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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: 1071992- H_CRS (Home and Community-Based Services-Community Residential Setting) 1071970-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon/Brittany Dolen 651-431-2155 Suspected Maltreatment Reported: It was reported that on more than one occasion, a staff person (SP1) and a supervisory staff person (SP2) yelled, used profanity, lost their temper, and got mad at two vulnerable adults (VA1 and VA2). Date of Incident(s): Ongoing prior to March 20, 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 (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: 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 two site visits conducted on April 1 and 11, 2024; from documentation at the facility; and through ten interviews conducted with VA1, VA2, four supervisory staff persons (P1, P2, P3, and SP2), another resident (R) of the facility, and three staff persons (P4-P6). Attempts were made via telephone and certified mail to contact and interview SP1, however SP1 did not respond to the requests. VA1’s plans said VA1 was diagnosed with mild intellectual disabilities, bipolar disorder type II, depression and anxiety. VA1 participated in mental health services as well as physical therapy and used a four wheeled walker to ambulate. Staff persons assisted VA1 in the bathroom, but s/he was able to do other things independently. VA1 enjoyed traveling, working out, attending church, watching television, and fashion. VA1 was employed, and it was important to him/her to maintain employment and contact with his/her friends and family. VA1was not subject to guardianship. VA2’s plans said VA2 was diagnosed with mild intellectual disabilities, diabetes, and narcolepsy. VA2 enjoyed playing bingo, attending church, riding his/her bike, and shopping. VA2 needed some support and supervision to ensure safety in the community but was primarily independent. VA2 was employed and was not subject to guardianship. VA1 told this investigator that s/he does not “have” to do chores if s/he does not want to. VA1 said SP2 and other staff persons used to “make” him/her do chores and VA1 “got in trouble” if s/he did not do them. SP2 told VA1 to do his/her chores “like a drill sergeant” and when SP2 yelled it was “like a high pitch scream” and “very annoying.” VA1 did not provide information regarding SP1. VA2 told this investigator that SP1 called VA2 “four letter words” but s/he did not remember what those words were. SP1 said these words “at nighttime” because VA2 “didn’t listen good enough” and “didn’t do stuff right.” VA2 “did not like” when SP1 got mad and swore at VA2. VA2 thought SP1 did this because of his/her “temper” and heard SP1 talk to VA1 the same way. VA2 said SP2 was “strict about doing stuff right” but denied SP2 swearing at or calling him/her names. The R told this investigator that s/he enjoyed basketball, going on outings in the community and playing video games. The R said staff persons at the facility are “nice” to him/her and denied staff persons yelling or swearing at him/her. The R denied not being able to go into the community if s/he wanted. The R “liked” the food at the facility and could get snacks whenever s/he wanted. The R denied hearing SP1 yell at VA2 but said s/he heard SP1 “yell” at VA1 in the mornings. The R denied hearing SP1 swear at VA1 or VA2 and denied that s/he heard SP2 yell at any of the residents P1, P2, and P3 provided the following information: · On an unknown date, P1 told P3 that VA2 told an unknown person that s/he was “super depressed” and “did not like” living at the facility. P3 thought this was a “red flag,” because VA2 had “always” been happy at the facility. · P3 then checked VA2’s case notes and noticed they were not “person centered” because VA2 was being told s/he “had” to do certain tasks before s/he could do other things. When P3 asked VA2 about this, VA2 told P3 s/he had to “ask” for food and soda and had to plan activities “way far in advance.” · On March 19, 2024, P3 told P2 that s/he was going to “pop” into the facility to check in and to address the concerns s/he had with VA2’s case notes. While at the facility, P2 and P3 spoke with VA1 and VA2 and each had concerns including that SP1 had “yelled” and “swore” at them. · VA1 told P2 and P3 that SP1 “yells and swears,” “gets mad at [VA1],” and SP1 said things like “F you” out loud. SP1 got upset with VA1 for “taking too long” in the mornings. VA1 also said SP1 told VA1 if s/he told anyone what was happening, “nobody” would believe VA1. VA1 said that SP2 saw SP1’s interactions and SP1 told VA1 s/he talked to SP2 about his/her anger and interactions and that SP1 was “going to be better.” P2 and P3 each said that SP2 did not tell any other supervisory staff persons, which was required by the facility. · VA1 told P2 and P3 that SP2 “yelled” at him/her sometimes when VA1 did not want to do something. · VA2 told P2 and P3 that SP1 was “very strict,” had “anger issues,” and got “mad” at VA2 if s/he did not “do what s/he was supposed to do.” VA2 also said that SP1 used “profanity,” “bad language,” “swore” at VA2, and “mouthed F you.” · VA2 told P3 that SP2 “raised [his/her] voice” when VA2 made SP2 “mad enough” but did not provide additional information or details. · Over the years, VA1 “preferred” to go on outings with SP1 and