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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: 1070765-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070738-HCBS (Home and Community-Based Services) Investigator(s): Scout Peterson/Samantha Wueste Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) “cuss[ed]” at a vulnerable adult (VA) and threatened to kill both the VA and him/herself. Allegation Two: It was reported that while helping the VA change, the SP was “frustrated” with the VA and “flung” the VA’s arm. The VA sustained two bruises on his/her right arm. Date of Incident(s): Allegation One: multiple unknown dates prior to October 20, 2024 Allegation Two: October 20, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 30, 2024; from documentation at the facility; and through seven interviews conducted with the VA, four facility staff persons (P1, P2, P5, and the SP), and two supervisory staff persons (P3 and the P4). The VA’s Coordinated Service and Support Plan dated July 24, 2024, provided the following information: · The VA was diagnosed with multiple sclerosis (MS) and depressive disorder. The VA was not subject to guardianship. The VA was able to verbally communicate but was difficult to understand due to dysarthria (weakened muscles used when speaking that caused slurred, slow speech). The VA lived at the facility for over ten years and required staffing 24 hours a day for assistance in all areas of daily living. The VA enjoyed shopping, interior décor, playing bingo, and spending time with his/her family. · Due to the VA’s diagnoses and physical limitations, the VA relied on others for “everything.” Staff persons assisted the VA with all personal cares that included dressing, grooming, bathing, toileting, transferring, positioning, and feeding the VA. Due to the VA being reliant on others for assistance and the VA’s “tendencies” to be “very impatient” and/or “irritable,” the VA often became “frustrated” when having to wait for staff persons to help him/her. When the VA was “upset,” s/he tended to become verbally aggressive and/or “disrespectful” to others. · The VA had specific routines s/he wanted to be maintained by staff persons and wanted to know ahead of time if things were going to be done differently or if there were changes or delays to his/her daily schedule and activities. It was important for staff persons to know the VA’s “tendencies” of when and how s/he liked things done. · The VA was not able to remember things as well as s/he used to. The VA had “minor, short-term memory issues” and “specific but infrequent instances of memory confusion.” The VA’s Individual Abuse Prevention Plan dated January 30, 2023, provided the following information: · The VA was susceptible to physical abuse due to “severe physical limitations” that resulted from the VA’s diagnoses. Staff persons used a Hoyer lift to physically assist the VA with all transfers, including into and out of his/her electric wheelchair and bed. The VA had “limited use” of his/her arms and sometimes had “difficulty” in using his/her wheelchair independently. Therefore, the VA would not be able to physically remove him/herself from situations that were potentially abusive. · The VA had a history of verbal aggression towards others which might provoke an aggressive response or make the VA susceptible to retaliation in the form of verbal and/or emotional abuse. If the VA showed signs of “frustration,” staff persons provided prompts to the VA to use “appropriate” interactions with others and to speak in a “calm manner.” · The VA’s diagnoses limited his/her cognitive abilities in being able to remember events or understand if a situation was potentially abusive. The VA also had difficulty communicating at times. The facility’s Individual Rights Policy stated that staff persons were to maintain and protect a client’s rights while providing care that reflected the client’s care plans. Clients were to be “treated with courtesy and respect” by staff persons and receive care and supports that maintained “dignity.” The facility was a single-family, one-story home with four bedrooms. The VA lived at the facility with two other clients, including (the C). The VA’s bedroom contained a hospital bed and Hoyer lift. Facility documentation showed that the SP and P1-P5 were each trained on the VA’s care plans, the Reporting of Maltreatment of Vulnerable Adults Act, and the facility’s Individual Rights Policy. Allegation One: It was reported that the SP cussed at the VA and threatened to kill both the VA and him/herself. According to the VA, s/he liked living at the facility and had been living there for “a couple” of years. The VA stated that there was “only one” staff person (the SP) who s/he “never” got along with. The SP had an “attitude” and the VA did not want the SP to work at the facility anymore. The SP used “mean words” when speaking to the VA, but the VA was not able to provide any additional information regarding