incident, the VA called the G and said s/he needed to talk about “something” a staff person had done; however, the VA did not tell the G that the SP used the “R word.” The G said that the VA “does not get sharp objects” because of his/her “history of suicidal ideation and violent outbursts.” The G believed that the VA’s use of sharps was addressed in his/her IAPP and said it was “cut and dry to avoid” the VA using them. Staff persons were trained regarding the VA’s support plans, behavior modification, conflict avoidance and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on February 20, 2024, the VA requested a PRN medication and scissors to open the medication. The SP was working and had not administered a PRN medication to the VA on any prior occasions, and also did not know if the VA was allowed to use scissors, so the SP attempted to call P2 and P4; but was initially unsuccessful resulting in the VA becoming more agitated. The VA said that the SP called him/her the “R word” and made other comments about the VA residing in a facility. The SP denied calling the VA the “R word” and said that it was the VA who called the SP that name along with other derogatory words. Given the conflicting accounts provided by the VA and the SP, that there were no other witnesses to the incident, that there was information that the VA made derogatory remarks about the SP on prior occasions, and that P1, P3, and the G each provided information regarding the VA’s credibility, there was not a preponderance of the evidence whether the SP engaged in actions or behavior that produced or could reasonably be expected to produce emotional distress. 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: 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 determined that policies and procedures were adequate but were not followed when the VA was not allowed to use scissors as outlined in his/her SMA. No retraining was needed because 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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