SP1 picked up extra shifts to meet the requests of VA1. When P2 saw SP1 at the facility, s/he was “upbeat and bubbly.” SP1 worked the awake overnight shift, from 11:00 p.m. until 9:00 a.m. and P2 started his/her shift at 8:00 a.m. P6 sometimes overlapped the morning shift. · P1 stated that s/he had previous concerns about SP2’s “tone” of voice s/he used with the residents, and it was “loud and abrasive” at times. SP2 “ran” the facility “how [s/he] wanted it, not how the company wanted it.” · VA1 and VA2 were both “very” independent, and P1 thought VA1 and VA2 were able to accurately report information. P3 thought VA1 could “exaggerate a little,” but had a “good memory” and was a “great” reporter and that VA1 did not have the “best” memory. P2 said that VA1 sometimes mixed-up dates or times, and that VA2 needed reminders to slow down when talking but each had a “good memory. “ · P1 stated that SP1 worked awake overnight shifts, was “very regimented,” and “liked things a certain way.” P1 thought SP1 was “strict” in the mornings and s/he also “had a temper with staff persons.” P1 did not have concerns with SP1’s interactions with residents at the facility. P4 provided the following information: · P4 did not see SP1 interact with the residents because they did not typically work together. On several occasions, VA2 told P4 that SP1 yelled and swore at him/her but VA2 did not tell P4 what swear words SP1 used. P4 thought s/he first heard VA2 say this “about five years ago” and it was “once or twice a year” that VA2 told P4 that SP1 yelled or swore at VA2. · On one occasion after VA2 told P4 that SP1 yelled and swore at him/her, SP2 was present and heard what VA2 said. SP2 then asked VA2 what s/he did to make SP1 yell at him/her but VA2 did not respond to SP2. · SP1’s behavior towards VA2 was discussed at “all” staff meetings. At a meeting three to four years ago, P2 said, “That’s just [VA2],” and “blew it off.” · P4 heard SP2 use a “strict tone” with VA1 but did not see or hear SP2 yell at VA1 or VA2. P5 provided the following information: · On an unknown date in 2023, P5 heard VA2 say that SP1 “swore” at the residents, but VA2 did not provide further information to P5. · In November or December 2023, P5 heard from a staff person P5 could not remember that SP1 told VA1 that if s/he talked to staff persons about him/her, SP1 would make VA1’s life “a living hell.” · On an unknown date, around January 2024, P5 arrived at work and saw SP1 tell VA1 to do something and VA1 told SP1, “No.” SP1 then yelled “Damnit [VA1]” in VA1’s face. SP2 was present for this incident and was “going on and on about it” and made the situation seem like VA1’s fault and that VA1 was in trouble. P5 did not remember additional details of the incidents such as what SP1 asked VA1 to do, what SP2 said, or how VA1 responded. · SP1 was “generally a jerk” and “screamed” at P5 when the residents were asleep. SP1 was “running through the house swearing” and P5 was worried SP1 would wake up the residents. P5 felt “scared” when this happened. · SP2 often got “frustrated or upset.” When SP2 got mad, s/he raised his/her voice and was “not nice at all.” SP2 “complained” to staff persons about the residents, but P5 did not have information regarding SP2’s interactions with the residents because s/he did not typically work with SP2. P6 provided the following information: · On an unknown date, around December 2023, a staff person who P6 did not recall, told P6 that SP1 was “yelling” at VA1 and P6 told SP2 what the staff person said. A “few days later” P6 asked VA1 if s/he felt comfortable at the facility. VA1 said s/he did but “did not like being yelled at.” P6 asked VA1 who yelled at him/her and VA1 said that SP1 yelled when VA1 “was not listening,” when s/he “forgets,” and when s/he “doesn’t do what [s/he] needs to.” P6 asked VA1 if s/he ever felt unsafe around SP1 and VA1 said, “When [s/he’s] yelling, yes.” P6 told VA1 that s/he should not feel unsafe at the facility because it is his/her home. During this conversation, VA1 told P6 that SP1 told VA1 if s/he “told” it would “make it worse.” After this conversation, P6 called SP2 and told him/her about the conversation. SP2 told P6 that s/he would speak with SP1 and VA1. P6 did not hear anything more about these concerns. · P6 did not work with SP1 and only saw his/her interactions with the resident for approximately twenty minutes when their shifts overlapped. P6 did not see any concerning interactions between SP1 and the residents during this time. · P6 thought SP2 was “stern and straightforward” with the residents and sometimes used a “disappointed” tone but P6 did not think that SP2 realized how his/her tone sounded. SP2 was “louder” and could come across as “intimidating.” P6 never saw SP2 be aggressive, insult swear or say derogatory things to the residents.
