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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 December 15, 2023, which must be destroyed. On January 13, 2025, an Order of the Commissioner of Human Services adopted the recommendation of a Human Services Judge to reverse the determination that SP1 was responsible for maltreatment. The original determination that SP1 was responsible for maltreatment was rescinded and SP1’s disqualification from direct care services was also rescinded.
License Number and Program Type: 1102152-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Danielle Morrison 651-431-5647
Suspected Maltreatment Reported: Allegation One: It was reported that there were concerns regarding a staff person’s (SP1) interactions and boundaries with two vulnerable adults (VA1 and VA2) including that SP1 yelled at VA1 and VA2; that SP1 had his/her hands near VA2’s throat and put his/her hands on VA2; that SP1 took away VA1’s iPad; and that SP1 prevented VA2 from getting food in the kitchen. Allegation Two: It was reported that VA2 grabbed a staff person’s (SP2) drink and SP2 physically wrestled and screamed at VA2 for grabbing SP2’s drink. Date of Incident(s): On going prior to April 3, 2023 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 5, 2023; from documentation at the facility; law enforcement records, and through nine interviews conducted with two facility supervisors (P1 and SP2), five facility staff persons (SP1, P2-P5), VA1’s guardian (G1), and VA2’s guardian (G2). A telephone interview was scheduled with a staff person (P6), but P6 did not answer at the scheduled time and P6 did not respond to a voicemail left at that time. The facility was a one level home. The facility had an open common area with a living room, dining room, and kitchen. To one side of the living room was hallway with two bedrooms and a bathroom, to the other side of the living room was another hallway with a bedroom, utility room, and another bathroom. There was a fourth bedroom to one side of the dining room and an activity room/office off of the kitchen and dining room. VA1’s diagnoses included profound intellectual disabilities and neuronal migrations disorder. VA1 liked to listen to music, play games on his/her iPad, and sketch. VA1 used a combination of American Sign Language, gestures, and an iPad to communicate his/her needs. VA2’s diagnoses included a moderate intellectual disability, seizure disorder, depression, aphasia, and autistic disorder. VA2 liked following routines, looking at magazines, and drinking coffee. VA2 was “nonverbal.” Facility records showed that SP1, SP2, and P1-P6 were trained on VA1’s and VA2’s plans. SP1, SP2, P1-P4, and P6 were trained on the Reporting of Vulnerable Adults Act. Allegation One: It was reported that there were concerns regarding SP1’s interactions and boundaries with VA1 and VA2 including that SP1 yelled at VA1 and VA2; that SP1 had his/her hands near VA2’s throat and put his/her hands on VA2; that SP1 took away VA1’s iPad; and that SP1 prevented VA2 from getting food in the kitchen. VA1’s Coordinated Services and Supports Plan (CSSP) stated that, “[VA1] is very routine oriented. [VA1]’s schedule and routine is very important to [him/her].” VA1’s CSSP stated his/her schedule as such: “[VA1] wakes up around 6 am. [VA1] eats breakfast and puts [his/her] dishes into the sink. [VA1] goes to the bathroom and takes a shower. [VA1] will then exercise, listen to music, do sensory activities and play on [his/her] iPad. [VA1] then eats lunch and then spends some time alone in [his/her] room stretching and watching TV. [VA1] has a snack at 3:30 [p.m.], takes [his/her] meds and goes to the bathroom with [his/her] iPad. Then [VA1] walks or exercises. [VA1] picks out [his/her] pajamas and plays on [his/her] iPad until supper. [VA1] goes to bed around 7:30 p.m., and watches TV until about 8:30 [p.m.] and then falls asleep.” G1 stated that s/he had concerns with SP1. On one occasion G1 went to the facility to visit VA1. When G1 entered the facility, VA2 attempted to grab G1’s