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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: 1072857-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen/Judith Schwanke 651-431-6701 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) were verbally abusive towards a vulnerable adult (VA), which was the sole cause of the VA’s suicidal ideation, requiring two hospitalizations. SP1 and SP2 told the VA s/he was “useless,” that staff persons had “given up” on him/her, and that there was “no hope” for the VA. The VA was isolating in his/her bedroom to avoid SP1 and SP2. Date of Incident(s): Multiple dates in January and February 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 20, 2025; from documentation at the facility and medical records; and through five interviews conducted with the VA, two staff persons (P1 and P2) two supervisory staff persons (SP1 and SP2), the VA’s case manager (CM), and the VA’s guardian (G). The VA’s plans said the VA was diagnosed with post-traumatic stress disorder, schizoaffective disorder, depressed type, seizure disorder, and cognitive impairment. Staff persons were responsible for assisting the VA with transportation to/from appointments, administering medication, scheduling appointments, monitoring the VA for physical ailments, reporting information to the VA’s care team and supporting the VA with his/her mental health symptoms. The VA and had a history of self-harm when his/her mental health symptoms were increased. The VA lived at the facility for approximately two years and moved out on March 7, 2025. The Incident Report and Internal Review, dated January 22, 2025, showed that on January 19, 2025, at 6:15 PM, the VA went to the staff person office and told P1 that s/he learned information about his/her family that “made [him/her] very upset” and that the VA did not see “any point in being alive.” P1 contacted the crisis line, and the VA spoke when them for approximately one hour. At that time, it was then determined that the “best course of action” would be to call 9-1-1 and have the VA hospitalized. During this conversation, the VA told the crisis line that s/he did not feel s/he would be safe at the facility that night. At approximately 7:50 p.m., law enforcement (LE) arrived, and the VA told LE that s/he had been “depressed” for “at least the past six months.” The Incident Report and Internal Review, dated February 19, 2025, showed that on February 10, 2025, at approximately 7:30 p.m., the VA told/showed P1 that s/he had “scratched” his/her arms “on purpose.” P1 called 9-1-1 and LE arrived and spoke with the VA, who was subsequently hospitalized. The VA provided the following information: · The VA went to the hospital twice because s/he was “suicidal.” The VA was “very depressed” and “did not feel like she belonged” at the facility. · The VA’s brain told the VA s/he was “fat” and “did not deserve to live.” · The VA was “bullied” by SP1 “a lot” because of his/her weight, how s/he ate, and how s/he “did things” but the VA did not provide further details. SP1 told the VA s/he “ate too much junk food.” SP1 told the VA s/he would “end up back in the hospital” because of “soda and pop.” SP1 called the VA a “pig” because of how s/he ate. · On an unknown date, the VA had a “disagreement” with SP1 about cleaning his/her room, and SP1 yelled at the VA and “slammed” the VA’s door. When SP1 did this, s/he told the VA s/he was “useless” or “worthless.” · SP1 “judged” how the VA spent his/her money and called the VA a “liar.” SP1 told the VA s/he should not buy junk food and should spend his/her money “right.” SP1 told the VA, “You do not need that,” but neither the G nor the CM told the VA that s/he could not have junk food. · No other staff persons were present when SP1 said the things as described by the VA but they made the VA feel as though s/he “did not deserve to be on the planet.” · “A couple days” after returning to the facility from his/her first hospitalization, the VA was in the staff lounge and SP2 told the VA s/he “belonged” at the hospital so the VA could “learn [his/her] lesson.” The VA did not provide additional information regarding this conversation. · The VA “felt” like s/he did “everything wrong” in SP1’s and SP2’s eyes, and that made him/her feel that SP1 and SP2 thought s/he was “useless.” · The VA told the G and the CM about SP1 and SP2 interactions with the VA, but did not tell staff persons because s/he did not want to “get in trouble” or be “yelled at” by SP1. When SP1 yelled at the VA, s/he looked “aggressive.” The CM Provided the following information: · The facility sent the CM weekly provider reports with updates on the VA. The CM first became aware that the VA wanted to move from the facility in a provider note from December 9, 2024. On an unknown date, the CM asked the VA about why s/he wanted to move, and the VA did not give the CM a reason. The CM later learned that the VA told the G, on an unknown date, that SP1 made the VA feel “bad” about him/herself, was “always mad” at the VA and said “demeaning” things to the VA. · The VA was hospitalized from January 18-29, 2025, and again from February 10-19, 2025, due to self-harm and suicidal ideations. While hospitalized the second time, the VA told an unidentified staff person at the hospital that s/he “did not feel safe around staff” and that SP1 and SP2 told the VA s/he was “useless”, and there was “no hope” for him/her. · The VA was an “emotional person” and thought SP1 and SP2 said “these things” because of the VA’s disabilities. The CM thought the VA took what SP1 and SP2 said “hard” and began to have thoughts that resulted in the VA’s suicidal ideation and hospital stay because s/he believed s/he was worthless. · The CM believed the VA was a reliable reporter of information. The G provided the following information: · On November 25, 2024, the G received an email from SP1 notifying the G that the VA tried to “hurt [him/herself]” with his/her fingernails and had “scratches” on his/her arms. The VA “tried to call” the G at following this incident, however, did not leave a voicemail so the G was not aware until s/he received the email from SP1. On an unknown date, the G talked to the VA about this incident and the VA “wanted to change the subject” and “wouldn’t answer the question.” The VA told the G “[SP1’s] always after me” and that staff persons and other residents did not like the VA. · The VA had a history of self-harm, suicidal thoughts, and hearing voices. January 19, 2025, was the first time the VA was hospitalized due to his/her mental health.
