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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: 1112473-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 two staff persons (SP1 and SP2) frequently hit a vulnerable adult (VA1) on the forehead to make VA1 “jump.” If VA1 jumped, SP1 and SP2 laughed at VA1. SP1 also told the other staff persons that they should not check on VA1 during the night so that VA1 did not wake and refuse to stay in bed. Allegation two: It was reported that SP1 deliberately used bleach around a vulnerable adult (VA2) even though VA2 hated the smell of bleach. If VA2 became upset, SP1 laughed at him/her. SP1 told the other staff persons that s/he “can’t stand” VA2 and planned to “make [VA2] mad.” Date of Incident(s): Ongoing, prior to September 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), clauses (1) and (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: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · 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 September 26, 2024; from documentation at the facility and law enforcement records; and through thirteen interviews conducted with two facility supervisory staff persons (P1 and P2), five staff persons (P3 – P7), SP1, SP2, VA2, VA1’s family member (FM), VA1’s guardian (G1), and VA2’s guardian (G2). VA1 enjoyed being outdoors, watching movies, going on community outings, swimming, playing bingo, and spending time with his/her friends and family members. VA1’s diagnoses included cerebral palsy, spastic quadriplegia, insomnia, osteoporosis, chronic otitis media, hip dysplasia, and intellectual disability. VA1 used a wheelchair for mobility. VA1 communicated through facial expressions and verbalizations. According to VA1’s Coordinated Services and Supports Plan (CSSP), VA1 was vulnerable to all forms of abuse or neglect, including physical, sexual, verbal/emotional, or financial exploitation. VA1 required 24-hour supervision. According to VA1’s Risk Assessment Detail, VA1 would not defend him/herself from abuse because s/he was unable to move on his/her own. VA1 might not recognize that s/he was being abused. VA1 had limited communication skills. If a staff person identified a situation as unsafe for VA1, they were to move VA1 to a safe location or intervene to keep VA1 safe. VA2 enjoyed listening to music, painting, doing arts and crafts projects, going on community outings, swimming, watching television, and spending time with his/her friends and family members. VA2’s diagnoses included cerebral palsy, diabetes, intellectual disabilities, major depressive disorder, and anxiety. VA2 used a walker or a wheelchair for mobility. According to VA2’s Risk Assessment Detail, VA2 was at risk of abuse because it would be difficult for him/her to move away from an abusive situation. VA2 was able to report abuse. Allegation one: It was reported that SP1 and SP2 frequently hit VA1 on the forehead to make VA1 “jump.” If VA1 jumped, SP1 and SP2 laughed at VA1. SP1 also told the other staff persons that they should not check on VA1 during the night so that VA1 did not wake and refuse to stay in bed. VA2 stated that s/he did not see the staff persons hit VA1’s head, but VA2 sometimes “tapped” VA1 to help him/her calm. P1, P2, P3, P4, P5, P6, and P7 provided the following information: · P3 stated that SP1 “smacked” VA1 on the forehead with his/her fingers, causing VA1 to “jump.” SP1 then laughed. P3 believed that SP1 thought it was funny and was not being mean. P3 saw SP2 hit VA1 on the forehead on two occasions, but not as “firm” as when SP1 did it. P3 never saw any mark on VA1’s head after the incidents. · P1 and P2 each stated that P3 told them that SP1 and SP2 “smacked” VA1 on the forehead to startle VA1 and were rude to the staff persons and clients. P3 told P1 that when SP1 and SP2 hit VA1 on the forehead, VA1 laughed and “thought it was a big game.” P2 stated that when s/he talked to SP1 and SP2, they told P2 that they gave “light taps” to VA1’s forehead to indicate that they “see” him/her and to make him/her laugh. P2 never saw SP1 or SP2 hit VA1’s forehead, but stated that VA1 liked to “play around” with the staff persons. SP1 told P2 that s/he tapped VA1’s forehead while G1 was present and G1 did not tell him/her to stop. P5 stated that when VA1 hit him/herself in the head, P5 would “trickle” his/her finger on VA1’s forehead or rub VA1’s forehead to improve VA1’s mood. P5 stated that s/he sometimes saw SP1 or SP2 massage VA1’s forehead to comfort him/her. P6 never saw any