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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: 1075952-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kimberly Anderson/Alice Percy 651-431-6553 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP) hit two vulnerable adults (VA1 and VA2) and was also verbally abusive to VA1 and VA2. Allegation two: It was also reported that on more than one occasion, the SP smoked marijuana while transporting VA1 and VA2 in the SP’s vehicle and in the company vehicle.
Date of Incident(s): Ongoing, prior to January 17, 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 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 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. 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 March 7, 2024; from documentation at the facility; and through ten interviews conducted with two facility administrative staff persons (P1 and P2), a staff person (P3), the SP, VA1, VA2, two residents (R1 and R2) who also resided at the facility, VA1’s guardian (G), and VA2’s case manager (CM). VA1 enjoyed playing video games, spending time in the community, and spending time with his/her friends and family members. VA1’s diagnoses included anxiety, depression, schizophrenia, and post-traumatic stress disorder (PTSD). VA1 had four hours of unsupervised time in the community each day. According to VA1’s Individual Abuse Prevention Plan (IAPP), when VA1 became upset, the staff persons were to remain calm and allow VA1 to communicate his/her frustrations and VA1 that his/her concerns were heard. According to VA1’s Support Plan Addendum – Intensive, facility staff persons were to provide services to VA1 to stabilize his/her mental health and to assist VA1 with community access and participation. VA1 had access to a cell phone and was able to arrange rides through Lyft and by using the metro bus system. VA2 enjoyed going on community outings, playing cards, watching sporting events, and spending time with his/her friends and family members. VA2 used buses and Lyft to access the community. VA2 worked at a community job three days each week. VA2’s diagnoses included schizophrenia, hypertension, and alcohol use disorder. VA2 was not subject to guardianship and had two hours of unsupervised time in the community each day. According to VA2’s Support Plan Addendum - Intensive, VA2 was on a legal provisional discharge after a civil commitment. VA2 was required to maintain sobriety and was required to call in daily for random drug tests and staff persons were to provide VA2 a ride to the lab as needed. The staff persons were to also assist VA2 with finding and attending 12-step meetings. According to VA2’s Individual Abuse Prevention Plan (IAPP), VA2 had a history of using intoxicating substances such as cocaine and alcohol, which was a contributing factor in VA2’s criminal history and mental health decline. The staff persons were to encourage VA2 to attend 12-step meetings and to motivate VA2 to remain sober. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on VA1’s and VA2’s plans prior to the incidents. Allegation one: It was reported that the SP hit VA1 and VA2 and was also verbally abusive to VA1 and VA2. According to the facility’s Incident Report and Internal Review, on January 11, 2024, VA1 told P1 that the SP was “verbally abusive” toward VA1 by yelling at VA1 “every day.” VA1 stated that the SP called VA1 a “pussy” and repeatedly told VA1 that s/he “would never find a [boy/girlfriend].” VA1 stated that on one occasion, VA2 “tapped” the SP on the arm to get the SP’s attention. The SP then “jumped up” and told VA2 not to touch him/her “like that” and “gave [VA2] a little hit on the arm.” On multiple occasions, when VA1 asked the SP if a meal was ready, the SP loudly clapped his/her hands, shook his/her head, walked “aggressively close” to VA1, pointed, and yelled at VA1 that his/her food was “over there.” The SP frequently “made little comments” to VA1 about how VA1 was unable to cook and that VA1 “can’t get a [boy/girlfriend].” VA1 stated that the comments “added up” and “felt negative.” The SP frequently yelled at VA1 and made VA1 feel like s/he “wasn’t a person.” Although the SP acted like s/he was “all smiles,” s/he was “hateful” when s/he interacted with the residents. VA1 “heard” from people in the community that the SP told others that VA1 was a “little snitch.” After the SP no longer worked at the facility, VA1 felt like s/he could eat his/her meals at the table instead of taking the food to his/her bedroom and “hiding away.” VA2 stated that on one occasion, VA2 was talking to the SP when s/he turned away from VA2. VA2 “touched” the SP’s shoulder and the SP hit VA2 on the arm, but did not injure VA2. The SP then told VA2 that VA2 “hit” the SP. VA2 “did not socialize too much” with the SP and “kept [his/her] distance.” R1 stated that there were “a lot of arguments” at the facility in the past couple of years, but s/he “stayed out of it.” R2 stated that the SP was “confrontational and aggressive.” The SP yelled at VA1 when VA1 “pissed off” the SP. On one occasion when the SP believed that someone at the facility stole earbuds from the SP, the SP went to R2’s bedroom, blamed R2 for taking them, and screamed R1 “at the top of [his/her] lungs.” The SP was “scary” when s/he “screamed” at R2. The SP also watched “inappropriate” and “triggering” television shows at the facility and continued to watch them after R2 asked the SP to watch another program. P1, P2, and P3 provided the following information: · P1 stated that on several occasions the SP was “argumentative” with VA1 and P1 had to “get between those two” when they argued. P1 had several coaching sessions with the SP about the residents being vulnerable adults and how the staff persons were to work with them. After the sessions, the SP told P1 that s/he would “do better.” P1 stated that on one occasion, VA1 told P1 that VA2 attempted to get the SP’s attention and tapped the SP’s shoulder and the SP “freaked out” and threatened to “call the cops” because VA2 hit the SP. · P2 stated that when s/he talked to VA1 about the SP’s interactions, VA1 told P2 that s/he was “not a snitch” and would not talk to P2 about the SP. P2 stated that the SP was “abusive and manipulative” with the residents and “tried to get things out of them.” The SP believed it was justified to “be mean” to the residents because they said mean things to him/her. The other residents were afraid to speak to P2 about the SP, but after the SP no longer worked at the facility, all four told P2 that the SP was “mean” and did not respect them. · P3 stated that the SP treated the residents “real shitty” and treated them like they were children instead of adults. The SP was “hostile with [his/her] words when talking to VA1, R1, and R2. The SP was also “hostile” with the residents when they interrupted him/her while s/he watched his/her television shows. VA2 did not tell P3 that the SP hit VA2 but said that the SP yelled at VA2. · P3 stated that s/he talked to P1 about his/her concerns regarding the SP’s behavior with the residents, but P1 typically “swept things under the rug.” The residents did not like to complain to the staff persons about other staff persons because they did not want to “snitch” on anyone. The SP provided the following information: · The SP stated that s/he was the only staff person who had a driver’s license so s/he frequently took the residents on community outings and to medical appointments. The SP believed that initially s/he had a “great relationship” with the residents. However, “it got rough” when the SP did not do what VA1 wanted to do. VA1 called the SP names and swore at the SP. On one occasion, VA1 told the SP that s/he would “break your fucking face” because the SP refused to take him/her to the store until P1 put gas in the facility’s van. · On one occasion, VA2 walked up to the SP and hit the SP’s shoulder “hard” and asked the SP to take him/her to a store. The SP told VA2 to back up and that VA2 hurt the SP when s/he hit the SP. The SP stated that s/he never put his/her hands on VA2 and did not hit VA2 after VA2 hit the SP. · The SP believed the VA1 and VA2 wanted the SP to stop working at the facility because the SP sometimes refused to take them to smoke marijuana with their friends or to take them on community outings “five or six times a day.” P1 and the SP tried to set up a system of going on community outings, but the residents did not follow the system. If the SP did not provide transportation when they wanted, they yelled, screamed, and “cussed” at the SP. On several occasions, the SP called the police because s/he was worried about his/her safety. The G stated that VA1 did not talk to him/her about the SP. The G was uncertain about VA1’s ability to be an accurate reporter of events. The CM stated that VA2 told the CM that the SP “was calling police” on one of the other residents, which concerned VA2. VA2 wanted to “keep distance” from the SP because s/he did not want to be “singled out” by the SP. VA2 told the CM that on one occasion when s/he tapped the SP on the shoulder to get his/her attention, the SP hit VA2 and then claimed that VA2 hit the SP first. The CM stated that VA2 was a reliable reporter of events. Relevant Rules and Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (a), clause (6) state that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion for Allegation one: VA1 and/or VA2 each provided consistent information to this investigator, P1, and/or the CM that on one occasion when VA2 “touched” the SP’s shoulder, the SP hit VA2 on the arm. The SP said that one time, VA2 walked up to the SP and hit the SP’s shoulder “hard” and asked the SP to take him/her to a store. The SP told VA2 to back up and that VA2 hurt the SP when s/he hit the SP. The SP stated that s/he never put his/her hands on VA2 and did not hit VA2 after VA2 hit the SP. Consistent information was provided by VA1 and R2 that the SP yelled and “screamed” at the residents. P1 stated that the SP was “argumentative” with the residents and P2 stated that the SP was “abusive and manipulative” with the residents. P3 stated that the SP treated the residents “real shitty,” treated them like they were children instead of adults, and was hostile around the residents. Although the SP denied yelling at or hitting the residents, s/he had reason to minimize his/her actions for fear of repercussions. In addition, given that the information provided by VA1, R2, P1, P2, and P3 was similar in nature, it was more likely that their accounts of the SP’s interactions were more accurate. Therefore, the SP’s actions as described by VA1, VA2, R2, P1, P2, and P3 were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were violations of Minnesota Statutes, section245D.04, subdivision 3, paragraph (a), clause (6). Although VA1 said that the SP’s actions caused VA1 to feel like s/he “wasn’t a person,” that the SP hit VA2, and that consistent information was provided that the SP’s behavior to the residents was confrontational and aggressive, there were no details of the incidents provided such as date, time, persons present, and/or circumstances of any incident. Yelling, screaming, and