bag. G1 went through a set of French doors to the activity room and VA2 followed. SP1 got “upset” with VA2 and with G1 for “stirring” VA2 up. There was a bottle of iced tea on the floor so G1 grabbed it to give to SP1 and SP1 said, “Just leave it on the floor.” G1 said it made him/her “very uncomfortable” and if SP1 talked to G1 like that how did s/he talk to VA1 and VA2. G1 also said that one evening SP1 escorted VA1 to an event an hour away from the facility. VA1 attended this event every year for the past 20 years. G1 said VA1 indicated that s/he was ready to go back to the facility, but SP1 insisted they stay at the event. When SP1 and VA1 finally were getting ready to leave, G1 had some treats for the car ride home for VA1 and SP1 said to VA1, “[VA1] your [G1] is crazy.” G2 was not aware of any concerns with VA2. G2 loved P1 and said P1 let G2 know if there were any issues. P6 provided information during the facility’s Internal Review that SP1 screamed at VA1 and VA2 and spoke to them in derogatory ways. When VA2 went into the kitchen for snacks, SP1 told VA2 s/he was getting “fat” and that SP1 was going to put him/her on a diet. SP1 got into VA1’s personal space, about two to three inches away from his/her face, and said, “If you hit yourself today, I will take away your iPad.” P6 described SP1’s tone of voice as loud, but when talking to the clients it was “like an angry tone.” P6 said on one occasion SP1 was upset with VA1 so SP1 got close to VA1’s face and made a “claw like” motion with both hands approximately four inches from either side of VA1’s face and SP1 said, “Grrrrrrr, you make me so mad, you have to stop hitting yourself.” P6 said this caused VA1 to accelerate his/her self-injurious behavior. P6 stated that s/he expressed concerns to SP2, but then SP1 confronted P6 about what s/he had said. P6 stated at that point s/he went to P1 and no longer expressed concerns to SP2. P6 did not provide further details regarding these concerns. P1, P2, P3, P4, and P5 provided information to this investigator and during the facility’s Internal Review. · P3 stated that s/he witnessed SP1 yell and seem “upset” with the individuals on many occasions. P3 said that when VA1 hit him/herself on the head, SP1 took VA1’s hands and yelled at him/her to stop over and over again. P3 said that when VA2 went towards the kitchen, SP1 yelled at VA2, “Get the hell out of there, you don’t belong in there.” P3 stated that SP1 brought in large cups of coffee to “taunt” VA2 and stood in front of VA2 to drink it. If VA2 moved, SP1 yelled, “Don’t even think about stealing my coffee.” · P3 stated that SP2 and P1 were aware of his/her concerns with how SP1 treated the clients. P3 said during a behavior basics training, every single idea presented to the staff persons, SP1 stated, “That’s not going to work, that’s stupid. We aren’t going to do anything different; they can’t tell us what to do.” · P4 stated that one weekend VA1 had a lot of self-injurious behaviors, and SP1 shamed VA1, made fun of VA1, and called VA1 “stupid.” SP1 refused to give VA1 his/her iPad even when VA1 was supposed to get it after supper. · P4 said SP1 left out a pan of brownies on the counter “knowing full well that [VA2] would go after these.” When VA2 grabbed for the brownies, SP1 started yelling “very loudly” and was angry at VA2 for going after the brownies. SP1 told VA2 that s/he was not going to get supper, and that VA2 was “stupid and bad.” P4 said that SP1 did let VA2 have supper. P4 said that SP1 mimicked and shamed the clients when they “self-stimmed” like humming. SP1 told them to “shut up” and that it bothered everyone. P4 said s/he told SP2 that SP1 yelled and SP2 told P4 that “is just [SP1];” SP1 was a loud person. · P4 said after the behavior basics training about programming, several staff persons were talking about how they were going to implement some of the ideas, and SP1 stated, “We are not going to do any of that crap, we are not changing a thing.” · P2 noticed “abrasive and dismissive behavior” from SP1 and SP2. P2 stated that SP1 came off as “abrasive and angry.” P2 said that when VA1 and VA2 made “self-stimming” noises, SP1 told them to be quiet. · P2 said that when VA2 approached the kitchen, SP1 got animated and screamed. P2 said SP1 told VA2, “Get the hell out of the kitchen.” P2 said that when SP1 yelled at the clients, SP1 screamed “at the top of [his/her] lungs” and it made P2 jump. · P2 said VA1 was supposed to get his/her iPad after dinner and at times SP1 did not let VA1 have it and SP1 told VA1 that s/he did not need it. When VA1 was “upset or anxious” SP1 “very loudly” told VA1, “Now you will go to bed since you can’t behave.” P6 told P2 that SP1 put his/her hands over VA2’s head and screamed, “When is enough, enough? When are you going to stop?” · P2 said that almost every shift that s/he worked with SP1, SP1 set VA2 down on the couch and did not let VA2 get up. SP1 did not restrain VA2 and VA2 was able to move on his/her own accord. SP1 told VA2 s/he could not get up off the couch. · P1 stated that there was interpersonal conflict between staff persons. P1 stated that s/he was not aware of any concerns regarding verbal or emotional abuse toward VA1 and VA2 by SP1 until April 3, 2023, when s/he was notified by law enforcement.
· P1 stated that SP1 was “very blunt” and sometimes if came off as “abrasive” or that SP1 was “mad.” P2 told P1 that SP1 was “aggressive” and “bossy” telling the clients what they could and could not do. P1 said P2 did not provide specifics. P6 told P1 that SP1 went up to VA2’s face and said, “Err you need to stop that,” and then mimicked VA2. · P1 said s/he tried to get staff persons at the facility to be consistent, but with SP1 it was “[SP1’s] way or no way.” After a behavior basics training, SP1 stated s/he was not going to do that and that it was not going to work. P1 said SP1 “never” spoke to VA1 or VA2 in a harsh way when P1 was present, but P1 heard that SP1 told VA2, “Get the hell out of the kitchen.” · P1 said that P6 stated that if s/he brought concerns to SP2’s attention nothing happened, and then it was shared with SP1 and P5 since they worked together more frequently. · P5 said that “sometimes” when VA1 had a “behavior” staff persons asked him/her for his/her iPad. P5 said s/he “usually” said the VA needed to not use his/her iPad for five minutes, and that because P5 did not want VA1 to hurt him/herself, after five minutes, P5 gave it back to VA1. P5 stated that P4 talked to VA1 “like a baby” in a little kitten voice. P5 was not aware of any staff persons raising their voices to VA1. · P5 said that if the stove was on, staff persons stopped VA2 from going into the kitchen, but they did not block VA2 from getting food. P5 had no concerns with how staff persons treated VA1 and VA2. SP1 provided the following information: · SP1 said his/her voice was “very loud” so people thought SP1 was “mean” or “mad.” SP1 stated the only time s/he raised his/her voice to VA1 was when VA1 hit him/herself in the head and SP1 tried to get VA1’s attention. SP1 stated s/he “never” spoke to VA1 “harshly” or got angry with VA1. · If VA2 went into the kitchen near the stove or a knife, SP1 yelled VA2’s name and tried to redirect VA2. SP1 said on one occasion, VA2 went to the refrigerator and grabbed a carton of premixed scrambled eggs. SP1 thought VA2 thought it was milk and VA2 went to drink it. SP1 stated that s/he slapped the carton out of VA2’s hands. · SP1 said that “absolutely” VA2 would go after brownies if they were left out, but SP1 did not remember making brownies. SP1 said VA2 had access to the refrigerator. SP1 denied refusing VA2 from getting food and the only time s/he blocked VA2 from going into the kitchen was if the stove was hot. · SP1 stated that VA1 had a schedule for when s/he had his/her iPad. SP1 denied taking VA1’s iPad away from him/her. · SP1 denied threatening to choke a client and stated that s/he “maybe” put his/her hands next to a client’s face to help the client shave. SP1 denied putting hands on clients in an aggressive manner and denied yelling at clients other than to get their attention and