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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: 1071647-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) made a vulnerable adult (VA) perform chores around the facility, made the SP clear her/his plate and wash dishes, and made “hurtful” comments to the VA. It was also reported that the SP refused to assist the VA with showering. Date of Incident(s): Unknown 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 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. 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 May 21, 2024; from documentation at the facility and through seven interviews conducted with two supervisory facility staff persons (P1 and P2), two staff persons (P3 and SP), the VA, a resident (R), and the VA’s guardian (G). The VA was diagnosed with Down Syndrome, mild developmental disabilities, and had hand tremors. The VA’s Individual Service and Support Advocacy (ISSA) plan stated that the VA required assistance with washing her/his hair in the shower because shampoo/conditioner left in may cause a rash on the VA’s scalp. The VA like to hang out with staff persons and was saving for a vacation to Branson, MO. The VA provided the following information: · The VA stated that s/he and the SP did not get along. The VA stated that the SP refused to help wash her/his hair and told the VA that s/he could do it on her/his own. This went on for an unspecified amount of time. When the SP refused to help the VA, another staff person would help the VA with her/his hair when showering. · The VA stated that the SP would have her/him do chores like cleaning and putting dishes away. The VA recalled one time s/he was putting dishes into the dishwasher, and s/he got dizzy and sat on the floor and the SP yelled at her/him for no reason. The SP said, “Don’t act dumb, act like a normal person,” and that the SP also called her/him “stupid.” · The VA gave donations to her/his church in the form of a check for two dollars for regular offerings. About every other Sunday, the VA also gave a five dollar check to support a local high school. The VA stated that one time the SP would not give the VA the checks. Again, another staff person assisted the VA with the checks. P3 provided the following information: · P3 stated that s/he witnessed the SP’s treatment of the VA from the time s/he began working with the SP until the time the SP was removed from the schedule. P3 documented what s/he witnessed and provided that document to P2. · The SP would have the VA do some cleaning, but P3 never heard the SP directly call anyone “stupid.” P3 did hear the SP make comments like “act like a normal person,” “don’t act dumb,” “are you dumb?” P3 recalled that one day, the SP told her/him not to give the VA tater tots but to give the VA veggies because the SP was mad at the VA. · P3 stated that the SP noted that the VA had refused to shower, but the VA said s/he had not. P3 noted there was a power struggle between the VA and the SP, and the SP would threaten the VA with not getting a pop or not going to church, but the SP never denied the VA necessities like a meal. However, with the VA, her/his pop was a big deal because the VA purchased her/his own pop. · P3 stated that the SP also sometimes did not help R with showering but that the SP got along with the R, as well as with the other residents at the facility except the VA. The undated document prepared by P3 and given to P2 stated that beginning with the first shift that P3 worked with the SP, there was a consistent pattern of the SP focusing on the VA, and that the SP had several conflicts with the VA. The SP made the VA do all household chores including dishes, garbage, sweeping, and even clearing the SP’s plate from the table and washing it. P3 overheard the SP say hurtful things to the VA such as, "Are you stupid?" "Don't act dumb," and "Act like a normal person.” The document did not specify when P3 overheard such comments and if they were made more than once. P1 provided the following information: · P1 talked to the SP about the allegations and P1 stated that the SP said s/he was just following the rules; the SP denied calling the VA any names. · P1 stated that most of the times, residents at the facility would assist with cleaning if asked but they were not required to do chores. When asked if it was against policy for the SP to require the VA to perform chores, P1 stated, “No,” but noted residents could not be made to do chores. P1 noted that the VA felt s/he was being singled out by the SP. · P1 stated that the facility was the payee for the VA, so they tracked the VA’s expenses and staff persons would have no reason to deny the VA from writing a check if the VA had funds in her/his account. P2 provided the following information: · P2 stated that prior to becoming aware of the allegations in the report, s/he knew that the SP and the VA had a history of little arguments; mostly “he said, she said,” kind of things. Around March/April of 2024, P2 noticed that the VA was becoming more upset and had stopped raising concerns to P2 but would mention once in while that things were good. · From time to time, P2 worked with the SP at the facility but had no concerns about the SP and never saw any issues between the SP and the VA. P3 informed P2 what s/he had been seeing between the SP and the VA. P2 spoke with the VA about it, the VA at first said nothing was wrong but then broke down and said that the SP called her/him hurtful names. The VA said that the SP was “too lazy” in regard to helping with showers. The VA recalled one