this. When the VA was asked if the SP ever “yelled” or “raised [his/her] voice” at the VA, the VA stated that this occurred “a couple of times.” P1 provided the following information: · On unspecified dates in 2024, P1 worked with the SP “several” times. P1 had “concerns every shift” regarding how the SP spoke to and interacted with the VA. On an ongoing basis, the SP was “short-fused” and “very verbally abusive and aggressive” when communicating with the VA. The SP told the VA things like s/he would “take [him/herself] out and everybody with [him/her].” The SP “argued” with the VA and was “not polite, respectful, or understanding” in how s/he communicated with the VA. · On October 20, 2024, and on unspecified dates prior to this, the SP “frequently swore” at the VA when speaking to him/her. The SP told the VA things like: “I don’t have fucking time right now; you need to calm the fuck down; [and/or] give me a fucking minute.” When the VA needed the SP’s assistance with daily tasks, the SP “swore” at the VA often and told the VA to “hold the fuck on” or responded with similar language to this. · The VA became “upset” when s/he felt like the SP would not listen to him/her and was “frustrated” or “angry” that the SP treated the VA this way. Although P1 said that how the SP interacted with the VA was “inappropriate” and “mean,” P1 did not inform supervisory staff persons of his/her concerns until October 22, 2024, when P1 was directly asked by a supervisory staff person who had overheard P1 speaking about the SP to another staff person. P2 and an audio recording completed by P2 dated October 16, 2024, provided the following information: · On October 16, 2024, P2 worked with the SP at the facility. At an unknown time, the C was in the living room when the SP spoke to the C in an “overbearing,” “patronizing,” and “directly confrontive” manner. During the SP’s conversation with the C, P2 started an audio recording of the incident. While P2 recorded the SP speaking to the C, the VA entered the living room in his/her electric wheelchair and then went to the “back hallway” while “roaming” the house. The SP stopped speaking to the C and asked the VA, “Where the hell are you going?” A few seconds after this, the SP asked the VA again, “Where the fuck are you going?” After this, P2 stopped recording. P2 did not talk to the SP or any other staff persons at that time about the incident. · On October 23, 2024, P3 and P4 asked P2 if s/he could come talk with them while P2 was working at the facility regarding a recent incident of the VA’s treatment by the SP. P2 was not aware of the incident that occurred on October 20, 2024, but P2 told P3 and P4 that when working with the SP on and prior to October 16, 2024, P2 heard the SP “yell” at the VA and speak to clients, including the VA, in a “really rude” way. P2 did not tell supervisory staff about these concerns prior to their conversation on October 23, 2024, because P2 was newly hired and did not know if the SP was “just naturally rude” or if it was something of “actual concern.” P2 then provided P4 a copy of the audio recording that P2 had taken on October 16, 2024. · On October 23, 2024, P2 told P4 his/her concerns of how the SP spoke to and treated the VA and gave P4 a copy of the audio recording. P5 stated that s/he had worked with the SP for over a year. All of the clients who lived at the facility, including the VA, would “swear” at staff persons and could be “hard to work with.” On an ongoing basis, the VA called the SP “a bitch,” told the SP to “fuck off,” and/or used similar language towards the SP when the SP assisted the VA. According to P5, the SP got “upset” and “couldn’t handle” how s/he was talked to by the VA. The SP and the VA would “go back and forth” with one another and the SP’s tone of voice when responding to the VA “sounded controlling and upset.” Although the SP swore when speaking to the VA, the SP was “usually responding back to” the VA after the VA spoke “disrespectfully” to the SP first. According to P5, staff persons were to remain calm when speaking to clients and redirect unwanted behaviors, but the SP could not walk away or “let things go” without “voicing [his/her] opinion.” P5 did not hear the SP call the VA any derogatory names. P3, P4, and the facility’s Incident Follow-up Report and Internal Review completed by P3 and P4 dated October 22, 2024, provided the following information: · P4 stated that in August and September 2024, there were concerns regarding the SP’s interactions with clients. On August 30, 2024, a “discussion with [the SP]” was had for being “rude” and “disrespectful” to clients and documentation showed that on September 22, 2024, the SP “swore” at clients. The SP “denied” that these incidents occurred and stated that s/he “conducted [him/herself] per [facility] standards.” · On October 22, 2024, at approximately 10 a.m., P3 was at the facility in a meeting with a client’s guardian when s/he “overheard” P1 talking to another