of the staff persons hit VA1’s forehead, but they might touch his/her forehead to calm him/her. P7 never saw SP1 or SP2 flick VA1 on the head. · P4 stated that VA1 liked when the staff persons interacted with him/her and made him/her laugh. P4 would “boop” VA1 by tapping him/her on the nose or forehead with his/her finger, which made got VA1’s attention and made VA1 “laugh hysterically.” VA1 seemed to enjoy the interactions with the staff persons. P4 stated that none of the staff persons would do anything to intentionally hurt VA1. P4 had no concerns about SP1’s and SP2’s interactions with VA1. · P1 stated that s/he did not observe SP1 or SP2 yell at or abuse the clients at any time and did not see either staff person hit VA1. P1 had no concerns about the care SP1 and SP2 provided to the clients. P2 stated that s/he talked to several of the other staff persons about SP1’s and SP2’s behaviors toward the clients and none of them had concerns about their behavior. P5 stated that SP1 and SP2 were good staff persons and s/he had no concerns about their interactions with the clients. P7 stated that s/he had no concerns about SP1’s and SP2’s interactions with the clients. · P1 stated that P3 told P1 that s/he was going to “retaliate” against SP1 and SP2. Several staff persons told P1 that P3 “doesn’t do a whole lot” during his/her work shift. P2 believed that there was “retaliation” going on between the staff persons. P5 believed that P3 made “far-fetched” complaints about SP1 and SP2 to the supervisory staff persons. P4 stated that P3 frequently sat at the computer the majority of his/her work shift instead of working with the clients. · P3 stated that G1 did not want the staff persons to wake VA1 during the night to check his/her adult disposable brief, but sometimes his/her brief was “pretty wet.” VA1 did not have any skin breakdown or rashes. P4, P5, and P6 each stated that G1 did not want the staff persons to wake VA1 during the night because VA1 had difficulty going back to sleep. If VA1 was awake, the staff persons changed VA1’s adult disposable brief if necessary. P5 believed G1 placed a sign in VA1’s bedroom to remind the staff persons not to wake VA1 during the night. SP1 and SP2 provided the following information: · SP1 stated that VA1 liked to “roughhouse” with the staff persons. The staff persons interacted with VA1 by doing things like having pillow fights, tickling him/her, and “booping” him/her on the nose. SP1 described booping as lightly tapping VA1’s nose or forehead and saying “boop.” VA1 typically laughed and smiled when SP1 or SP2 booped him/her. SP1 and SP2 had each booped VA1 for years and did not cause pain to VA1 when they did so. SP2 stated that some of the other staff persons also booped VA1 in order to make VA1 giggle. · SP1 and SP2 each stated that G1 told the staff persons not to wake VA1 during the night because it was hard for VA1 to go back to sleep. The staff persons still checked on VA1 every two hours and if VA1 was awake, they changed his/her adult disposable brief if it was soiled. · SP1 did not believe there was interpersonal conflict between him/her and P3 until P1 and P2 talked to SP1 about the complaints made about him/her. SP2 believed that P3 told P1 and P2 that s/he was concerned about SP1’s and SP2’s interactions with the clients because P3 believed SP1 and SP2 complained about P3 not working during his/her work shifts. G1 stated that VA1 had a “high startle reflex” and G1 did not believe that VA1 would interact in a playful manner with the staff persons if they hit him/her on the forehead. G1 was concerned that any staff person would try to startle VA1. Prior to learning about these incidents, G1 had no concerns with the care SP1 and SP2 gave VA1 and stated they were “very loved staff.” G1 stated that s/he was frequently at the facility and never observed any of the staff persons behaving in a way that concerned him/her. Facility documentation showed that SP1, SP2, and P1 – P7 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on VA1’s and VA2’s plans prior to the incidents. Relevant Rules and Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (b), state that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion for allegation one: Regarding SP1 and SP2 hitting VA1 on the forehead to make him/her jump and then laughing at VA1: Although it was reported that SP1 and SP2 hit VA1 on the forehead in order to make VA1 startle and then laughed at VA1, no information was provided that SP1 and SP2 did more than lightly tap VA1 on