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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: 1070576 -H_CRS (Home and Community-Based Services-Community Residential Setting) 1070559 -HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler Suspected Maltreatment Reported: It was reported a staff person (SP) was rude to a vulnerable adult (VA) while at a gas station. Date of Incident(s): On or around January 31, 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), 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 a site visit conducted on March 13, 2025; from documentation at the facility; and through five interviews conducted with a facility staff person (P1), a facility supervisor (P2), the VA’s guardian (G), and the SP. The VA was interviewed, however provided minimal information related to the alleged incident. Facility documentation showed the VA liked to go into the community for snacks and food. The VA required 1:1 staffing during awake hours. The VA was diagnosed with developmental disabilities, intermittent explosive disorder, and anxiety. The VA understood when staff persons recommended s/he purchase personal needs items, but was not able to understand his/her finances, and relied on staff persons for assistance. The VA could become overwhelmed in the community and have mental health symptoms. Staff would provide guidance and assist the VA in redirecting him/her to calmer areas or ending the activity. The VA was susceptible to emotional abuse as the VA would not know how to appropriately interact with persons that were verbally aggressive, and his/her reactions could make him/her a target for further emotional abuse. Staff would role-model appropriate interactions with others, and provide informal education on how to respond to verbally aggression as needed. P1 took the VA to a gas station and a community person there told P1 that a staff person matching the SP’s description was rude to the VA on a previous date when the SP and the VA were at the gas station. P1 said there were no other details that were provided by the community person to the context of how the SP was “rude.” P1 said s/he had not witnessed the incident, or the SP engage in any other concerning interactions with the VA. The facility completed an Internal Review, which provided the following information: · P2 received an email on January 31, 2025, stating on an unknown date a community person said a staff person brought the VA to the gas station and that staff person was speaking “very rudely” toward the VA. A description of the staff person was provided, and the SP was the only staff person at the facility that matched the description. · The facility’s Code of Conduct stated that a safe and effective treatment setting required all employees to demonstrate a high level of personal and professional conduct. This included using a person-centered approach in interactions with the individuals served, treating everyone with courtesy, professionalism, dignity, and respect, providing a safe and therapeutic environment. · The facility determined the SP failed to adhere to this policy by using rude or demeaning language directed at the VA, thereby failing to provide a therapeutic environment for the individual served. · The facility policy Direct Care and Treatment Workplace Relations stated that the following behaviors were expected of all employees: interact with individuals in a professional, respectful, therapeutic, and supportive manner; respond promptly to requests, complaints, and problems. The policy indicated that with individuals, employees would use therapeutic and respectful language and behavior; interact therapeutically with individuals in their living and programming areas; teach and role model good problem-solving skills, effective communication skills, and appropriate social skills. The policy outlined that the following behaviors related to employees were not acceptable: yelling, swearing, demeaning language, or name-calling, and failing to respond therapeutically to individual questions or requests. · The facility policy Conduct Between Staff and Individuals Receiving Supports stated that individuals were to be treated with courtesy, dignity, and respect. Staff would use strategies, including person-centered and positive support strategies when interacting with individuals. The policy also stated that staff persons would use polite language, refrain from using condescending, demeaning, or provocative language or gestures. · The facility determined the SP demonstrated an untherapeutic environment by using rude or demeaning language around the individual receiving services. P2 said the SP was temporarily assigned to the facility in February 2025, due to issues with a vulnerable adult at another facility. P2 said the VA would frequently go to the gas station, and the description of the staff person involved matched the SP. P2 was not present for the alleged incident, and had not observed or been informed of any concerns other concerning interactions between the SP and the VA. The G said s/he was informed a staff person was a “little rough” with the VA, but the staff person was no longer working at the facility. The SP provided the following information: · The SP said s/he had taken the VA to a gas station one time, and denied being rude to the VA, or using any demeaning, disparaging, or derogating language toward the VA. · The SP said s/he may have been confused for a different staff person that took the VA to the gas station. · The SP described having a previous issue with a different vulnerable adult while at another facility. The SP said s/he was reassigned to another facility due to the issue. P1, P2, and the SP completed training on Reporting of Maltreatment of Vulnerable Adults Act and the VA’s client specific programming. The SP’s job description stated staff persons responsibilities included providing respectful, comprehensive, and person-centered direct care services to individuals. Staff persons should be sensitive to and respectful of cultural and other differences when carrying out job responsibilities and in interacting with vulnerable adults. Conclusion: On or around January 31, 2025, a community person observed an alleged interaction between the VA and the SP. The community person informed P1 of the interaction, and described the interaction as “rude.” The community person provided a physical description of the staff person involved, which matched that of the SP. P1 and P2 said there was no specific information provided regarding how the SP was “rude” to the VA. The SP denied being rude to the VA, and believed s/he was mis-identified as the SP. There was no information the VA was impacted by the alleged rude interaction. Based on the information there was no other person who worked at the facility who matched the description, and it was more likely than not the SP was the person observed by the community person. Although the community person said the SP was rude, given there was no specific information which showed what made the interaction “rude,” and that the SP denied being rude, there was not a preponderance of the evidence whether the SP engaged in conduct that was repeated or could be reasonable expected to cause emotional distress. It was not determined whether emotional abuse (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 and determined the facility’s policies and procedures were adequate, but not followed. The facility provided all staff persons with additional training on Person Centered Services and Positive Supports. The SP was required to completed additional training on policy and procedures. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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