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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: 1117669-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that staff persons (SP1, SP2, and SP3) behaved inappropriately toward a vulnerable adult (VA) including saying that the VA was “sexy,” rubbing their bodies against the VA, and putting the VA in a “chokehold.” Date of Incident(s): Prior to April 10, 2025 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 2, paragraph (c): 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. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. Summary of Findings: Pertinent information was obtained during a site visit conducted on April 24, 2025; from documentation at the facility, law enforcement records, and the VA’s medical records; and through interviews conducted with facility staff persons (P1, P2, P3, and SP2), the VA, and the VA’s guardian (G). Two letters, one certified, were sent to SP1 and SP3 requesting an interview with this investigator, but they did not respond to the letters or other attempts to contact them. A tour of the facility on the date of the site visit showed that there was a window in the VA’s bedroom door which staff persons could look through to check on the VA when the door was closed. The facility had a video recording system with cameras placed in common areas of the facility. Facility documentation showed that the VA was diagnosed with diabetes, disruptive mood regulation disorder, an intellectual disability, expressive language disorder, and attention deficit hyperactivity disorder. The VA did not like to be “bossed around” and became upset when s/he could not do what s/he wanted to do. The VA might become defiant when his/her environment was not as s/he wanted it to be, and one of his/her goals was to positively accept unfavorable answers to his/her questions. The VA liked to be encouraged, and it was helpful when staff persons separated complex tasks into simpler steps. A resident (R) resided at the facility with the VA, but the VA hoped to live alone someday with support from staff persons. A Rights Restriction for the VA denied him/her unsupervised access to the kitchen and required the kitchen to be locked because the VA had a history of eating foods that were not recommended for persons with diabetes and a history of attempting to harm him/herself with kitchen utensils. The VA did not require assistance from staff persons to complete activities of daily living and was independent with his/her personal cares. The VA liked social interaction and was kindhearted. Interviews with this investigator, records from a law enforcement agency, facility documentation, the VA’s medical records, and the facility’s Internal Review, provided the following: · The VA stated that on unspecified dates, SP1, SP2, and SP3 told him/her that s/he was “sexy” and “beautiful,” touched/grabbed his/her buttocks, and put the VA in chokeholds. SP1 told the VA that s/he would “feel this big one” in him/her, and SP3 banged the VA’s head into the wall and showed his/her intimate body parts to the VA. Unspecified staff persons laughed at the VA when s/he attempted to harm him/herself and the VA had a history of attempting to get hit by cars. The VA was unable to provide details about when or where these incidents occurred and said that they were not witnessed by others. · General Event Reporting forms (GERs) for the VA showed that on March 16, 2025, after a van ride with the R, the VA pushed past staff persons into the office where s/he dropped and broke a safe. When the safe opened, the VA obtained a knife from the safe and held the knife to his/her neck, threatening to harm him/herself. A 9-1-1 call was made, and law enforcement officers (LEOs) came to the facility. The LEOs calmed the VA and took him/her to a hospital, where s/he was admitted for observation. · The VA was discharged back to the facility after s/he calmed, and on March 20, 2025, the VA went to the R’s bedroom and lay on the floor. With redirection, the VA left the R’s bedroom, but s/he obtained a belt from his/her bedroom, placed it around his/her neck, and tightened it. Staff persons redirected the VA and assisted him/her to remove the belt from his/her neck, but s/he said that s/he hid a pocketknife in the facility and planned to “run away” at 5 p.m. Staff persons observed the VA and a few minutes later, the VA wanted to clean his/her bedroom. Staff persons gave the VA a broom and offered to help him/her, but the VA told staff persons to leave his/her bedroom, and they did. The VA then closed the bedroom door and barricaded it with chairs, broke the broom, and cut his/her finger with a piece of the broom. · Staff persons called 9-1-1 and observed the VA through the window in the bedroom door until LEOs arrived. When LEOS came, the VA agreed to go with them to look at stuffed animals the LEOs brought with them. When the VA exited the facility to see the stuffed animals, s/he ran down the driveway and the LEOs ran after him/her. The VA stopped when another LEO and emergency medical technicians (EMTs) turned their vehicles into the driveway. LEOs and EMTs assessed the VA and observed superficial cuts on his/her right forearm and leg. The VA was transported to a hospital via ambulance and staff persons followed them to the hospital, remaining with the VA until s/he was admitted. · The VA was discharged back to the facility and on April 3, 2025, the VA entered the facility kitchen and obtained a lighter, the keys to the facility van, and scissors, and put them into his/her pocket. Staff persons redirected the VA and tried to deescalate him/her, but the VA did not calm or return the items to staff persons, and 9-1-1 was called. When the LEOs arrived, the VA calmed and was taken via ambulance to a hospital. Staff persons completed timely Behavior Intervention Reporting Forms (BIRFs) and Internal Reviews for the above incidents. No information showed that the VA was recently placed in a restraint. · On April 4, 2025, the facility issued a Temporary Service Suspension Notice (TSSN) to the G and the VA’s case manager. The facility determined that it could no longer provide services to the VA because the VA’s conduct posed an imminent risk of harm to the VA or others and positive support strategies were implemented but were not effective and additional support strategies or less restrictive measures would not resolve the issues that led to the suspension. However, in an interview with this investigator, P1 and P2, who were supervisory staff persons, said that the facility reconsidered the TSSN and decided that the VA could return to the facility upon discharge from the hospital. P1 was the SPs’ direct supervisor and was at the facility daily in close contact with the VA and staff persons who provided direct care to him/her. · The VA’s medical records showed that received and telehealth mental health services from providers in the same health care system as the hospital. The VA