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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: 1069360-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that a staff person (SP) and a vulnerable adult (VA) got into an altercation and as a result, the VA sustained bruising on his/her arms. Date of Incident(s): September 8, 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 7, 2024; from documentation at the facility and law enforcement records; and through four interviews conducted with two supervisory staff persons (P1 and P3), a facility staff person (the SP), and the VA. Attempts were made via phone and mail to interview another supervisory staff person (P2), but P2 did not respond to those requests. The VA was diagnosed with autism. According to the VA’s Individual Abuse Prevention Plan, the VA was susceptible to physical abuse by other persons because of his/her inability to identify potentially dangerous situations, lack of community orientation skills, and inability to deal with physically aggressive persons. Staff persons encouraged the VA to notify them if s/he was physically abused. If staff persons observed potential or active physical abuse, they were to take necessary steps to reduce harm to the VA. Staff persons were to “immediately” report the abuse according to the facility’s policies. There was no documentation that the VA had any history of self-injurious behavior. The VA provided the following information: · On September 8, 2024, the VA went into the kitchen and got out a popsicle. The SP told the VA that s/he was not allowed to eat a popsicle and then went into the living room and gave another client (C) a popsicle in front of the VA. The VA picked up the SP’s cell phone that was in the living room and told the SP that s/he was not going to give the SP his/her cell phone. · The SP went behind the VA and “wrapped” his/her arms around the VA to try and grab the phone. The SP grabbed each of the VA’s arms near his/her biceps. The SP tried grabbing the cell phone with one hand and when that did not work, s/he “trip[ped] up” the VA who ended up on the floor in a balled-up position. The SP “twisted” each of the VA’s arms and eventually got his/her cell phone away from the VA. · The VA went to his/her bedroom and texted P2 and a family member (FM) of the VA a picture of a bruise on the VA’s arm. Later that evening, the FM came to the facility and spoke to the SP. The SP “blamed” the VA for breaking the cell phone. · Later that night, the VA told P2 about the incident and P2 told the VA that P2 would “deal with it” on September 9, 2024, when P2 worked next. The FM provided the following information: · On September 8, 2024, at approximately 7 p.m., the VA texted the FM that there was an “altercation” with the SP. The VA also texted a picture of his/her left arm that was “covered in marks from [the VA’s] inner elbow to bicep.” The FM tried to contact a supervisory staff person but was unsuccessful. · Later that night, the FM went to the facility. There was “finger shaped” bruising on the VA’s left arm that had “worsened” compared to the picture the VA sent earlier. The FM also saw marks on the VA’s right arm and scratches on the VA’s back and shoulders. · The VA provided the following information to the FM: o Earlier that day, there were popsicles in the freezer and the VA asked the C if s/he could have one and the C agreed. The VA went and got a popsicle out of the freezer and the SP took it away and said it was not for the VA. The VA tried to explain that the C said s/he could have one but the SP still took it away. o The VA was “upset” and wanted to show the SP how it felt to have something taken away so the VA took the SP’s cell phone. The VA held the phone close to him/her and the SP “grabbed” the VA “roughly” and “tackled” the VA to the floor. o The SP tried to slam the VA’s head against the floor but was not able to. · The FM then went to talk to the SP, who “began to lie” and said that the VA cut him/herself during a fall. The FM remained “calm” and explained previous incidents that s/he experienced at his/her employment. The SP finally explained what happened but then said that the VA broke the SP’s cell phone during the incident. The FM then filed a police report. A photo sent from the VA to the FM showed bruising around the VA’s left bicep. The VA’s right arm and back were not visible in the photo. There were no other photos or documentation of the VA’s injuries. The VA and the FM provided consistent information in the law enforcement report. The SP was not charged with a crime because the VA declined charges. P3 stated on September 9, 2024, P2 called P3 and said that there was an incident between the VA and the SP but “everything was fine.” P3 asked P2 if the VA was injured and P2 responded, “No.” P3 asked if the police were involved and P2 responded that s/he had not spoken the police but the FM did. P2 said everything was resolved and “fine.” P3 did not find out about the VA’s injuries until speaking to P1. P1 provided the following information: · On September 9 or 10, 2024, P3 called P1 and said there was an incident where the VA broke the SP’s cell phone. P1 said that since staff persons were not supposed to have