staff person about an incident that occurred between the SP and the VA. At approximately 11 a.m. after P3 finished the meeting, P3 asked P1 and P4 to talk to discuss what P3 had overheard. P1 told P3 and P4 that s/he did not want to work with the SP “going forward” because the SP was “mean” to the clients. P1 said that on October 20, 2024, from approximately 1:30 to 7:00 p.m., while working with the SP, the SP was “verbally abusive” to the VA and used “foul language” when speaking to the VA. The SP told the clients, including the VA, that s/he was “fucking sick of their shit” and that s/he would “kill [him/herself] and [the VA].” The SP also “refused” to help the VA get up after the VA requested assistance in repositioning or transferring from his/her bed. The SP “slammed” the VA’s dresser drawers and told the VA that “[s/he] could fucking lay there.” · After talking to P1, P3 and P4 remained at the facility and spoke with all clients and staff persons who were at the facility, including the VA and P5. The VA told P3 and P4 that s/he was “frustrated” with the SP but the VA could “not recall” specific details of how the SP treated him/her but that the SP was “a bitch.” The VA said that things “always” had to be “[the SP’s] way” but was not able to provide additional information when asked for an example. The VA also said that the SP “always yell[ed].” P5 worked with the SP the day prior to the incident, as well as with the VA the day after the incident. P5 told P3 and P4 that on October 19, 2024, the SP was “pissed off,” “yelled” in front of the VA, and “slammed” the VA’s dresser drawers. The SP told the VA that s/he did not “give a fuck whether [the VA] liked [the SP’s] attitude or not.” · On October 23, 2024, P3 and P4 spoke with P2 about the SP. P2 told P4 that s/he was “uncomfortable” with how the SP spoke to the clients, including the VA, but did not know how to respond to the situation. P2 said that on October 16, 2024, s/he recorded a conversation between the SP and the C approximately two minutes into the conversation because P2 “was not sure” if the way the SP spoke to clients was a “concern or not.” During the recording, the SP stopped talking to the C and started talking to the VA who had entered the room, “swearing” at the VA asking the VA where s/he was going. P2 then gave them a copy of the recording. According to P3 and P4, the audio recording was the “concrete proof” that was needed for supervisory staff persons to “confront” similar prior concerns that had been addressed with and denied by the SP regarding how s/he spoke to clients, the SP’s tone of voice, and the SP’s demonstration of “power over” clients. · On October 24, 2024, P4 spoke to the SP about the concerns regarding the way s/he interacted with the VA on October 20, 2024, and ongoing prior to this date. P4 told the SP there was a recording of the SP speaking to clients in a way that did not align with the facility’s expectations on how staff persons were to treat clients, including the SP “swearing” at the VA. The SP did not listen to the audio recording but denied swearing at the VA or treating the VA “inappropriately.” The SP provided the following information: · On unspecified dates prior to October 20, 2024, supervisory staff persons “always” took the SP aside to talk about the “condescending” tone of voice the SP used when speaking to clients. The SP was not trying to speak in a “condescending” manner but described his/her tone of voice being “very monotone” when speaking to clients, including the VA. In using this tone of voice “all day, every day,” the SP said that s/he could avoid a change in his/her voice that might make clients or other staff persons question if the SP was “upset” or “mad.” The SP got along “pretty well” with other staff persons and “never” heard any staff persons or clients “complain” about how she interacted with the clients. · The SP stated that s/he could not remember if s/he “swore” at a client on October 16, 2024, or if s/he “yelled” at the VA and/or used “vulgar language” when speaking to the VA on October 20, 2024. The SP denied “raising [his/her] voice” in a “yelling way” when speaking to clients but used a “raised voice” if it was needed to gain a client’s attention. The SP said that “there were times” s/he and other staff persons swore in conversations “with” the clients, but the SP stated that s/he did not swear “at” the clients. The SP then gave an example saying that s/he would “never” say something like, “What the fuck are you doing?” to a client. Relevant Rules and/or Statutes: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) stated a person's protection-related rights include the right to be treated with courtesy and respect and receive respectful treatment of the person's property. Conclusion for Allegation One: A. Maltreatment: Information from the VA, P1, P2, P5, and the facility’s Incident Follow-up Report and Internal Review was consistent that the SP spoke to the VA, in a