arguing with residents was not accidental or therapeutic conduct, however, without additional details of incidents, there was not a preponderance of the evidence whether the SP’s actions could reasonably be expected to produce physical pain or emotional distress. It was not determined whether physical and/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 and/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). Allegation two: It was also reported that on more than one occasion, the SP smoked marijuana while transporting VA1 and VA2 in the SP’s vehicle and in the company vehicle. VA1 stated that the SP frequently smoked marijuana while working at the facility and then slept on the sofa “all day.” The SP then refused to drive the residents on community outings for approximately six months. On one occasion, VA1 went outside to ask the SP to take him/her to a store and saw the SP sitting in his/her car and smoking marijuana. The SP “was pissed” to see VA1 and “kind of peeled off” to the end of the driveway in his/her car and continued to smoke marijuana. On multiple occasions, the SP smoked marijuana in the facility’s van and sometimes drove to smoke marijuana with “other people” before returning to the facility. VA2 stated that the SP vaped marijuana while driving the residents, including VA2, in the facility’s van. VA2 never smoked marijuana with the SP and the SP’s use of marijuana around VA2 did not affect VA2’s drug tests. VA2 knew that the SP was smoking marijuana because s/he knew what marijuana smelled like. R1 stated that the SP used a vape pen while working at the facility, but R1 was uncertain if it was marijuana in the vape pen. R2 stated that on several occasions the SP smoked marijuana at the facility but none of the resident’s smoked marijuana with the SP. The SP drove “aggressively” and smoked marijuana in the facility’s van while the residents were in the vehicle. R2 did not say anything to the SP about smoking in the vehicle. P1 and P3 provided the following information: · P1 stated that after the SP stopped working at the facility, VA2 told P1 that the SP smoked marijuana while driving VA2 to his/her 12-step meetings in the facility’s van. P1 never saw the SP smoke marijuana while working at the facility and none of the other staff persons told P1 that the SP smoked marijuana at the facility. · P3 stated that on November 2, 2023, the SP drove VA1 in the facility’s van to purchase marijuana. After they smoked marijuana together, they got into an argument. The SP was “always smoking” marijuana in his/her vape pen in his/her car or on the facility’s patio. P3 could tell that the SP smoked marijuana because of the smell. The SP had a second vape pen to use with tobacco. P3 talked to other staff persons about the SP smoking marijuana. The SP provided the following information: · The SP stated that s/he did not smoke marijuana and had never smoked marijuana at the facility. The SP never had marijuana in the facility’s van or in the facility. The SP smoked a vape pen that contained a loon mint flavor of tobacco. VA2 once asked to use the SP’s vape pen, but the SP said, “No,” and VA2 bought a similar one.
· The SP denied smoking marijuana when s/he drove VA2 to his/her 12-step meetings or when s/he took any of the residents on community outings. VA1 smoked marijuana in the facility’s basement and on the patio when VA2 was present. VA1 used medical marijuana and smoked it “almost every day” so there was the smell of marijuana in the facility. · On one occasion, the SP took VA1 to get his/her medical marijuana at the dispensary. The G stated that VA1 told P1 that the SP smoked marijuana in the facility’s driveway. VA1 did not have any rights restrictions on the use of marijuana and VA1 had used marijuana since it became legal. The CM stated that VA2 told the CM that when the SP drove VA2 to his/her 12-step meetings, the SP smoked a marijuana vape pen in the facility’s van. VA2 was concerned that because s/he rode in the van while the SP smoked marijuana, s/he might test positive for marijuana during one of his/her random drug tests, which could impact his/her provisional discharge. According to the facility’s Drug and Alcohol Policy, all staff persons must be free from the abuse of prescription medications or being in any manner under the influence of a chemical that impairs their ability to provide services or care. Conclusion for Allegation two: Although VA1, VA2, R2, and P3 provided consistent information that the SP smoked marijuana while working at the facility and VA2 and R2 provided consistent information that the SP smoked marijuana while driving the residents, the SP denied the allegations. In addition, there were no details of the incidents provided such as date, time, persons present, and/or circumstances of the occurrences. Given this, that there was no information that any resident was harmed as a result of the SP’s actions, and that VA2 was required to take random drug tests which might have been negatively impacted by being near the SP when s/he smoked marijuana, but there was no information provided that this occurred, there was a not preponderance of the evidence whether the SP was under the influence of marijuana while driving the residents. It was not determined whether neglect occurred (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 two internal reviews and determined that the facility’s policies were adequate, but were not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On February 19, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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