· On February 10, 2025, the VA was hospitalized a second time. An unidentified hospital personnel told the G that the VA said if s/he had to go back to the facility, s/he was “going to hurt him/herself.” When the G asked the VA about this, the VA did not provide specific reasons why s/he felt this way but that SP1 told the VA s/he was “stupid” and that s/he needed to “grow up.” SP1 also told the VA s/he did not like the VA and did not want the VA around and which made the VA “not feel good about [him/herself].” · The VA did give the G specific things that made him/her feel unsafe at the facility, but did say that SP1’s “tone of voice” and “how [SP1] said things” made the VA feel that way. · The G tried to talk to staff persons about concerns, but they “got defensive.” The G explained to staff persons that s/he was not “blaming” them, but that the VA was interpreting things they said to be negative and encouraged staff persons to be “person centered” to make sure their communication was not negative. The G thought that SP1 and SP2 were “never” willing to see things from the VA’s perspective. · The G thought there was “some actuality” to what the VA said, but that the VA was “not always” a reliable reporter of information. The VA’s interpretation could be “exaggerated.” P1 and P2 provided the following information: · On an unknown date, a little over a month before the VA moved out, the VA told P1 s/he had “some problems” with SP1 and was not enjoying living at the facility. P1 asked the VA what problems s/he had with SP1, but the VA did not give examples and said s/he did not like the way s/he was being talked to. P1 did not tell anyone about this conversation because the VA asked that it be “private.” P1 did not think was the VA said was “alarming.” · Between January and February of 2025, the VA was hospitalized two times for “suicidal thoughts.” Around Valentines Day 2025, the VA told P2 that s/he “scratched” him/herself with his/her nails on the arm and was “upset” about “some stuff” with his/her family. The VA then showed P2 his/her arm which had “minor scratches” and P1 called 9-1-1. · P1 and P2 each stated that s/he did not hear any staff persons ever tell the VA s/he was worthless, that there was no hope for the VA, or that s/he could not return to the facility. SP1 provided the following information: · SP1 stated the VA “had [his/her] moments” and “had really bad days” where s/he would “shut down, be quiet and stay in [his/her] room.” SP1 thought s/he and the VA were “very close” and the VA told SP1 “a lot of things [s/he] did not like to share with other people.” · In December 2024, the VA told SP1 that s/he wanted to move because s/he “wanted a change of staff” but did not provide further details. · On an unknown date in January 2025, P1 called SP1 and said the VA was “really struggling” and “wanted to hurt [him/herself].” SP1 told P1 to call the crisis line, who then directed P1 to call an ambulance. The VA was hospitalized but returned to the facility following this hospitalization. While the VA was in the hospital, SP1 learned that the VA had been throwing up his/her medication. SP1 said the VA “always” took his/her medication in front of staff persons and swallowed them with water. On an unknown date, SP1 talked to the VA about throwing up medication and the VA told SP1 s/he was “going to keep doing it because the voices in [his/her] head told [him/her] to.” SP1 knew the VA had a history of hearing voices but was not aware s/he heard voices at the facility. · SP1 denied telling the VA s/he was worthless, that there was no hope for the VA, and/or that SP1 was done with the VA. SP1 had not heard any other staff persons use that kind of language with the VA or heard from other residents that staff persons spoke to the VA in such a manner. SP2 provided the following information: · The VA had a history of trauma as well as cognitive deficits. S/he was “pretty bubbly” to everyone at the facility, and SP2 never witnessed the VA be “cross” with anyone. · In the beginning of January 2025, a new resident moved into the facility. After this individual moved in, the VA “started to not be [his/her] usual, bubbly self.” Staff persons tried to talk to the VA about what was wrong, or what they could do to help but all the VA told staff persons s/he “did not want to talk about it” and that the G knew, so they “left it alone.” · The VA was hospitalized twice recently, on two dates that SP1 could not remember. After the VA was discharged the first time, the G told SP2 that the VA told hospital staff s/he had been hearing voices that were telling him/her to throw up his/her medications and s/he did so. · Following the VA’s first hospitalization, SP2 was in the staff