night asking the SP for help and the SP did not help the VA. The SP later told the VA, that s/he did not tell the SP that the VA was ready. When the SP would not help with showering, P3 would help. · P2 had mentioned to the SP in the past that staff persons could not restrict the VA from having a check written as long as the VA had money in her/his account. The SP provided the following information: · The SP denied making any hurtful comments to the VA, denied that there was a power struggle between her/him and the VA, and denied making the VA perform chores. The SP stated that s/he asked the VA if s/he wanted to help with chores and sometimes the VA said, “Yes,” and sometimes the VA declined to help. The VA would help clear the table and help with dishes. The SP had been told by her/his supervisors, P1 and P2, that the residents at the facility were capable of helping with chores. · The SP provided a screenshot of an email to the VA’s guardian that P2 asked her/him to review before sending. The email outlined recent problems that staff persons had experienced with the VA. The email noted that the VA had refused to shower for a few days, refused to wash clothes other than undergarments, refused to exercise, and left his/her belongings spread around a lower-level living room and bedroom which created a fire hazard. The SP asked the guardian to stop by and help get the VA back on track. · The VA would make donations to the church via personal checks but staff persons did not know how much the VA had in her/his checking account and per the VA’s guardian was told to limit the VA’s check writing but the facility said they could not do that because that would be a rights restriction The G provided the following information: · The G stated that s/he had been notified about the SP allegedly not helping the VA with showering, but when the G talked to the VA about it, the VA downplayed the whole thing. The G could not find any email other than an email notification regarding the VA planning a trip to Branson, MO and an email regarding that the VA was called dumb by a staff member and a staff member refused to write checks for the VA’s church donations. · With respect to the VA’s checks, the G stated the s/he did not recall saying anything about limiting the VA’s check writing and had never done that but only asked to be made aware of any check writing over $50. The R stated that back in April of 2024 s/he had knee surgery and required assistance with showering. R asked the SP for assistance but the SP would decline, this happened about three times; the R did not know if the SP was occupied with any other responsibility at the time the assistance was sought. The R ended up getting assistance from another staff person. R stated that s/he did not have any other kind of problem with the SP and never heard the SP being unkind to any resident at the facility. The facility’s personnel and training records showed that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s plans. Relevant Rules and/or Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights include the right to be treated with courtesy and respect. Conclusion: Information was consistent that the SP and the VA did not get along. On more than one occasion, the SP refused to assist the VA with washing her/his hair. The VA’s ISSA plan stated that the VA required assistance with washing her/his hair in the shower because shampoo/conditioner left in may cause a rash on the VA’s scalp. There was no information that the VA ever developed a rash as a result of the SP refusing to help the VA, as another staff person provided that assistance to the VA. The SP also refused to provide the R with assistance in showering, but like the VA, the R was assisted by another staff person. It was reported that the SP made the VA perform chores around the facility. According to P1 residents at the facility would assist with but they were not required to do chores. P1 noted that residents could be asked to help but could not be made to do chores. On at least one occasion the SP made hurtful comments to the VA such as, "Are you stupid?" "Don't act dumb," and "Act like a normal person,” which the VA confirmed happen on one occasion. The VA also confirmed that the SP tried to limit the number of checks the VA could provide to her/his church but again another staff person stepped in and helped the VA. The above actions by the SP were non-therapeutic conduct, were not consistent with the role of a professional caregiver in a DHS licensed program and were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, there was not a preponderance of the evidence whether SP’s actions were repeated or could reasonably be expected to cause the VA emotional distress. In addition, given that there was no information that showed that the VA sustained an injury and other staff persons helped the VA with washing his/her hair, there was not a preponderance of the evidence whether the SP’s actions were a failure to provide the VA with care that was reasonable and necessary to obtain or maintain the VA’s physical or mental health or safety. It was not determined whether neglect or emotional abuse 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 or 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). Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but were not followed. At the time this report was written, the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate correction, the facility was not issued a correction order for the violation outlined in this report.
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