|
AMENDED 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.” NOTICE: This Amended Maltreatment Investigation Memorandum supersedes a version dated January 26, 2025, which must be destroyed. The original version was incorrectly dated as being issued on January 26, 2025, and should have been dated as being issued on January 16, 2025. The amended version contains the correct date issued.
License Number and Program Type: 1104769-HCBS (Home and Community Based Services) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: Allegation One: It was reported that an unknown staff person took “personal items” and $150 from a vulnerable adult (VA).
Allegation Two: It was reported that a physical altercation occurred between the VA and two unknown staff persons (later determined to be SP1 and SP2), during which SP1 or SP2 called the VA “retarded” (referred to as the r-word throughout the remainder of the report) and “autistic.” It was also reported that the VA sustained a swollen eye from the altercation. Date of Incident(s): Allegation One: Unknown Allegation Two: August 25, 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), clauses (1) and (2); and subdivision 9, 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. · 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 24, 2024; from documentation at the facility and law enforcement records; and through 8 interviews conducted with two staff persons (SP1 and SP2), a supervisory staff person (P), the VA’s case manager (CM), the VA, and three additional community persons (C1, C2 and C3). SP1’s and SP2’s interview was conducted in conjunction with law enforcement. The VA’s guardian was relatively new to working with the VA and did not have additional information to provide related to this investigation. The VA was diagnosed with generalized anxiety disorder, attention deficit hyperactivity disorder, moderate intellectual disabilities, autism spectrum disorder, and prenatal drug exposure. The VA had a 24-hour plan of care and 2:1 staffing 24 hours a day, the VA required “constant supervision” due to self-injurious behaviors. The VA received transportation services, behavioral supports, medication management, mental health support, and supervision from the facility. The VA lived alone in an apartment that was owned by the facility. The VA enjoyed playing video games, writing, and attending sporting events. Facility documentation showed that SP1 and SP2 were each trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Allegation One: It was reported that an unknown staff person took “personal items” including Air Pods, and $150 from the VA. According to the VA’s Coordinated Services and Supports Plan, the VA was able to make small purchases and shared that s/he preferred to use his/her credit card. The VA was inconsistent when it came to identifying coins and knowing the value of money. The VA had an outside provider acting as his/her representative payee that supported that VA in managing his/her money and paying his/her bills. The VA received $100 in cash for personal needs once a month that s/he used when s/he wanted to purchase something, and the VA “benefitted from verbal assistance” and “constant supervision” to complete his/her shopping needs. The VA had someone with him/her “at all times” while shopping to “support [him/her] with all transactions” and received transportation to and from stores as requested. The VA stated that s/he left his/her AirPods in a staff persons car and the staff person’s car was broken into and the AirPods were stolen. The facility was reimbursing the VA for the AirPods. The VA had cash missing but did not remember the amount or when it happened. The VA also did s/he know who was working at the time. The CM spoke to the VA on September 18, 2024, and the VA told the CM that the VA left his/her AirPods in a staff person’s car and the staff person could not find them. The VA told the CM that the facility was giving him/her cash in order to obtain replacement AirPods. The VA also told the CM that s/he was missing $150 but could not provide the CM a specific timeframe for when the cash went missing but the CM thought it was “probably within the last month.” The P stated that the VA’s guardian was in charge of managing the VA’s finances and did not have any information about any staff persons taking or using the VA’s money. The P did not have any additional information to provide about the VA’s finances, but thought that the VA kept cash and had a credit card. The P stated that the VA frequently accused others of taking things that the VA him/herself lost. The VA’s AirPods were stolen from a staff person’s car and the facility reimbursed the VA in cash for the AirPods. SP1 and SP2 each stated that they did not know anything about the VA’s finances, did not know if the VA kept cash on his/her person, and never took cash or any other things from the VA. The P, SP1, and SP2, provided consistent information neither the facility nor staff persons were responsible for managing the VA’s finances and did not have a policy related to managing client finances. Conclusion for Allegation One:
According to information provided by the P, the CM and the VA, the VA left his/her AirPods in a staff person’s car and the AirPods were taken from the staff person’s car. The facility reimbursed the VA in cash for the missing AirPods. According to information provided by the CM and the VA, the VA also had cash that went missing but there was no additional information about the circumstances of how or when the cash went missing. SP1 and SP2 denied knowing anything about the VA’s finances, and the P stated that the VA had a history of losing things and accusing others of taking the lost items. In addition, the P, SP1, and SP2 provided consistent information that staff person were not responsible for managing the VA’s finances. Therefore, there was a preponderance of the evidence whether any staff person took the VA’s money. It was not determined whether financial exploitation occurred (In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. Allegation Two: It was reported that SP1 and SP2 engaged in a “physical altercation” with the VA during which one or both of the staff persons called the VA the r-word and “autistic.” It was also reported that the VA sustained a swollen eye from the altercation. The VA’s Individual Abuse Prevention Plan stated: · The VA had a “tendency to falsely report incidents” and “misunderstand social cues.” The VA also had an “addiction to online activities” that increased his/her susceptibility to multiple forms of abuse. · 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 because s/he was verbally/physically aggressive to others According to the facility’s Internal Review on August 25, 2024, at approximately 3 p.m., the VA live-streamed on TikTok with his/her friends (C1-C3). The VA requested that SP1 and SP2 give him/her space, and SP1 and SP2 did so. “Shortly after,” the VA approached SP1 in “an unusual manner” and without provocation, the VA smacked SP1’s wrist and walked away. The VA then returned to speak to SP1 and accused SP1 of hitting the VA’s wrist. SP1 and SP2 gave the VA the space s/he needed to deescalate after the incident and did not engage further with the VA regarding the incident. The VA did not provide additional context, evidence or details about the incident other than that SP1 hit him/her on the wrist. The VA told law enforcement that on August 25, 2024, around 3 p.m., the VA was assaulted by a staff person who provided services to the VA and “filled in on the weekends.” The VA could not remember the name of the staff person but provided a physical description and a description of the vehicle that the staff person drove. The VA stated that the incident started “because of a debate” that led to a verbal fight and turned into a “physical altercation” in which the staff person hit the VA on the arm. The VA stated that s/he was live streaming on TikTok when the altercation occurred, and there were three witnesses who saw it happen on the live stream. Law enforcement officers asked the VA for a copy of the live stream, but the VA could not find the video. The VA provided limited information to this investigator because s/he preferred for this investigator to obtain information from C1-C3 about the incident. The VA stated that s/he was live-streaming on TikTok with C1-C3, when a staff person hit him/her on the right arm near the wrist. The VA then “took a pillow” to block him/herself from the staff person who continued to hit the pillow the VA was holding. The VA stated that s/he heard C3 on the other end of the TikTok live-stream say, “Stop.” The VA stated that s/he could not access the TikTok live recording because it was no longer in his/her TikTok history because the TikTok live-streams only saved for 30 days. [Note: The incident occurred on August 25, 2024, and this investigator asked the VA to access the recording on his/her mobile device on September 18, 2024, at which time the video was not in the VA’s history. According to tiktok.com, TikTok Live replays are available for review and download for 30 days.] C1, C2, and C3 each provided the following information to law enforcement: · C1 was watching the VA’s live stream on TikTok and saw a staff person try to take the VA’s gaming equipment. When the VA did not let them, the staff persons “became angry” and “physically grabbed” the VA by the arms. Staff persons called the VA “names” and were “screaming” at the VA. · C2 was watching the VA’s live stream on TikTok and heard staff persons “scream and yell” at the VA because they wanted to use his/her gaming equipment. Staff persons called the VA names such as the r-word and “autistic.” The staff persons kept yelling and subsequently “put hands” on the VA. The live stream then ended and C2 did not see anything further. Later that evening, C2 joined the VA’s live-stream again and saw that the VA was “visibly distraught” and “emotionally in distress.” C2 noticed “slight redness” under one of the VA’s eyes that appeared “minorly swollen,” but could not remember which eye. · C3 was watching the VA’s live stream on TikTok when staff persons began to “torment and scream at” the VA because they wanted to use his/her gaming equipment and the VA did not want them to use it. C3 stated that s/he saw a “hand swing at [the VA]” but could not see anyone’s face. C3 stated that the VA picked up a pillow to try and protect him/herself from the hit. C3 then saw a hand swing towards the pillow that the VA was holding. C3 stated that the livestream went on pause and s/he could not see anything further. C1 told this investigator that s/he was watching the VA’s live stream on TikTok when an argument ensued between the staff persons working and the VA because of politics. C1 stated that s/he saw the staff persons “abuse” the VA but did not provide further details about the alleged incident. C1 did not have a copy of the video. C2 told this investigator that on August 25, 2024, the VA was live-streaming on TikTok and C2 watched the live-stream. The VA was playing on his/her gaming equipment when a staff person told the VA to get off his/her gaming equipment, which then turned into an argument between the staff person and the VA. C3 saw “a punch coming at [the VA],” but before C3 saw anything else, the live stream ended. C3 could still hear audio through the live-stream