redirect them. SP2 stated that s/he had not witnessed SP1 talk harshly to any of the facility clients and SP2 had not witnessed any negative behavior from SP1 with the clients. SP2 stated that SP1 was just “a loud person.” SP2 stated that no staff persons said anything to him/her regarding how SP1 treated clients. SP2 said that if VA1 needed to “calm down” staff persons removed the iPad and told VA1 s/he could have it back once VA1 “calmed down.” SP2 stated that staff persons did not “snatch” VA1’s iPad but asked VA1 for it and VA1 responded “pretty good” to that. SP2 said s/he had expressed concerns to P1 about P2 and what s/he talked about in front of clients. SP2 denied yelling at clients and stated s/he treated clients how s/he wanted people to treat his/her family. Law enforcement was not investigating further. Conclusion for Allegation One: A. Maltreatment: Information was provided from staff persons interviewed and the internal review that SP1 had an “angry tone” of voice when speaking with VA1 and VA2. SP1 called VA1 “fat,” and “stupid,” and called VA2 “stupid,” and “bad.” SP1 told VA1 and VA2 to “shut up” when they used “self-stimming” techniques such as humming. SP1 yelled so loudly it made P2 jump. SP1 yelled at VA1 when VA1 hit him/herself in the head, SP1 yelled at VA2, “Get the hell out of the kitchen,” SP1 yelled at VA2, “Don’t even think about stealing my coffee,” and SP1 yelled at VA1, “Now you will go to bed since you can’t behave.” P2 heard SP1 yell, “Get the hell out of the kitchen.” P6 said on one occasion SP1 was upset with VA1 so SP1 got close to VA1’s face and made a “claw like” motion with both hands approximately four inches from either side of VA1’s face and SP1 said, “Grrrr, you make me so mad. You have to stop hitting yourself.” P6 stated that SP1 got into VA1’s personal space, about two to three inches away from his/her face, and said, “If you hit yourself today, I will take away your iPad.” P2 and P4 stated that SP1 refused to let VA1 have his/her iPad after supper which was in VA1’s plan. G1 stated that s/he had encounters with SP1 and G1 said it made him/her “very uncomfortable” and G1 stated if SP1 talked to G1 like that how did s/he talk to VA1 and VA2. P1 stated that SP1 came off as “abrasive” or “mad.” P1 stated s/he had not witnessed SP1 yell at VA1 and VA2 but had heard from other staff persons that SP1 did so. P5 had no concerns with how staff persons treated VA1 and VA2. SP2 stated that s/he had not witnessed SP1 talk loudly or harshly to any of the clients at the facility and SP2 had not witnessed any negative behavior from SP1 with the clients. SP1 said his/her voice was “loud” and people thought s/he was “mad.” SP1 denied yelling at VA1 and VA2 other than to gain their attention. SP1 said that “maybe” s/he had put his/her hands near a client’s face when helping them to shave. SP1 denied putting his/her hands on clients in an aggressive manner and SP1 denied gesturing to choke VA2. SP1 said VA1’s iPad time was scheduled, and s/he denied taking VA1’s iPad away from him/her. Although P1 and SP2 had not heard SP1 yell at the clients, P5 had no concerns with how staff persons treated clients, and SP1 denied yelling at VA1 and VA2 other than to gain their attention, given that P2, P3, P4, P6, and G1 had all witnessed different occasions of SP1 yelling at VA1 and VA2, using derogatory words toward VA1 and VA2, and using threatening statements or gestures toward them, there was a preponderance of the evidence that SP1 engaged in repeated oral and gestured language toward two vulnerable adults that would be considered by a reasonable person to be threatening and derogatory. It was determined that 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: 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). 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. SP1 received training on VA1’s and VA2’s support plans, behavior basics training, and the Reporting of Maltreatment of Vulnerable Adults Act. SP1 was responsible for maltreatment of VA1 and VA2. 