SP2 provided the following information: · VA1 was “manipulative and spoiled” and did not want to do things for him/herself. · VA2 was “helpful” and liked to be active. VA2 had issues with boundaries and needed reminders of personal space. Staff persons assisted VA2 with medication, making meals, and daily activities and reminders. VA2 was “pretty independent” but needed some reminders. · On an unknown date in February 2024, a staff person who SP2 did not identify, told SP2 that VA1 told them s/he was “in fear for [his/her] life.” SP2 spoke with VA1 about this, and VA1 told SP2 s/he felt this way because SP1 “yelled” at him/her. VA1 denied that SP1 had ever threatened physical violence towards VA1 and then stated s/he “guessed” s/he was not in fear for his/her life. · The day following this conversation, SP1 “heard” SP1 raise his/her voice. SP2 addressed this with SP1 and told him/her that s/he was not allowed to “raise [his/her] voice or be disrespectful” to the residents. SP1 told SP2 that s/he was “really trying hard” to not raise his/her voice and to not be disrespectful to the residents. · On an unknown date, SP2 heard SP1 tell VA1 “you need to get your shit together. You know what to do.” · SP2 denied yelling at VA1 and VA2 and said that any time a staff person talked to VA1 in something other than “a low voice,” VA1 thought they were “raising their voice.” SP2 said his/her voice was “loud to start with” and that s/he did not “necessarily” yell at VA2 but “probably” raised his/her voice to encourage VA2 to complete his/her physical therapy. The facility’s personnel files showed that P1-P6 and SP1 and SP2 were all trained on the VA1 and VA2’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights included the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: Regarding SP1’s interactions with VA1 and VA2: VA1 told P6 that SP1 called him/her “four letter words” but could not remember the words s/he was called. VA1 provided consistent information to P2, P3, and P6 that SP1 yelled and swore at him/her. VA2 stated that SP1 called VA2 “four letter words” but s/he did not remember the words. VA2 said that s/he “did not like” when SP1 got mad and swore at VA2. VA2 also stated that s/he heard SP1 talk to VA1 in the same way. VA2 provided consistent information to P2, P3, and P4 that SP1 yelled and swore at VA2. The R stated that SP1 yelled at VA1 but not VA2 and the R had not heard SP1 swear. P1-P6 provided information the SP1 was easily frustrated and would yell and swear at VA1 and VA2 and that SP1’s interactions with the residents had been discussed with SP1, but SP1’s interactions continued. SP1’s actions of yelling and swearing at VA1 and VA2 was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, was not accidental or therapeutic conduct, and were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Given that VA1 and VA2 provided consistent information to multiple persons on multiple dates, that the R and others staff persons saw SP1 yell at VA1 and/or VA2 on multiple dates, there was a preponderance of the evidence that SP1 engaged in repeated oral language toward VA1 and VA2 that would be considered to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be expected to produce emotional distress. 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). Regarding SP2’s interactions with VA1 and VA2: VA1 provided information that SP2 yelled “like a drill sergeant,” “like a high pitch scream.” and provided consistent information to P2, P3, and P6 that SP2 yelled at him/her. VA2 denied that SP2 yelled or called VA2 names, and the R denied hearing SP2 yell at any of the residents. P1 had concerns with SP2’s “tone of voice” because sometimes SP2 “loud and abrasive.” P4 thought SP2 used a “strict” tone with the residents, P5 thought SP2 often got “frustrated or upset” with the residents, and P6 thought SP2 was “stern and straightforward” with the residents. There was no information provided that SP2 swore at VA1 and/or VA2 and no additional details regarding the incidents. SP2 denied yelling at VA1 and VA2 and denied calling VA1 or VA2 names. Although information regarding SP2 yelling varied, VA2 and the R provided consistent information that neither had seen SP2 yell, but information from VA1, P1, P4, P5, P6, and SP2 was consistent that SP2’s tone of voice changed when s/he became frustrated or upset with a resident. SP2’s interactions as described by VA1, P1, P4, P5, and P6 was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, was not accidental, and were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, while VA1 could have interpreted the actions of SP2 as mean and/or yelling, VA2 and the R provided consistent information that neither had seen SP2 yell, and there were no details regarding SP2’s interactions. Therefore, there was not a preponderance of the evidence whether all of SP2’s interactions were therapeutic conduct or whether SP2’s engaged in conduct that would be reasonably expected to produce emotional distress. It was not determined whether 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 was trained on VA1’s and VA2’s plans and the reporting Maltreatment of Vulnerable Adults Act. At the time of the incidents, SP1 was employed by the facility and was in direct care of VA1 and VA2. SP1 was witnessed, by multiple staff persons yelling at and calling VA1 and VA2 names. SP1 was responsible for the 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 “recurring” maltreatment but did not meet the definition of “serious.” SP1 was responsible for the emotional abuse of VA1 and VA2. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. Staff persons received additional training related to the incident and SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that SP1 was responsible for maltreatment is subject to appeal. On May 16, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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