manner that was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and was a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). The VA told this investigator that the SP used “mean words” and “yelled a couple of times” but could not remember specific examples of this. On October 22, 2024, the VA told P3 that the SP “always yell[ed]” and that the SP was “mean.” P1 stated that the SP was “not respectful or polite,” “short-fused,” and “very verbally abusive and aggressive” to the VA on an ongoing basis. P1 stated that the SP “swore” when speaking to the VA, saying things like, “I don’t have fucking time right now; you need to calm the fuck down; [and/or] give me a fucking minute.” On October 20, 2024, the SP “slammed dresser drawers” and told the VA that s/he “could fucking lay there” when the VA had asked the SP for assistance in repositioning. On this same day, the SP also told the VA that s/he “would kill [him/herself] and [the VA].” P2 stated that the SP was “overbearing,” “patronizing,” “rude,” and “directly confrontive” when speaking to VA. P2 was “uncomfortable” with how the SP interacted with clients and recorded the SP’s interaction. An audio recording showed that on October 16, 2024, the SP stopped talking to the C when the VA entered the room and asked the VA, “Where the hell are you going?” and “Where the fuck are you going?” P5 stated that s/he heard the SP use a “controlling and upset” tone of voice and “language” when speaking to the VA but it was in “response” to the VA speaking “disrespectful” to the SP and the SP not being able to “handle” being talked to this way. The SP denied “yelling” and “swearing” at the VA other than “raising [his/her] voice” as needed to gain a client’s attention. The SP said his/her tone of voice was “very monotone,” however, supervisory staff persons had spoken to the SP on multiple, unspecified dates because the tone of voice the SP used when speaking to clients “sounded condescending.” Although the SP denied the allegation, given that information provided by the VA, P1, P2, P5 and facility documentation completed by P3 and P4 and in an audio recording was consistent regarding the SP’s interactions with the VA that were not accidental or therapeutic, there was a preponderance of the evidence that the SP engaged in repeated oral language towards the VA that would be considered by a reasonable person to be disparaging, threatening, humiliating, harassing, and derogatory which could reasonably be expected to produce emotional distress. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was responsible for the care of the VA. The SP received training on the VA’s support plans, the Reporting of Maltreatment of Vulnerable Adults Act, and the facility’s Individual Rights Policy. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated emotional abuse for which the SP was responsible did not meet the definition of serious or recurring maltreatment. The individual interaction the SP had with the VA likely did not rise to the level of maltreatment and it was the repeated nature of the SP’s verbal interactions that were maltreatment and therefore were considered a pattern of behavior and a single incident. Allegation Two: It was reported that while helping the VA change, the SP was “frustrated” with the VA and “flung” the VA’s arm. The VA sustained two bruises on his/her right arm. P1 stated that on October 20, 2024, P1 and the SP were in the VA’s bedroom helping the VA to reposition. The SP “grabbed” the VA’s arm and “whipped it around.” The VA “yelped” and told the SP, “Ouch, you hurt me.” The SP “argued” with the VA that s/he did not “pull [the VA] that hard.” P1 stated that s/he was “shocked” that the SP had “pulled [the VA] away from [P1] forcefully.” P1 did not say anything to the SP at the time but tried to “comfort” the VA. P1 did not see any injuries to the VA. P1 stated that s/he was not aware of any other incidents when the SP was “forceful” or “physically aggressive” to the VA. The VA stated that staff persons assisted him/her with daily tasks including taking a shower or getting dressed. When asked if the SP had ever handled the VA “aggressively” while assisting him/her with daily tasks the VA stated “at times” but could not provide any additional information. The VA stated that on an unknown date after October 20, 2024, staff persons asked the VA about bruises on his/her arm but the VA did not know how s/he got them. P3 stated that on October 22, 2024, at approximately 11 a.m., P1 told P3 that on October 20, 2024, the SP became “irritated” while assisting P1 in changing the VA. P1 told P3 that when the SP was rolling the VA to his/her side, the SP “flung” the VA’s arm. After talking to P1, P3 went to check on the VA to see if the VA had any injuries. At that time, P3 saw two small bruises on the VA’s right arm. The VA “complained” to P3 that his/her arm was “hurting” but the VA could not recall why or how s/he got the bruises. The VA did not require any medical attention for the bruises. The facility provided two photographs of the VA’s bruises that were taken by P3 on October 22, 2024. The photographs showed a lightly colored bruise approximately one fourth of an inch on the outside of the VA’s upper right arm. A smaller and more faint discoloration of the VA’s skin was shown slightly above the bruise.
