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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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) placed the VA in a hold resulting in a broken left hip. Date of Incident(s): December 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); and subdivision 17, paragraph (a): 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 failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on January 15, 2025; from documentation at the facility and hospital medical records; and through six interviews conducted with the VA, a facility health care professional (HCP1) and four staff persons (the SP, P1, P3, and P4). The VA’s diagnoses included schizophrenia, post-traumatic stress disorder, and diabetes. The VA was under civil commitment as mentally ill and dangerous. The VA resided on Redwood unit and enjoyed playing cards and bingo. The VA was not subject to guardianship. On December 5, 2024, the VA was transferred to Redwood unit due to increased auditory hallucinations and difficulty managing those symptoms. Three days prior to the transfer, the VA assaulted a peer because s/he believed the peer was “doing witchcraft” on the VA. This investigator reviewed videos that showed the following two incidents occurring on December 7, 2024: · In the first video, (there was no audio) eleven clients and three staff persons (identified as the SP, P1, and P2) were observed in a canteen area where clients purchased items from vending machines. Some clients were standing while others were sitting at round tables. One client (C1) was wearing a hoodie with the hood up and sitting at a table when the VA walked behind C1 and rapidly threw three punches to the back of C1’s head. It was likely that at least one of the punches connected with C1 because s/he immediately stood up and ran to the other side of the table. The SP, P1, and P2 were each involved with assisting and monitoring the clients and their purchases. There was no indication that any of the staff persons were aware of the incident until C1 rapidly stood up and ran away from the VA and around the table. · In the second video, the clients were walking in a hallway after leaving the canteen and were almost to the door leading to Redwood unit. P2 was walking near the middle of the group, P1 was near the back of the group walking next to a different client (C2), who was walking directly in front of the VA. The SP was a few steps behind the VA. The VA took a few fast steps forward and raised his/her fist as if to punch C2 from behind. The SP observed the VA’s actions and immediately stepped forward and wrapped his/her arms around the VA’s torso as the VA punched C2. When the VA hit the back of C2’s head, C2 fell to the floor directly in front of the VA. The VA and SP then tripped over C2 and fell to the floor. A Serious Injury Report stated that in the afternoon of December 7, 2024, the VA reported hearing command auditory hallucinations and requested and received his/her PRN (as needed) medication. Shortly after, the VA again requested a PRN, and it was provided. The VA’s plan for safety included watching movies in his/her room and s/he was reminded that a staff person would get the VA a pop if s/he did not feel safe going to the canteen. The VA chose to go to the canteen with other clients from Redwood unit. While in the canteen area, the VA swung his/her fists at C1, and unidentified staff persons intervened. (Interviews showed the intervention was verbal redirection from the SP). While walking back to Redwood unit, the VA ran up behind C2 and assaulted C2 with closed fists. The SP “grabbed” the VA from behind and assisted the VA to the floor. While attempting to place the VA in the “recovery position” the VA said that his/her legs were broken. The VA was escorted in a wheelchair to his/her room where an assessment showed no visible malformations, and no discoloration or areas of edema. During passive range of motion, the VA expressed significant pain in his/her knee region and range of motion was ceased immediately. An ice pack and pain medications were provided prior to the VA’s transport to a local hospital for further assessment. The VA’s hospital records showed the following: · On December 7, 2024, an x-ray of the VA’s pelvis and “lateral views of the left hip” showed there was “no definite acute fracture or dislocation. Questionable lucent lesion of the left femoral head.” · The VA returned to a hospital on December 10, 2024, and was diagnosed with a fractured left hip that was surgically repaired on December 11, 2024. The VA was discharged from the hospital to the Forensic Nursing Home on December 16, 2024. The VA provided the following information: · On December 7, 2024, when s/he went to the canteen, s/he was “hearing voices” that told him/her to “hurt somebody” so the VA walked behind C1 and “punched [C1] many times.” Unidentified staff persons (determined to be the SP, P1, and P2) were in the immediate area and the SP told the VA, “No, no, no, not acceptable.” · When walking back to Redwood unit, the VA again heard voices telling him/her to “punch that person in front of you” so the VA “hit [C2] a few times” with the VA’s fists. The SP put his/her arms around the VA’s waist and “tackled” the VA from behind resulting in the VA and SP landing on the floor with the VA on his/her stomach and the SP on top of the VA. The VA was instantly in pain and believed that his/her leg was broken from the fall. The VA was given pain medication every four hours and was taken to a hospital that same day. An x-ray of the VA’s leg showed “nothing is wrong” despite the VA telling them s/he was in pain and could not walk because his/her leg was broken. The VA returned to the facility but returned to the hospital “either the next day” or the “same day” and it was determined the VA needed hip surgery. · The VA did not believe the SP needed to “tackle” him/her and should have just told the VA to “stop.”
