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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: 1072539-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Alice Percy 651-431-3444 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP) was verbally abusive to a vulnerable adult (VA) and called the VA names. Allegation two: It was reported that three long distance international calls and several text messages were made using the VA’s cell phone, but were not made by the VA. Allegation three: It was reported that the facility’s elevator was blocked so that the VA was unable to access the main floor of the facility. In addition, the SP sometimes slept during his/her work shift. Date of Incident(s): Ongoing, prior to July 16, 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); and subdivision 9, 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: 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property 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 two site visits conducted on August 1 and 8, 2024; from documentation at the facility; and through ten interviews conducted with three facility administrative staff persons (P1, P2, and P3), two staff persons (P4 and P5), the SP, a client (C), the VA’s case manager (CM), and the VA’s two guardians (G1 and G2). The VA initially agreed to an interview, but ended the interview before answering any questions and then refused a subsequent interview. An additional staff person (P6) was offered an interview, but declined to provide information. The VA enjoyed being outside, listening to music, going to concerts, and spending time with his/her friends and family members. The VA’s diagnoses included mild intellectual disability, attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), cerebral palsy, left-side weakness, and pervasive developmental disorder. The VA used a wheelchair for mobility. According to the VA’s Coordinated Service and Support Plan (CSSP), the VA could ride around the neighborhood in his/her powerchair without the supervision of a staff person, as long as s/he notified a staff person where s/he was going. On April 1, 2024, supportive technology was added to the VA’s plan so that a mechanism was added to the facility’s elevator that the VA could use to open and close the elevator door. The facility was a rambler-style building with the main living areas and two bedrooms on the main level and two bedrooms on the walk-out lower level. A vertical lift was installed so that clients on the lower level could access the main level without using the stairs. Each client had their own bedroom, bathroom, and living area. The VA and the C had bedrooms on the lower level of the facility. There were typically two staff persons at the facility in the morning, two in the evening, and one during the overnight hours. Allegation one: It was reported that the SP was verbally abusive to the VA and called the VA names. G1 and the CM provided the following information: · The CM stated that the VA told the CM that the SP called the VA “messy ass” and “block head” and told the VA to go to the lower level of the facility so the SP “did not have to see [the VA’s] face.” The CM stated that in July 2024, G1 sent an email to the CM about a staff person being verbally abusive to the VA. · The CM stated that the VA had a history of providing inaccurate information about events. In the past, the VA provided information to the CM that s/he did not like the SP and wanted to get the SP fired. G1 stated that the VA sometimes “fabricated stories” so s/he would remind the VA to “tell the truth.” P2, P3, P4, and P5 provided the following information: · P4 stated that s/he typically worked with the SP for short periods of time at the end of his/her work shift and had no concerns about the SP’s interactions with the clients. P4 never heard the SP call the VA names, but the VA sometimes called the staff persons names. P4 stated that the VA often told P4 that s/he did not like the SP. P5 stated that s/he never heard the SP call the VA names. P3 stated that the SP denied calling the VA names. P2 had no concerns about the SP’s interactions with the clients and stated that s/he was “one of my best staff.” · P1 and P2 each stated that the VA was not always a reliable reporter of events. P2 stated that the VA told some of the staff persons that s/he “wanted to get [the SP] fired.” P2 stated that in the past, the VA had “conflicts” with other staff persons. The SP stated that s/he never called the VA names such as “messy ass” and never heard any of the other staff persons call the VA names. The SP believed the VA complained about the staff persons to G1 in order to “get the staff persons in trouble.” In the past, the VA told the SP that s/he did not like the SP and wanted to “get [the SP] fired” from his/her job at the facility. According