the nose or head as they said “boop.” Other staff persons stated that they rubbed or tickled VA1’s forehead in order to calm VA1 and none of the staff persons had concerns that SP1 and SP2 caused pain or that their actions were meant to startle VA1. No injury occurred to VA1 during the interactions. Given that consistent information was provided that VA1 laughed when the staff persons tapped his/her face and that VA1 enjoyed rough housing with the staff persons, there was not a preponderance of the evidence whether all of SP1’s and SP2’s actions were therapeutic in nature or whether SP1’s and SP2’s actions could reasonably be expected to produce physical pain, or injury or emotional distress to VA1. It was not determined whether physical and 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: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and/or 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 SP1 telling the other staff persons not to check on VA1 during the night: Although it was reported that SP1 told the other staff persons not to check on VA1 during the night, consistent information was provided that G1 asked the staff persons to not wake VA1 during the night because VA1 had difficulty falling asleep again once s/he awoke. There was also a sign in VA1’s bedroom asking the staff persons not to wake VA1 during the night. The staff persons continued to check on VA1 every two hours and checked VA1’s adult disposable brief if s/he was awake during the night. Given that no information was provided that VA1 developed any rashes or skin breakdowns or sustained any harm because his/her adult disposable brief was not changed during the night, there was not a preponderance of the evidence whether SP1’s actions were a failure to supply the VA with necessary care or services necessary to maintain VA1’s physical health and safety. 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). Allegation two: It was reported that SP1 deliberately used bleach around VA2 even though VA2 hated the smell of bleach. If VA2 became upset, SP1 laughed at him/her. SP1 told the other staff persons that s/he “can’t stand” VA2 and planned to “make [VA2] mad.” VA2 stated that the staff persons “swear a lot.” Sometimes if VA2 spoke loudly, the staff persons asked him/her to be quieter because s/he was causing the other clients anxiety. VA2 hated the smell of bleach and when s/he smelled a scent s/he did not like, it sometimes caused him/her to cough or have a headache. P1 used to use bleach cleanser, but no longer did so. On one occasion, SP1 yelled at another client “to make a point.” P1, P2, P3, P4, P5, P6, and P7 provided the following information: · P3 stated that SP1 sprayed and mopped “the entire house” with a bleach cleanser “in hopes of pissing [VA2] off.” SP1 also sprayed the cleanser on VA2’s bedroom door, on the floor, and the dining room table. SP1 did not tell P3 that s/he did it to annoy VA2, but P3 did not know why else SP1 cleaned the floors at that time. VA2 left his/her bedroom after the smell of the cleanser had dissipated, so VA1 did not react to the smell of bleach. SP1 also told P3 that s/he “hated” VA2. P3 stated that VA2 was a “frustrating client.” · P1 stated that the staff persons used a spray bottle of multi-cleaner that contained bleach to clean the countertops in the facility’s kitchen. P1 and P2 each stated that P3 told them that SP1 and SP2 sprayed bleach “all over the house” because VA2 hated the smell of bleach. They sprayed the bleach cleanser outside VA2’s bedroom door, on the dining room table, and on the dining room floor prior to mealtime. P2 talked to VA2 about bleach being used at the facility and VA2 told P2 that after the staff persons sprayed the table before dinner, VA2 asked them not to do that again and they stopped spraying the table. SP1 told P2 that s/he would not spray VA2’s bedroom door with bleach because it would stain the wood. P4 stated that the staff persons frequently used a bleach cleanser and “it was never an issue.” VA2 never complained to P4, P5, P6, or P7 about the smell of bleach or the cleaning products. · P1 stated that on one occasion SP1 told P1 that s/he did not like to work at the facility because s/he did not like VA2. At the time, VA2 was sitting nearby, but P1 did not believe VA2 heard SP1’s comment. P1 stated that on another occasion P3 told P1 that s/he “couldn’t stand” VA2 because s/he was “acting like a bitch.” At the time, VA2 was in his/her bedroom and P1 was uncertain if VA2 heard P3’s comment. P1 told P3 that