|
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: 1071814-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071801-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-6553 Suspected Maltreatment Reported: It was reported a staff person (SP) pinched a vulnerable adult’s (VA) arm and pulled the VA’s hair. Date of Incident(s): Multiple incidents on and prior to October 7, 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): 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 18, 2024; from documentation at the facility; and through six interviews conducted with facility staff persons (P1, P4, and P5), facility supervisors (P2 and P3), and the SP. The VA was not interviewed due to his/her limited communication. Facility documentation showed the VA enjoyed going on car rides, watching movies, and spending time with his/her family. The VA was non-verbal and diagnosed with Angelman syndrome. The VA required 24-hour supervision and could be “easily manipulated or mistreated.” The VA’s Individual Abuse Prevention Plan provided the following information: · The VA was unable to communicate if s/he was being physically abused but would “likely cry out.” · The VA was visually checked daily while bathing for any signs of physical abuse. Staff persons were to intervene or contact 9-1-1 if they observed the VA being physically abused. If the VA was injured or signs of abuse were found, staff persons should document, and the facility would complete an investigation. · The VA might display self-injurious behaviors (SIBs) when s/he was upset or overstimulated. The SIBs included crossing his/her arms and “squeezing really hard” or biting his/her arms. The facility was a single level home with four bedrooms. The facility’s front door opened into an entryway which was located between the living room and dining room. The dining room and the kitchen had a shared wall with a cutout, which provided direct sightlines from the kitchen sink to the dining table. The bedrooms were in the rear of the facility, along a hallway. Two bathrooms were in the middle of the hallway, with two bedrooms on each side of the bathrooms. On October 7, 2024, while at the VA’s day program, the facility was informed the VA had bruising on his/her left forearm. A photo taken of the VA’s left arm at the day program showed a purple and red bruise that had an irregular shape and was approximately the size of a quarter. P2 completed a full body check of the VA after s/he returned to the facility from the day program on October 7, 2024. P2 saw two concerning marks on the VA. The first mark was the bruise described above, and the second mark was a bruise which was located on the VA’s left bicep/shoulder area. P2 did not take a picture of the second bruise on October 7, 2024, however P2 said it was similar to the bruise on the VA’s left forearm at that time. On October 10, 2024, P2 took a picture of the second bruise, but the bruise had mostly healed. P2 said in the October 10, 2024, photo there were additional “scratches” near the bruise, as well as on the VA’s neck, but those scratches were from the VA. Information from the facility, including an Internal Review (IR), and from interviews completed by this investigator provided the following mostly consistent information: · P1 said on September 13, 2024, after cleaning the kitchen, s/he walked into the living room and observed the SP and the VA. The VA was sitting in a chair, and the SP was attempting to complete medication administration. P1 saw the SP pinch the VA’s left arm, and saw the VA’s skin between the SP’s fingers while the SP pinched the VA. The VA stopped moving, and P1 looked away from the alleged incident because s/he did not want the SP to know s/he observed the interaction. · P1 said that on a later unknown date, P1 saw the SP pull the VA’s hair “really hard” while assisting the VA with personal cares. P1 made eye contact with the SP, and the SP immediately stopped pulling the VA’s hair. · P1 did not inform anyone of the above incidents until October 9, 2024. · On October 3, 2024, the VA’s progress note stated the VA had a bruise on his/her arm. · P2 said P1 called him/her on October 9, 2024, and provided information that was consistent with the information above regarding the SP pinching the VA and pulling the VA’s hair. P1 also told P2 that on October 6, 2024, P1 saw the SP pinch the VA’s left forearm while at the dining room table. P1 told P2 the SP pinched the VA “so hard” that the SP’s hand was shaking. (Note: within the IR and P1’s interview with this investigator, P1 did not provide information related to the SP pinching the VA on October 6, 2024.) · P2 said the VA had a history of self-inflicted bruises near his/her wrist from biting him/herself, and “little, tiny” self-inflicted bruises caused by the VA bumping into objects. Those bruises typically “disappeared” within a day or two. P2 said the bruises s/he saw on October 7, 2024, was not consistent with the VA’s self-inflicted bruises. · P3 said the SP worked at the facility for “a couple months,” and appeared to have a positive relationship with the VA. P3 said