to the facility’s Rights of Persons Served policy, the clients had the right to live without the fear of abuse, neglect, or financial exploitation. The clients were to be treated with courtesy and respect and free from bias or harassment. The clients also were to have use of all common areas in the facility. Facility documentation showed that the SP, P1, P2, P3, P4, and P5 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion for Allegation one: The CM stated that the VA told him/her that the SP called the VA “messy ass” and “block head” and told the VA to go to the lower level of the facility so the SP “did not have to see [the VA’s] face.” However, given that P2-P5 had no concerns regarding the SP’s interactions, that the SP denied the allegations, and there was no additional information, including from the VA, to support or refute what the VA told the CM, there was not a preponderance of the evidence whether the SP’s use repeated oral language that could reasonably be expected to emotional distress to the VA. 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). Allegation two: It was reported that three long distance international calls and several text messages were made using the VA’s cell phone, but were not made by the VA. The C stated that s/he never saw a staff person use the VA’s cell phone. G1 and the CM provided the following information: · G1 stated that on the VA’s May 2024 cell phone bill, the charges were approximately $70 higher than usual. When s/he contacted the telephone company, s/he was told that there were three international calls made on the VA’s cell phone that increased the bill. There were also several text messages to and from the same phone number. G1 did not believe that the VA had the “capacity” to make an international telephone call and did not know anyone who lived in that country. · The VA typically kept his/her cell phone with him/her unless it was charging. The VA had a lock on his/her cell phone, but the code was “simple.” The CM stated that in June 2024, G1 sent an email to the CM regarding three unauthorized long-distance calls and several text messages made on the VA’s cell phone that resulted in charges on the VA’s telephone bill. The CM did not believe that the VA knew anyone in the country that was called and texted with his/her cell phone and did not believe the VA had the skill to call the same long-distance number multiple times. P1, P2, P3, P4, and P5 provided the following information: · P3 stated that s/he received a telephone company statement that showed when calls and texts were made to a foreign country on the VA’s cell phone. P5 stated that the VA frequently made calls on his/her cell phone, but P5 did not know who the VA called. P5 stated that s/he did not use the VA’s cell phone to make calls because s/he had his/her own cell phone. P4 stated that s/he never saw the SP use the VA’s cell phone, but the VA frequently used his/her cell phone. The VA had a “necklace” on his/her cell phone so that s/he could keep the cell phone on him/herself. At night, the VA left his/her cell phone on the charger in his/her bedroom. The VA sometimes used voice-activated texts on his/her cell phone. · The SP told the staff persons that s/he never used the VA’s cell phone because s/he had his/her own cell phone. P1, P2, and P3 each stated that the staff persons, including the SP, denied using the VA’s cell phone to make calls or texts and told them that they had free apps to use when making international phone calls. P1 was uncertain if the VA would “trust” the SP with the VA’s cell phone. P2 believed that the SP was not working at all of the same times the calls and texts were made. Consistent information was provided that the VA sometimes went into the neighborhood without the supervision of a staff person and the staff persons were uncertain if the VA allowed anyone to use his/her cell phone at those times. The SP stated that the VA typically used his/her cell phone to call or text his/her family members. All of the staff persons had their own cell phones and did not need to use the VA’s cell phone. The SP denied using the VA’s cell phone to make international calls because the SP had his/her own cell phone. The VA never used the SP’s cell phone. According to an email from the VA’s cell phone company: · Texts were made from the VA’s cell phone to or from an international number on – o May 22, 2024: Received text at 6:45 p.m., sent text at 7:55 p.m., sent text at 8:24 p.m., received text at 8:40 p.m., and received text at 8:42 p.m. o May 23, 2024: Sent text at 9:21 a.m. o May 25, 2024: Received text at 7:57 p.m. o May 27, 2024: Sent text at 8:30 p.m. o June 5, 2024: Sent text at 4:20 p.m. · Telephone calls were made from the VA’s cell phone to the same international phone number on – o May 22, 2024: 9:31 p.m. - 16 minute call o May 