P5 stated that s/he worked with the VA on October 21, 2024, and did not see any bruises or injuries on the VA’s arm. P5 stated that the VA had “difficulty” “controlling” his/her electric wheelchair independently and often sustained “minor injuries,” such as bruising, by running into the walls. P5 had not seen the SP “getting physical” with the VA “at any point” when working with the SP. P5 was not aware of any times when the SP did not assist the VA with daily tasks that were required. The facility’s Incident Follow-up Report and Internal Review provided information that was consistent with the information provided by P3 and the following additional information: · On October 21, 2024, the VA had received an injection in his/her right arm and “complained of pain” during the day. A staff person working with the VA told P3 that the VA had “complained of arm and wrist pain” while getting up that morning, prior to receiving the injection later that day. · On October 22, 2024, P3 saw “two bruises” on the “outside of [the VA’s] upper right arm,” approximately eight to nine inches from where the VA had received the injection. According to P3, the sizing and placement of the bruises on the VA’s arm were consistent with P1’s statements of the SP “grabbing” and “flinging” the VA’s arm on October 20, 2024. The VA told P3 that s/he “could not recall” any incidents of his/her arm being injured and P3 stated that the VA did not “complain of current pain or show signs of pain.” The SP stated that the VA had MS and needed “full cares” with staff persons assisting the VA with “pretty much all of [his/her] daily needs.” Staff persons used slide sheets to help reposition or change the VA while the VA was in his/her bed, with a staff person on each side of the bed. The SP stated that “occasionally” when staff persons were changing the VA, the VA’s arm fell across his/her body and “go straight.” When this occurred, the SP “grabbed” the VA’s shirt sleeve or “picked up [the VA’s arm] and placed it back over [his/her] stomach” so the VA’s arm would not “get squished” when the SP assisted the VA in rolling over. Conclusion for Allegation Two: P1 provided consistent information during his/her interview and to P3 that on October 20, 2024, the SP was “frustrated” while assisting P1 in repositioning/changing the VA. The SP “grabbed” the VA’s right arm, “flung” or “whipped” the VA’s arm to the side, and “forcefully” caused the VA to roll to his/her side. P1 stated that during this incident, the VA “yelped” and told the SP that s/he had “hurt” the VA but P1 did not observe any injuries to the VA. P1 stated she had not seen similar concerns of the SP being “physically aggressive” to the VA prior to this incident. On October 22, 2024, P3 saw two small bruises located on the VA’s upper right arm. The VA stated that “at times,” the SP “handled the VA aggressively” when assisting the VA with daily tasks but could not provide any additional information. On a date the VA could not recall, the VA stated that staff persons asked the VA about bruises on his/her arm but the VA “didn’t know” what happened. The SP stated that when s/he assisted another staff person in repositioning or changing the VA, the VA’s arm would “occasionally fall across [the VA’s] body.” The SP would then “pick up” and move the VA’s arm as needed to prevent the VA’s arm from being “squished” when rolling the VA back to his/her side. Given P1’s and the SP’s conflicting accounts of the incident, credibility was left as a determining factor. The SP had reason to minimize his/her interactions for fear of repercussions and there was no information provided that P1 had reason to provide inaccurate information. Therefore, it was more likely than not that the SP “grabbed” and “flung” the VA’s arm when assisting with repositioning the VA. This was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that the VA’s bruises were not observed until two days after the incident, it was not determined whether this incident caused the bruises to the VA’s arm or whether the VA sustained the bruises by any means other than accidental. It was not determined whether physical 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). Action Taken by Facility: The facility completed an Internal Review and found their policies adequate, but not followed by staff persons. All staff persons were retrained on maltreatment reporting criteria. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. In addition, on May 7, 2025, the facility was issued a Correction Order for the violation outlined in this report.
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