was evaluated at hospitals in the health care system on March 16, 20, 22, and 25, 2025, and April 3, 2025. The VA’s April 3, 2025, evaluation showed that s/he had a consultation with a hospital behavioral health provider due to suicidal ideation and s/he expressed discord with facility staff persons. It was suspected that there was “psychological motivating gain” given the VA’s expressed displeasure, and s/he was discharged back to the facility. · The next day, the VA was evaluated at the hospital for a similar “complaint,” and told a physician that s/he would attempt to die by suicide if s/he was discharged back to the facility. The physician documented that s/he thought that the VA needed inpatient services, and the VA was transferred to a hospital (hospital 2) with an inpatient unit that provided services to persons with mental illnesses. At hospital 2, the VA said that s/he felt safe. The VA was assessed by a mental health care professional (MHCP) and ultimately admitted to hospital 2 but the MHCP was concerned that admitting the VA to hospital 2 would cause increased behavioral concerns for the VA and documented that s/he should return to the facility to work with staff persons and community MHCPs. · When the VA learned that s/he might be discharged back to the facility, s/he repeated his concerns regarding staff persons, said that s/he was depressed, wanted to harm him/herself, felt hopeless and helpless, had difficulty concentrating, was irritable, and tried to get hit by a car because s/he felt that s/he had no purpose in the world and could be with his/her family members if s/he died. The VA repeated the concerns investigated in this report but thought that s/he would be okay if s/he resided in another facility or stayed in a hospital. The VA did not provide detailed information regarding his/her concerns and added that staff persons were “rude” and “mean.” The VA was admitted to a secure unit of hospital 2 that provided mental health care services to adults and was in that unit on the date of the site visit. The G supported the VA’s discharge back to the facility. · Information was consistent from P1, P2 and P3 (who was an administrative staff person), that the VA usually had two to one staffing at the facility during all shifts. P2 said that the VA was difficult to redirect at times. The VA might dislike some staff persons and information was consistent that the VA had an extensive history of saying that s/he would get staff persons fired or cause the facility to be closed when s/he was upset. The video recordings from the recording system were reviewed and did not show the incidents the VA described, but there were no cameras in the VA’s bedroom or bathroom. However, the VA did not require assistance with showers or activities of daily living. There were no concerns with the SPs’ work at the facility and SP3’s employment at the facility ended about a month before the VA raised concerns about him/her. · SP1 and SP3 did not complete an interview with this investigator, but SP2 said that s/he did not witness the incidents that the VA described and denied that s/he said that the VA was sexy, rubbed his/her body against the VA, or put the VA in a chokehold. Records from the law enforcement agency showed that LEOs’ accounts of their responses to the incidents described by staff persons in the GERs were generally consistent. The law enforcement agency was aware of the concerns investigated in this report and took no further action. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: Information was consistent that the VA might become upset when s/he could not do what s/he wanted to do, or when his/her surroundings were not as s/he wanted them to be. The VA was working to improve negative reactions to being told no and wanted to live as independently as possible. The VA did not require assistance from staff persons with activities of daily living. The VA said that on dates s/he could not recall, SP1, SP2, and SP3 told him/her that s/he was “sexy” and “beautiful,” touched/grabbed his/her buttocks, and put the VA in chokeholds. SP1 told the VA that the VA would “feel this big one” and SP3 pushed the VA’s head into the wall and showed his/her intimate body parts to the VA. Staff persons laughed at the VA. There were no witnesses to the incidents and the VA was unable to provide details about them. The facility completed timely GERs, Internal Reviews, and BIRFs regarding the incidents with the VA, and P1, P2, and P3 each stated that the VA was difficult to care for. SP1 and SP3 did not complete an interview with this investigator, but SP2 said that s/he did not witness any of the incidents the VA described and denied that s/he engaged in the actions described by the VA. The facility’s video recording system did not capture any of the incidents the VA said occurred. The VA was evaluated at hospitals and admitted several times in March and April of 2025, and his/her medical records showed that a hospital behavioral health provider suspected that the VA engaged in some actions for “psychological motivating gain.” After the April 3, 2025, the VA was discharged back to the facility. The next day, the VA was again evaluated at the hospital and told a physician that s/he would attempt to die by suicide if s/he was discharged back to the facility. The VA was transferred to an inpatient unit that provided services to persons with mental illnesses. The VA was assessed by an MHCP and admitted to hospital 2 but the MHCP was concerned that admitting the VA to the hospital would worsen behavioral concerns for him/her and documented that the VA should return to the facility to work with staff persons and community MHCPs. The G supported the VA’s discharge to the facility. The VA said that the SPs told him/her that s/he was beautiful and sexy, grabbed his/her buttocks, put him/her in chokeholds, banged his/her head, that SP1 told the VA that s/he would feel this big one, and that SP3 showed his/her intimate parts to the VA. However, the VA had a history of providing inaccurate information and saying that s/he would get staff persons fired or the facility closed. Given this, that the video recording system showed none of the incidents, that there were no concerns regarding the SPs’ work, and that the G supported the VA’s return to the facility, there was not a preponderance of the evidence whether SP1, SP2, or SP3 engaged in nontherapeutic conduct which could reasonably be expected to produce physical pain or injury or emotional distress, or whether there was sexual contact between the VA and SP3. 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; 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). It was not determined whether sexual abuse occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast). Action Taken by Facility: The facility completed an Internal Review which determined that their policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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