23, 2024: 8:31 p.m. - 2 minute call o May 27, 2024: 6:58 p.m. - 2 minute call · Total charges were $66.81. According to the facility’s time card information: · On May 22, 2024: P5 worked 7:05 a.m. - 10:13 p.m. The SP worked 3:35 - 11:03 p.m. · On May 23, 2024: P5 worked 7 a.m. - 11 p.m. The SP worked 3:26 – 10 p.m. · On May 27, 2024: P5 worked 2:26 to 10:16 p.m. The SP worked 3:44 - 11:08 p.m. · On June 5, 2024: P5 worked 7 a.m. – 10:02 p.m. The SP worked 4:32 - 11 p.m. Conclusion for allegation two: On May 22, 23, and 27, 2024, three international telephone calls were made from the VA’s cell phone to an international phone number. The charges for the three calls totaled $66.81. At the time of each phone call, P5 and the SP worked at the facility and it was possible either made the call. However, while it was unlikely that the VA made the telephone calls, it was possible that s/he also did so. Given that P5 and the SP each denied using the VA’s cell phone, that the VA declined to provide information for this report, and that the VA sometimes went around the neighborhood without the supervision of a staff person so it was unknown if any community person used the VA’s cell phone at those times, there was not a preponderance of the evidence whether a staff person willfully used the VA’s phone resulting in charges that had to be paid by the VA. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Allegation three: It was reported that the facility’s elevator was blocked so that the VA was unable to access the main floor of the facility. The C stated that s/he typically accessed the main level of the facility by using the stairs, but sometimes used the elevator. On one occasion, on the main level of the facility, the C found a chair sitting in the elevator doorway, holding the door open so that it could not be used. The C did not recall the date of the incident, but stated that at the time of the incident, the SP was working at the facility. The C did not tell anyone about the chair blocking the elevator door and did not move the chair until the VA asked the C to “fix” the elevator so that s/he could use it. The C believed the chair blocked the elevator door for approximately 30 minutes. The C believed that on an unknown number of other occasions a chair was placed to block the elevator door, but “couldn’t say specifically” when that occurred. On “many” occasions, the C saw the SP sleeping on the living room sofa when s/he was supposed to be working at the facility. G1, G2, and the CM provided the following information: · G1 stated that the VA frequently told G1 that s/he was unable to use the elevator to go to the main level of the facility. The staff persons told G1 that a piece of carpet sometimes caused the elevator door to “stick.” The CM stated that in July 2024, G1 sent an email to the CM about a staff person blocking the elevator so that the VA could not use it. On several occasions, the elevator was not working and the VA was unable to access the main living areas of the facility. The elevator door had to be closed before the elevator would move and the CM was uncertain if someone blocked the elevator door from closing. · G1 stated that the VA frequently told him/her that the SP slept while working at the facility. G1 asked the VA to take a photograph of the SP sleeping and send it to G1, which the VA did. On July 7, 2024, at approximately 5 p.m., G2 drove the VA back to the facility after the VA spent time with G1 and G2. G2 stated that the SP “rolled [his/her] eyes” when G2 and the VA entered the facility and then sat on the sofa and slept. G2 took a photograph of the SP sleeping on the sofa. G2 stated that the SP slept during the hour G2 was at the facility. P5 was also working at the facility. P1, P2, P3, P4, and P5 provided the following information: · P1 stated that initially the VA was unable to open the door to the elevator, but the facility had an “auto opener” installed so that the VA could use the elevator without assistance. At some point, the elevator door would get “stuck” and “over time the carpet got raised” so the elevator door did not easily close and the VA had to ask the staff persons for assistance with using the elevator. When the door became “completely stuck,” the facility’s maintenance person fixed the elevator door. P5 stated that the VA was able to use the facility’s elevator without assistance. P5 was unaware of any time when the elevator was not working. P4 “heard” that the elevator was not working on two occasions, but did not have any additional information about the elevator not working. · P4 stated that although s/he heard that the VA was locked out of the elevator, the staff persons did not have a key to lock the elevator. P4 stated that at times the VA complained that something was “wrong” with the elevator, but the VA was able to get