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 emotional abuse for which SP1 was responsible was not “serious maltreatment” because it did not meet the definition but was recurring because SP1 was responsible for emotional abuse of both VA1 and VA2. Allegation Two: It was reported that VA2 grabbed SP2’s drink and SP2 physically wrestled and screamed at VA2 for grabbing SP2’s drink. VA2’s plan stated that “[VA2] lacks understanding of personal boundaries/space, [s/he] may attempt to take objects from people, grab objects from people, bump into them to get an object by them, etc. [S/he]’s not typically trying to cause harm but just get whatever item [s/he] is focused on at that moment.” G2 stated that about six months ago there was an incident with a staff person and G2 where VA2 grabbed the staff person’s drink, and the staff person dumped the drink over VA2’s head and stated, “If you want it fucking take it.” G2 was not able to recall who the staff person was. P1, P2, P3, P4, and P5 provided the following information to this investigator and during the facility’s Internal Review: · P2 had not witnessed any physical aggression or abuse towards any of the individuals. P2 heard from another staff person (P2 believed it was P3) that on an unknown day in December 2022, VA2 grabbed a water bottle and did not let go. SP2 retaliated by physically pushing VA2 into the back room onto a piece of furniture where SP2 laid on top of VA2 until VA2 let go of the drink. P2 told this investigator that while VA2 reached for a drink, SP2 “wrestled” VA2 onto a lounge chair in the office, SP2 screamed at VA2, and ripped the drink out of VA2’s hands. P2 did not witness this but was told this by P3. P2 stated that this was his/her biggest concern with SP2.
· An email correspondence in January 2023 between P1 and someone from employee relations, provided information that P3 observed an incident between SP2 and VA2 involving VA2 taking a water bottle and SP2 retaliating by physically pushing VA2 into the back room on furniture when SP2 laid on top of VA2 until s/he let go of the drink. · However, P3 stated during the Internal Review in April 2023 that s/he had not witnessed anything “like this” occur in regard to VA2 being “slammed” to the ground. P3 told this investigator that SP1 and SP2 often brought in items that VA2 tried to grab. P3 stated that in November 2022, SP2 brought in a bottle of pop and VA2 tried to take it and SP2 struggled with VA2 to get it back. P3 said that VA2 pulled SP2’s hair and pushed SP2, then SP2 turned around and pushed VA2 and told VA2 to “stop,” and then SP2 shoved VA2 to the couch. · P1 was told it was a water bottle that SP2 attempted to grab from VA2. There was a push by VA2 as VA2 pulled the bottle away from SP2 with one hand and pushed SP2 with the other. In that push/pull moment both VA2 and SP2 sort of sat on the chair in the back room which was very brief. After this incident P1 spoke with SP2 and told SP2 that if VA2 got ahold of someone’s drink there should be verbal attempts to retrieve the item, but no physical hand over hand attempts, unless VA2 was attempting to drink something that would harm him/her. VA2 could become physical. P1 stated that VA2 was physically stronger than SP2 so P1 found it “impossible” that SP2 could have laid on top of VA2 until s/he gave up the bottle. · P1 heard that P2 said it was SP1 who told him/her that SP2 “tackled” VA2 to the ground. When P1 asked SP1 about that SP1 said s/he “never said that.” Then P1 heard that SP1 was the person who tackled VA2 to the ground. P1 was aware of the above situation but was not sure who said that SP2 “slammed” VA2 to the ground. P1 stated that you could not have your hands on VA2 to redirect him/her for more than a second and VA2 “was gone.” · P4 did not observe any physical aggression toward VA2 by SP2. P4 stated that there was one incident where VA2 ran outside and into a road with traffic when SP2 intervened and put him/herself between VA2 and the road and had a hold of VA2’s arms. · P5 had “never” observed anyone grabbing, pushing, pulling, or being physical