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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: 1110598-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kim Huettl Anderson/Heidi Murphy 651-431-6553 Suspected Maltreatment Reported: It was reported that a staff person (SP) spit in a vulnerable adult’s (VA’s) face. Date of Incident(s): August 31, 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 subdivision2, 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 October 15, 2024; from documentation at the facility; and through five interviews conducted with the VA, a facility staff person (P1), two supervisory staff persons (P2 and P3), and the VA’s guardian (G). Attempts were made by phone and U.S. mail to contact and interview a staff person (SP), but the attempts were unsuccessful. The facility was a single family, split-level residence in a residential neighborhood that was staffed 24 hours. The VA’s Coordinated Services and Supports Plan stated that the VA enjoyed going on van rides, listening to music, and watching movies. The VA was diagnosed with autism, fetal alcohol syndrome, mild intellectual developmental disorder, impulse control disorder, intermittent explosive disorder, unspecified depression disorder, and complex trauma/post-traumatic stress disorder. The VA’s Coordinated Services and Support Plan Addendum stated that the VA had a history of physical aggression toward others, including spitting, hitting, kicking, pushing, biting, and pinching. Staff persons were to redirect the VA when s/he was physically aggressive and encourage the VA to take a break from the situation. The VA’s Intensive Support Self-Management Assessment stated that the VA’s cognitive diagnosis impaired the VA’s judgment and memory. The facility’s Maltreatment Internal Review provided the following information: · On September 2, 2024, P1 told P2 that on August 31, 2024, at 6:20 p.m., the VA had returned to the facility after a van drive and questioned the SP about always being on his/her cellphone at work. The VA then hit and spit on the SP and the SP spit back at the VA. P1 “de-escalated” the incident by suggesting that the VA go for a walk or watch TV in his/her room. The VA chose to watch TV in his/her room. · On September 3, 2024, P2 spoke to the SP and P1 about the incident. P1 told P2 that on the date of the incident, s/he saw the VA hit and spit at the SP and the SP “spit back [in the VA’s] face.” The SP told P2 that on the date of the incident, the VA hit the SP on the head and spit at the SP. The SP told the VA that if s/he spit on him/her, the SP would “spit back” on the VA. The SP said that during this time, P1 took the VA to another room to calm. · On September 9, 2024, P3 spoke to the VA, the SP, and P1 about the incident. The VA told P3 that on the date of the incident, s/he hit the SP on the head because the SP “ignored” the VA when the VA asked the SP why s/he was always on his/her cell phone. The VA told P3 that the SP attempted to “redirect” him/her and the VA hit the SP a couple more times and spit on the SP. The SP then spit back in the VA’s face. P1 told P3 that on the date of the incident, s/he was in the VA’s bedroom cleaning. P1 then heard the SP and the VA “raising” their voices and the VA stating, “You are really going to spit at me?” P1 came out of the bedroom and observed the VA wiping his/her face but did not see the SP spit at the VA. The SP told P3 that on the date of the incident, the VA hit him/her on the head and when s/he tried to redirect the VA, the VA hit him/her a couple more times. The VA also spit at the SP. The SP then said to the VA, “Don’t you think I won’t spit back at you?” The SP denied spitting at the VA. · On September 10, 2024, a supervisory staff person (P4), spoke to P1 and the SP about the incident. P1 told P4 that at the time of the incident, s/he was coming out of the VA’s bedroom when s/he saw the VA punch and spit at the SP. The VA then “yelled” that the SP spit at him/her and P1 saw the VA wiping his/her face. P1 told P4 that s/he did not see any “liquid” on the VA’s face. The SP told P4 that the VA hit and spit at him/her. The SP asked the VA why s/he spit on him/her and told the VA that the VA “cannot spit on people [because] it could go in their mouth.” The SP denied spitting at the VA. The VA said that on the day of the incident, s/he returned to the facility after a van ride with the SP. The SP was in the dining room on his/her phone and the VA got upset and asked the SP why s/he was always on his/her phone. The SP ignored the VA, which upset the VA so the VA spit on the SP and in return, the SP spit on the VA. P1 got in between the VA and the SP and the VA went to his/her bedroom. P1 provided the following information: · On the date of the incident, P1 was in the VA’s bedroom and the SP and the VA were in the living room. P1 heard the SP say that the VA hit him/her. P1 then walked into the dining room and saw the VA wiping his/her face. P1 did not see the VA hit or spit on the SP or the SP spit on the VA. P1 intervened and separated the VA from the SP. · The VA had a history of hitting and spitting on staff. P1 never saw any staff person spit on the VA and did not know why someone said that s/he saw the SP spit at the VA. The VA had a history of calling police stating that staff persons did things to him/her and then when police arrived, the VA told law enforcement that staff persons had not done anything to him/her. P2 provided the following information: · On September 2, 2024, around 12:25 p.m., P2 called P1 who said that on August 31, 2024, around 6:20 p.m., the VA “hit” the SP and “spit” on the SP and the SP “retaliated” by spitting back on the VA. · P2 then spoke to the SP who said that on the date of the incident, the VA hit and spit on the SP. The SP responded by saying s/he would spit back on the VA and call the police. The SP denied that s/he spit on the VA. · P2 believed the VA’s account of the incident, in part because P1 also told P2 that the SP spit on the VA. · The VA had a history of physical and verbal aggression when s/he was upset, including hitting and throwing things at staff. Staff persons were trained to use de-escalation and redirection techniques to calm the VA. Staff persons were prohibited from retaliating against the VA. P3 provided information that was consistent with the information s/he provided for the internal review. The G stated that the VA had a history of “randomly attacking” staff. The VA had made “false accusations” in the past but had also made truthful ones. The G was aware from a facility incident report that the VA had hit and spit on staff but was not aware that staff allegedly spit on the VA. Facility training records showed that the SP, P1, and P2 received training on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans prior to the incident. Conclusion: The VA told P3 and this investigator that on August 31, 2024, the SP spit at him/her, and according to P2, P1 told P2 that s/he saw the SP spit on the VA. However, P1 told this investigator and P3 that s/he did not see the SP spit on the VA, but s/he did hear the VA say that the SP spit at him/her, and immediately afterward saw the VA wipe his/her face. The SP told P2 and P3 that s/he did not spit on the VA. Given that the VA’s plans, P1, and the G stated that the VA was not consistently an accurate reporter of events and the conflicting information provided by P1, there was not a preponderance of the evidence as to whether the SP spit on the VA. 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: 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 their policies were adequate, but not followed, and that there was no need for additional training. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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