and the staff persons were “screaming really loud” but C3 could not make out what they were saying. C2 did not remember the staff persons who were working, but stated that they were different than the staff persons who typically worked with the VA. C2 did not have a copy of the video. C3 told this investigator that on August 25, 2024, s/he was watching the VA live stream on TikTok when s/he saw a staff person hit the VA on the arm. C3 did not hear the staff persons say anything to the VA but they were “just screaming.” C3 did not remember the staff persons’ names who worked during the incident, nor did s/he remember what they looked like, or which hand the staff persons hit the VA with. C3 did not have a copy of the video. SP1 provided the following information: · SP1 worked with the VA “a couple of times,” and a maximum of five times. The VA “mostly was really calm” and often live streamed on TikTok with his/her friends. SP1 did not think that the VA was an accurate reporter, but also stated that s/he has “never had to deal with [the VA] much.” · On August 25, 2024, SP1 worked with SP2 at the VA’s. During the day, the VA was live-streaming on TikTok and “humiliated” and “degraded” SP1 and SP2 to the viewers of the live-stream. SP1 said that the people the VA interacted on TikTok with, tried to “influence” the VA to ”humiliate” and “degrade” the staff persons. At one point, the VA propped his/her phone up and “smacked” SP1’s wrist. SP1 “stayed as calm as possible” and immediately went outside of the VA’s apartment, into the hallway, where s/he waited until s/he calmed and then s/he went back into the VA’s apartment. SP1 denied hitting the VA and did not see any other staff persons hit the VA. · SP1 denied calling the VA names or calling the VA the r-word or “autistic.” SP1 never heard any other staff persons call the VA names or call the VA the r-word SP2 provided the following information: · On August 25, 2025, SP2 worked with SP1 at the VA’s. This was the first and only time SP2 worked with the VA. At an unknown time, SP1 and SP2 were sitting on a couch in the living room and the VA was sitting on a separate couch in the living room. The VA was live-streaming on TikTok, and someone on the live-stream got “under [the VA’s] skin.” The VA removed his/her shirt, “got mad,” and threw pillows around the living room. The VA then took a pillow and hit SP2 with the pillow and turned to SP1 and hit SP1’s wrist. SP1 and SP2 left the apartment into the building hallway and gave the VA “space.” · After the incident, SP2 cleaned up the living room. SP2 said that because of the VA’s diagnoses, SP2 did not take the incident “too seriously.” The VA was “normal” at the end of the shift when SP2 left and was still live streaming on TikTok. · SP2 stated that s/he never hit the VA, never yelled at the VA, never called him/her any names, and never called him/her the r-word. SP2 never saw SP1 hit, yell at, or call the VA any names. SP2 “heard” that the VA “lied” in the past. The P provided the following information: · The VA live streamed on TikTok and got involved in political debates that made the VA “rattled” and left the VA feeling “very upset.” · The P was told by an administrative staff person, that it was alleged that on August 25, 2024, SP1 and SP2 “assaulted” the VA while the VA was live streaming on TikTok. The P said s/he was not informed of the incident until after this investigator notified the facility about the investigation. The P stated that SP1 and SP2 “wouldn’t do anything to hurt [the VA]” and s/he had no concerns about their interactions. Nothing was similar was reported in the past regarding SP1’s and SP2’s interactions with the VA or any other clients. · The VA was not an accurate reporter of events and “dramatized” events. The CM did not have any information about the incident. Law enforcement took no additional action and closed their report. Conclusion Allegation Two:
C1, C2, C3, and the VA provided information that on August 25, 2024, while the VA was live streaming on TikTok, there was an altercation between the VA and SP1 and SP2. C1-C3 provided different information to law enforcement and this investigator about what occurred including what prompted the incident, what was said, and the physical interactions between staff persons and the VA. The VA stated that staff persons hit him/her on the wrist, the VA grabbed a pillow to block him/herself and the staff persons continued to hit the VA. C1-C3 nor the VA were able to provide a copy of the video to this investigator. SP1 and SP2 each denied hitting the VA or seeing the other hit the VA. SP1 and SP2 each stated that the VA hit SP1 on the wrist. SP1 and SP2 also each denied yelling or screaming at the VA or calling the VA names, and never saw the other staff person do so. Information provided by SP1, SP2, the P and included in the VA’s plans showed that the VA was not an accurate reporter of events. Given that C1-C3 provided different details to law enforcement and this investigator, that the video was not available for review even though it was requested prior to the 30 day TikTok automatic delete, that SP1 and SP2 each denied the allegations, and that law enforcement took no additional action, there was not a preponderance of the evidence whether SP1 and/or SP2 hit the VA, caused injury to the VA, or yelled at and called the VA names. It was not determined whether physical or 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult or 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 and followed, the facility determined that SP1 and SP2 “followed proper protocols and handled the situation professionally.” Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