with any of the clients. P6 provided information during the facility’s Internal Review that s/he had not seen or heard that anyone was physically aggressive or abusive toward the clients. SP1 did not witness SP2 push or fall onto a couch with VA2. SP1 said s/he heard that it was him/her who “body slammed” VA2 to the floor. SP1 said that would be “nearly impossible to do” and that one time there was an issue getting VA2 back into the house, and that it took five staff persons and law enforcement officers to get VA2 back in the house. SP1 said VA2 was strong when s/he was mad and “little [SP2] not able to put VA2 on the couch.” SP2 stated in the Internal Review that s/he did not remember the incident. When SP2 spoke with this investigator, SP2 said s/he did not remember all of the details, but that in January 2023, SP2 and SP1 were working and VA2 grabbed SP1’s coffee. SP2 said that SP1 put MiraLAX or something else for his/her stomach in his/her coffee, so SP2 did not want VA2 to drink it. SP2 went to grab the coffee, and VA2 ran into the office area, SP2 asked for the coffee back. SP2 said s/he was able to grab it and VA2 pushed SP2 down and they both fell onto the chaise lounge chair. SP2 said they got up and VA2 drank the coffee. SP2 said nothing happened because of what was in the coffee. SP2 was not sure if SP1 saw what happened. Law enforcement was not investigating further. Conclusion for Allegation Two: P3 stated that in November 2022, SP2 brought in a bottle of pop and VA2 went after it and SP2 struggled with VA2 to get it back. P3 said that VA2 pulled SP2’s hair and pushed SP2, then SP2 turned around and pushed VA2 and told VA2 to “stop,” and SP2 shoved VA2 to the couch. SP1, P1, P2, P4, P5, and P6 had not witnessed SP2 push VA2. P2 stated s/he head from P3 that VA2 grabbed a water bottle and did not let go. SP2 retaliated by physically pushing VA2 into the back room onto a piece of furniture where SP2 laid on top of VA2 until VA2 let go of the drink. P2 told this investigator that while VA2 reached for a drink, SP2 “wrestled” VA2 onto a lounge chair in the office, SP2 screamed at VA2, and ripped the drink out of VA2’s hands. P1 heard there was a situation in which VA2 grabbed a water and in an attempt to get it back from VA2, SP2 grabbed for it, and VA2 pushed SP2 away and they both fell into the lounge chair. SP2 stated that VA2 grabbed SP1’s coffee which contained MiraLAX or something similar to help SP1’s stomach, so SP2 went to grab it back, VA2 ran into the office, SP2 got a hold of the coffee, VA2 pushed SP2 and they both fell into the chaise lounge chair. SP2 said VA2 got up and drank the coffee. SP2 said nothing happened because of what was in the coffee. Although SP2 grabbed for a drink out of VA2’s hands and P3 said that SP2 pushed VA2 and shoved him/her to the couch, given that SP1, P1, P2, P4, P5, and P6 had not witnessed this, that SP2 was intervening in a potentially harmful situation, and that it was reasonable that SP2 and VA2 fell unintentionally, there was not a preponderance of the evidence whether all of SP2’s actions were non-accidental or could be reasonable expected to produce physical pain or injury. It was not determined whether 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). Action Taken by Facility: The facility completed an Internal Review and found their policies adequate, but not followed by staff persons. All staff persons received training on supports and methods for the clients at the facility. P1 and SP2 were retrained on maltreatment reporting criteria. SP1 no longer worked at the facility.
Action Taken by Department of Human Services, Office of Inspector General: SP1 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 SP1 was responsible for maltreatment and the disqualification of SP1 are each subject to appeal. In addition, on December 15, 2023, the facility was issued a Correction Order for a staff person not being up to date with vulnerable adult training and for not reporting maltreatment as required.
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