office with SP1 when the VA came in. The VA was “very bubbly” and SP2 asked the VA how s/he was doing and the VA said, “Good,” and that s/he was “sorry for doing that to staff.” [Note: There was no information provided regarding what the VA was referring to when s/he said, “doing that to staff.”] SP2 told the VA s/he did not need to apologize. The VA said s/he was “glad to be back” but still wanted to move. SP2 asked the VA why s/he wanted to move, and the VA told SP2 that s/he “just wanted a change.” · SP2 did not know why the VA did not feel safe at the facility. SP1 told SP2 that s/he spoke with the G who told SP1 that s/he knew why the VA did not feel safe, but the G would not tell SP1 the reason. · SP2 never heard staff persons tell the VA s/he was worthless, that there was no hope for him/her or that the VA could not return to the facility after being hospitalized, and stated, “If I had, it would have been addressed immediately.” SP2 also denied saying these things to the VA. Two documents titled Prehospital Care Report v3.5, completed by Lakes Region EMS (emergency medical services) provided the following information: · On January 19, 2025, EMS was called for a suicidal patient, who was the VA. The VA informed EMS staff that s/he was having “thoughts of suicide” for the past month. The VA then stated that s/he “throws up a lot” and was “feeling lonely” due to the death of people close to her and it had “become too much.” The VA informed EMS staff that s/he had been throwing up her medications and that s/he wanted to “throw up until [s/he] dies.” The VA shared information regarding his/her past trauma, and when asked, stated s/he felt safe at the facility and that nobody there had hurt her. · On February 10, 2025, EMS was called for a suicidal patient, who was the VA. The VA informed EMS staff persons that s/he “hears voices” and that those voices told the VA to “cut [him/herself].” Medical records provided the following information: · During his/her time in the Emergency Department, as well as each subsequent hospitalization, the VA told HCP’s that s/he did not feel staff persons at the facility offered to help him/her when s/he asked, but did not verbalize any other concerns regarding staff persons care of the VA while at the facility. · On February 18, 2025, the VA told HCP’s that s/he was “agreeable” to return to the facility following his/her discharge, however the VA was “concerned” because an unidentified staff person told him/her that s/he needed to stay at the hospital for two weeks to “learn [his/her] lesson.” The medical records provided no additional information regarding the statement. The facility’s personnel files showed that P1, P2, SP1 and SP2 were each trained on the VA’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Conclusion: The VA said that SP1 “bullied” him/her, told the VA that s/he was a “pig,” “judged” the VA regarding how s/he spent his/her money, called the VA a “liar,” and on one occasion yelled at and slammed the VA’s door. The VA also said that SP2 told the VA s/he “belonged” at the hospital so that the VA could “learn [his/her] lesson.” The VA did not provide details regarding including dates/times of the incidents but stated that no other persons were present when SP1 said the aforementioned. The VA had a history of self-harm when his/her mental health symptoms were increased. On January 19, 2025, the VA told the LE that s/he had been depressed for “at least the past six months,” and the EMS report stated that the VA told EMS staff that s/he was having thoughts of suicide for the past month. On February 10, 2025, the VA told EMS that s/he was hearing voices to cut him/herself. Although it was alleged that SP1’s and SP2’s interactions with the VA resulted in the VA’s increased suicidal actions and ideations requiring two hospitalizations, given that the VA had a history of suicidal thoughts/behaviors as well as auditory and visual hallucinations; that there were little details regarding the interactions; that there was conflicting information regarding the VA’s reliability for reporting accurate information; that P1, P2, SP1, and SP2 each stated that they had not seen/heard any staff persons say anything to the VA that was concerning; that SP1 and SP2 each denied the allegations; and that there was no other information to support or refute the VA’s accounts, there was not a preponderance of the evidence whether SP1 and/or SP2 engaged in repeated oral language that could reasonably be expected to produce emotional distress. 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 policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: No additional action taken.
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