the elevator to work by continuing to press the elevator control button. P1 and P2 each stated that the VA told them that the SP locked the elevator door with a key, but only P2 had access to the key. The VA told P2 that the SP blocked the elevator door with a chair on the main level of the facility, but could not tell P2 how s/he knew that a chair blocked the door. The SP told P2 that s/he did not lock the elevator door or block it so that the VA could not use it. · P1 stated that on one occasion the VA sent a photograph to P2 of the SP sleeping at the facility and on a second occasion G1 sent a photograph to P1 and P2 of the SP sleeping on the couch. On both occasions, P5 was also working at the facility. P1 and P3 each stated that the SP told them that s/he was sleeping on one occasion because s/he felt ill, but was not sleeping on the other occasion. The SP told P2 that on one occasion s/he sat on the sofa with his/her eyes closed in order to “distance” him/herself from G1 and G2. The SP told P2 that on the other occasion, s/he lay on the sofa to watch a movie with the VA. P5 and P4 each stated that they never saw the SP sleeping while they worked at the facility. The SP provided the following information: · The VA did not need assistance to use the facility’s elevator. A key to lock the elevator was stored in the staff office and only the supervisory staff persons had access to the key. The SP denied ever placing a chair in the door of the elevator to block the elevator door from closing. At one time, the elevator was “broken” and a repair person fixed the elevator, but the SP did not know what was wrong with the elevator. · On one occasion, G1 and G2 brought items to the facility for the VA. The SP helped them carry the items to the VA’s bedroom. The SP then sat on the sofa and watched television with one of the other clients. Although G1 and G2 later said that the SP was sleeping on the sofa, the SP stated that s/he was awake while s/he sat on the sofa, but had his/her eyes closed for a few seconds as s/he prayed for family members who were in the hospital. At that time, P5 was also working at the facility. · On a second occasion, the SP felt ill and vomited in the facility’s bathroom. Because s/he then felt “dizzy,” s/he lay on the sofa and watched television with the VA. The SP told P5 that s/he was feeling ill. The SP believed s/he “fell a little bit asleep” for approximately 30 minutes because s/he was dizzy. The SP then felt better and assisted the VA with taking a shower. G1 provided three photographs taken at the facility by the VA and G2. One photograph, taken by the VA on an unknown date in May 2024, showed the SP lying on the sofa with his/her eyes closed. Two photographs, taken by G2 on July 7, 2024, showed the SP sitting upright on the facility’s sofa with his/her eyes closed. Conclusion for allegation three: While it was reported that the SP locked the elevator so that the VA was unable to use the elevator to access the main level of the facility, consistent information was provided that the SP did not have access to the key needed to lock the elevator. It was also reported that a chair was used to block the door of the elevator on at least one occasion, which resulted in the VA being unable to use the elevator for a period of time. No additional information was provided about who placed the chair in the doorway of the elevator or when it occurred. Consistent information was provided that the elevator sometimes did not work properly because it became blocked by carpeting. When the door became “completely stuck,” the facility’s maintenance person fixed the elevator door. It was also reported that the SP slept while working at the facility and three photographs were provided by G1 that showed the SP sitting and lying on the sofa with his/her eyes closed. While the SP stated that s/he was awake but sitting with his/her eyes closed on one occasion, the SP stated that s/he may have slept for a few minutes on the second occasion because s/he was ill. While sleeping during his/her work shift was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, there was another staff person working at the facility at the time of the incident who was available to assist the VA and the other clients if needed. Given that the SP did not have a key to lock the elevator, that it was unclear if the elevator door was intentionally blocked, and that another staff person was working at the time the SP slept, there was not a preponderance of the evidence whether there was a failure to supply the VA with necessary care or services. 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the staff persons. After the incidents, the staff persons were retrained on the facility’s policies. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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