their personal cell phones at the facility, they would not replace the SP’s cell phone. · Approximately one week later, another staff person at the main office told P1 that s/he received a phone call about the SP’s cell phone and that the VA had bruising on his/her arms because of the incident. P1 went to the facility and spoke to P2 who confirmed that the VA had bruises on his/her arms and showed P1 the picture of the VA’s arms that the VA texted. P1 then went and spoke to the VA who gave P1 the police report and showed P1 his/her arms. The VA provided consistent information to P1 as s/he did to the FM and this investigator about the incident. · P1 went to the main office and had P2 come explain what happened. P2 said that on September 8, 2024, the FM texted P2 about the incident. P1 told P2 that s/he should have handled the incident when s/he was first notified about it and not wait until the following day. P2 said s/he told P3 about the incident but forgot to send the pictures of the VA’s arms. · P1 then spoke to P3 who provided consistent information as s/he did to this investigator. P1 then spoke to the SP who said that the VA took his/her cell phone so s/he went behind the VA and grabbed both of his/her arms. P1 asked the SP if s/he realized it was “not appropriate” and the SP responded that s/he was more concerned about his/her cell phone.
The SP provided the following information: · On the day of the incident, the VA went and got a popsicle from the freezer. The SP tried to verbally redirect the VA but was “unsuccessful.” The VA went into a nearby room and took the SP’s cell phone. At one point, the VA threw the cell phone and it broke. The VA was able to get the phone again and tripped and as s/he fell s/he tried to throw the cell phone. The SP was worried the cell phone would hit one of the other two clients who were in a nearby room behind the SP so the SP “tried to hold” the VA so s/he did not hurt them. The SP “held” the VA’s upper arm with his/her hand while s/he tried getting the phone away from the VA. · The VA stood up and the SP was able to take the cell phone away from the VA. The SP denied grabbing the VA’s arms. The SP then gave the VA space and took the other clients to their bedrooms. The SP did not see bruises or injuries on the VA. · Approximately two hours later, the VA came out of his/her bedroom and had bruises on both of his/her arms. The SP thought the bruises on one arm was from when s/he held the VA’s arm. The SP also heard “noises” when the VA was in his/her bedroom so the VA “possibly” hurt him/herself. · Later on, the SP spoke to P2 and explained what happened “from start to end” with the incident. P2 instructed the SP to write an incident report. Facility documentation showed that staff persons, including the SP, were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: On September 8, 2024, the VA took the SP’s cell phone. The VA provided consistent information to the FM, P1, law enforcement, and this investigator that the SP grabbed the VA’s arms when trying to get the cell phone back. Photos taken after the incident showed bruising around the VA’s left bicep. The FM stated that later that evening when s/he saw the VA, the VA had bruising on both upper arms and scratches on his/her back and shoulders. The SP stated that during the incident, s/he held the VA’s upper arm to get his/her cell phone and that the bruises on one arm was from when s/he held the VA’s arm. The SP said s/he did this in order to prevent the VA from hitting the other clients (who were in another room) with the cell phone. The SP’s admitted use of physical force to obtain his/her cell phone was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. The VA provided consistent information to this investigator, the FM, law enforcement, and P1 about the incident; and had injuries that were consistent with his/her account of the incident. The SP provided conflicting information to P1 and the DHS investigator; and had reason to minimize his/her actions for fear of repercussions. Therefore, the VA’s account of the incident was determined to be more credible than the SP’s. There was a preponderance of the evidence that the SP grabbed the VA’s upper arms and twisted the VA’s arms to get his/her cell phone away from the VA, causing bruises on the VA’s left bicep (as documented in a photo), bruises on the VA’s right arm, and scratches on the VA’s back and shoulders. 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 VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. 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 abuse for which the SP was responsible not recurring maltreatment but was “serious” maltreatment because the VA sustained bruises on his/her upper arms and scratches on his/her back and shoulders. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but not followed. The SP and P2 no longer worked 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. On March 5, 2025, the facility was issued a correction order for failure to update policies and procedures as needed, and for training staff persons on outdated and incorrect policies. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal.
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