the VA had bruising that was observed in late September and early October 2024, which prompted P1 to come forward with his/her concerns. P3 said P1 was “crying and shaking” when s/he told P2 of the concerns, and P1’s speech was difficult for P3 to understand due to language barriers. · P4 said “sometimes” s/he saw the SP grab the VA by the arm and face with “force” while completing medication administration. · P5 said s/he had not witnessed the SP pull the VA’s hair, but on an unknown date s/he witnessed the SP grab the VA’s arm “tightly” while they were at an emergency room. Additionally, P5 saw the SP grab the VA’s arm while completing medication administration. · P1, P2, and P4 said the SP often became frustrated while working and took multiple breaks outside. · The SP denied pulling the VA’s hair or pinching the VA. The SP said s/he had only held the VA’s arms to guide him/her to the bathroom. The SP said s/he assisted the VA with “hair binders,” and that could have looked like s/he was pulling the VA’s hair. The SP said that staff persons held the VA’s hand down during medication administration, but the SP tried to “not be the person holding [the VA] down.” · The facility retrained all employees on reporting maltreatment, controlled/restricted procedures, service recipient rights, and medication refusals. The facility’s Emergency Use of Manual Restraints (EUMR) Policy provided the following information: · A EUMR would be used when a person posed an imminent risk of physical harm to him/herself or others, and when it was the least restrictive intervention that would achieve safety. Property damage, verbal aggression, or a person's refusal to receive or participate in treatment or programming on their own did not constitute the use of an EUMR.
· It was prohibited to use an EUMR for a substitute of adequate staffing, as behavioral or therapeutic programming to reduce or eliminate behavior, as punishment, or for staff convenience. Prior to the alleged maltreatment, P1-P5 and the SP were each trained on Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, medication administration, and the VA’s client specific programming. Conclusion: A. Maltreatment: It was reported that the SP pinched the VA on or around October 7, 2024. Information from photos and P2 showed that on October 7, 2024, the VA had two bruises, one each on his/her left forearm and bicep. Although the VA had a history of self-inflicting bruises during SIBs, P2 said the October 7, 2024, bruises were not consistent with injuries caused by the VA’s previous SIBs, and there was no information provided that the VA engaged in SIBs on or around October 7, 2024. P2 said that P1 told him/her s/he saw the SP pinch the VA’s arm on October 6, 2024. However, P1 did not provide information to this investigator, nor for the facility’s IR, that s/he witnessed an incident on October 6, 2024. During P1’s interview with this investigator s/he stated the only observed incident of the SP pinching the VA was on September 13, 2024. During the investigation information was obtained about additional concerning interactions between the SP and the VA. P1 said s/he saw the SP pull the VA’s hair on an unknown date, P4 said “sometimes” the SP grabbed the VA’s arm and face, and P5 said s/he saw the SP grab the VA’s arm on two occasions. Although the information provided by P1 and P2 was not consistent regarding whether P1 saw the SP pinch the VA on October 6, 2024, there was consistent information provided by P1, P4, and P5, that the SP engaged in multiple incidents of non-therapeutic physical contact with the VA. The SP’s actions included pinching the VA’s arm so hard that the SP’s hand was shaking, pulling the VA’s hair, and grabbing the VA’s arm and face. Due to the inconsistent information about whether the SP pinched the VA on October 6, 2024, it could not be determined whether the SP caused the bruises that were observed on the VA on October 7, 2024. However, due to the consistent information from P1, P4, and P5 about the SP’s conduct toward the VA, there was a preponderance of the evidence that the SP engaged in multiple incidents of non-therapeutic conduct which would reasonably be expected to cause physical pain and/or injury to the VA. It was determined that physical 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s client specific information, the facility’s policy and procedures, and medication administration prior to the incident. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated physical abuse for which the SP was responsible was recurring maltreatment because the SP physically abused the VA on multiple occasions. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The facility completed additional staff training and took corrective action to protect the persons that received services. The SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. During the course of the investigation, it was determined that a background study violation occurred. On February 27, 2025, the facility was issued a $200 fine for the background study violation. The Order to Forfeit a Fine is subject to appeal.
|