P1 provided information consistent with the Serious Injury Report as well as the videos. P1 said that s/he observed the first incident out of the “corner of” his/her eye and that s/he saw the VA “swing” at C1. P1 heard the SP tell the VA to “stop.” Regarding the second incident, P1 saw the SP wrap his/her arms around the VA’s torso and they “went to the ground” with the VA landing on his/her stomach. P1 immediately used his/her radio to initiate an incident command system (ICS). P1 believed the SP responded to the incident as trained. As the VA was manually restrained, staff persons attempted to place the VA on his/her side and the VA immediately said his/her leg hurt. HCP1 said that s/he and another health care professional (HCP2) responded to the hallway when the ICS was announced. HCP1 was told that prior to the manual restraint, the VA had an incident near the pop machines where s/he assaulted C1 and then on the way back to Redwood unit, the VA assaulted C2 and C2 fell to the floor with the VA and SP falling on top of/over C2. The VA said that his/her “leg hurt bad” and HCP1 did a “full assessment” and provided the VA with pain medications, ice packs, and extra pillows for his/her leg prior to the VA being transported to a hospital. HCP2 documented that when s/he responded to the ICS, the VA was on the floor outside Redwood Unit. The VA complained of left leg/hip pain. The VA was assisted into a wheelchair and returned to his/her room where s/he was helped into bed. P3 responded to the ICS and was told that the VA “struck” C2, resulting in a restraint. The VA was on the floor complaining of pain while being assessed by an unknown HCP. P3 was asked about his/her restraint training, specifically regarding the SP implementing a restraint alone. P3 said that staff persons needed to determine their “personal safety” and if they did not feel safe, they would call for assistance prior to initiating a manual restraint. However, if a staff person felt comfortable restraining on their own, they were trained to wrap their arms around the persons torso and lean back to stop the forward momentum. While “two persons” were recommended for a restraint, once a staff person does a “wrap around” the torso, other staff person(s) assisted. P4, a supervisory staff person, said that staff persons were trained to make sure two staff persons were “available to help” if a manual restraint was initiated. P4 reviewed the videos and believed the staff persons responded as trained. The SP’s documentation and an interview with this investigator provided the following information: · The SP only worked with the VA “a few days” before the incidents occurred and was aware that the VA “randomly assaults” others and for that reason the VA was moved to Redwood unit. · On December 7, 2024, around 6:30 p.m., several clients, P1, P2, and the SP went to the canteen. While at the canteen, the VA assaulted C1. (The SP said that s/he did not witness the assault but was told it occurred by P2.) The SP talked to the VA and asked him/her if s/he was “okay” to return to Redwood unit and the VA said, “Yes,” and then “mumbled some sentences.” When in the hallway near Redwood unit, the VA started to run towards C2 who was directly in front of the VA. As the VA punched C2 in the back of the head, C2 fell to the floor. The SP wrapped his/her arms around the VA but due to the forward momentum, the SP and VA tripped over C2 resulting in the SP and VA also falling to the floor. · The SP believed s/he responded to the incidents as trained. However, in hindsight the SP also said that possibly the VA should have been brought back to the unit after it appeared s/he “possibly assaulted” C1 near the soda machines. Facility information showed the prior to the incident staff persons were trained regarding restraint and seclusion, person-centered thinking, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on December 7, 2024, the VA assaulted C1 by punching him/her in the back of the head. When walking back to the unit, the VA ran towards C2 and punched him/her in the back of the head, resulting in C2 falling to the floor directly in front of the VA. As the second assault occurred, the SP wrapped his/her arms around the VA’s torso and the VA and SP fell over C2. The VA was provided immediate medical attention, and an initial x-ray did not indicate a fracture. Three days later the VA went to the hospital and another x-ray determined the VA had a fractured left hip that required surgery. Although the VA likely sustained a hip injury during the incident, given the VA’s history, that P1 and P2 were each available to assist as needed when the SP initiated a manual restraint, and that there was a risk for further harm by the VA if the SP did not intervene, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic or whether the VA sustained the injury by any means other than accidental. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). 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 a Serious Injury Report and submitted it to the Office of Ombudsman for Mental Health and Developmental Disabilities and the DHS. The also facility completed an internal review and determined that policies and procedures were in place and were followed. Additional training included reminding staff persons to not hesitate to call an ICS if additional resources were needed and training regarding restraint and seclusion documentation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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