his/her comment was unacceptable and P3 apologized. A short time later, P1 and P2 talked to P3 about him/her being rude to the clients. SP2 told P2 that P3 “had issues” with VA2 more than SP1 did. · P2 stated that s/he talked to several of the other staff persons about SP1’s and SP2’s behaviors toward the clients and none of them had concerns about their behavior. However, one staff person told P2 that SP1 told P2 that s/he disliked VA2. P4 stated that P3 told him/her that VA2 was a bitch, but VA2 was not present at the time. P3 never heard SP1 say anything negative about VA2 that VA2 could overhear. P6 never heard any staff person being rude to the clients. · P4 stated that P3 did not try to de-escalate VA2 when s/he became upset, but instead told VA2 that s/he needed to stop complaining. P5 stated that P3 was sometimes “short” with the clients. P6 stated that P3 was not a hard worker. SP1 and SP2 provided the following information: · SP1 heard P3 swear when talking about the clients, but did not hear him/her swear at the clients. SP2 heard P3 refer to VA2 as a bitch when talking to another staff person. SP2 was uncertain if VA2 overheard P3’s comment. SP1 believed that P3 intentionally was not an accurate reporter of events. SP2 stated that VA2 and P3 “butted heads constantly” and P3 tried to “get under [VA2’s] skin.” · SP1 stated that VA2 had a lot of life changes and lost his/her independence. SP1 tried not to make VA2 mad, because VA2 “felt everyone is against [him/her].” At times, if SP1 asked VA1 to wash his/her hands before a meal, VA2 would be upset with SP1 “for days.” SP1 did not say that s/he could not “stand” VA1, but stated that VA2 was sometimes difficult to work with. SP1 never told anyone that it was his/her goal to make VA1 mad during his/her work shift, because it made his/her job harder when VA1 was upset. SP2 stated that s/he “never had a problem” with VA2. · SP1 stated that P2 purchased cleaning supplies for the facility. SP1 and SP2 each stated that the staff persons used a bleach cleanser or bleach wipes to wipe the kitchen counters and table prior to each meal. After SP1 learned that VA2 did not like the smell of bleach, SP1 stopped using the bleach cleanser in the kitchen. SP1 and SP2 each stated that they did not use bleach cleanser in order to annoy VA1. SP1 stated that s/he did not spray bleach cleanser on VA2’s bedroom door. G2 stated that VA2 texted G2 with concerns about SP1, SP2, and P3 being rude and disrespectful to VA2. When G2 visited VA2, the staff persons frequently were sitting and talking to each other rather than interacting with the clients. G2 heard the staff persons talking about other staff persons, which G2 did not feel was appropriate. VA2 hated the smell of bleach. The FM stated that in the past, on multiple occasions VA2 told the FM that SP1, SP2, and P3 were “best friends” and frequently “sat and talked about their personal lives” and ignored the clients. VA2 told the FM that they also called VA2 names. The FM was unclear if SP1, SP2, and P3 called VA2 names or if VA2 overheard them talking about VA2 and saying rude things about VA2. VA2 recently told the FM that SP1, SP2, and P3 often sprayed bleach water on the table prior to serving meals even though they knew that VA2 hated the smell of bleach. The FM believed that VA2 was an accurate reporter of events. Conclusion for allegation two: Although P3 stated that SP1 and SP2 deliberately tried to annoy VA2 by doing things such as using bleach in the facility when cleaning, there was no direct corroboration of P3’s statements. SP1 and SP2 each denied using bleach to “piss off” VA2 and SP1 stated that upsetting VA2 only made his/her job harder. SP1 stated that when s/he learned that VA2 did not like the smell of bleach, s/he stopped using bleach products around VA2. None of the other staff persons had concerns about SP1’s and SP2’s interactions with VA2. Given that only P3 provided information that SP1 and SP2 deliberately upset VA2 and that SP1 and SP2 each denied doing so, there was not a preponderance of the evidence whether all of SP1’s and SP2’s actions were therapeutic in nature or whether SP1’s and SP2’s actions could reasonably be expected to produce emotional distress to VA2. 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). 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. The staff persons were retrained on the facility’s policies. SP1 and SP2 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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