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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: 1070052-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh 651-431-3444 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) provoked a vulnerable adult (VA) by making disparaging and degrading comments to and about the VA. During the course of the investigation, it was also alleged there were concerns with how additional staff persons treated the VA. Date of Incident(s): Ongoing prior to April 3, 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), 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 April 11, 2024; from documentation at the facility; and through 16 interviews conducted with two supervisory staff persons (P1 and P11), one client (C) who lived at the facility, the VA, the VA’s guardian (G), eleven staff persons (P2-P10), SP1, and SP2. The VA was diagnosed with a traumatic brain injury (TBI) and therefore his/her short-term and long-term memory were affected as well as his/her ability to process information and communicate his/her needs. The VA was also diagnosed with seizure and mood disorders. The VA enjoyed sunbathing in the summertime. The VA was unable to recall staff persons names or other clients who lived with him/her. The VA said s/he had no concerns with how staff persons treated him/her at the facility, but also said s/he would not remember if staff persons said upsetting comments to him/her. There were approximately 28 staff persons who worked at the facility and on average there were four to six persons working at a time. Information from all sources was consistent that there were interpersonal conflicts between several staff persons including P2, P3, P5, SP1, and SP2. P3 provided the following information: · Over the “past couple months” P3 was concerned with how SP1 and SP2 treated the VA. P3 stated that SP1 and SP2 told P3 they “joked” with the VA, but because of the VA’s TBI, the VA did not understand the “tone.” SP1 and SP2 “poked” at the VA until the VA was “riled up.” At times, P5 was also present during those interactions and “put a stop to it.” P5 told the VA to “calm down,” which did not usually work and made the VA more upset. However, P5 did not tell SP1 or SP2 to “quit joking.” · From November 2023 until March 2024, SP1 and SP2 said things to the VA such as calling him/her “gay” and that the VA “liked it up the butt.” [Note: The word gay should not be used as an indicator of the gender and/or genitalia of the VA.] On an unknown date in mid-March 2024, when SP1 said this to the VA, the VA became upset. P3 could not provide additional details such as specific dates or times when the incidents occurred because it happened “over so many shifts” and “way too often.” · Whenever the VA saw SP1 or SP2 s/he said, “Fuck you,” under his/her breath. On March 23, 2024, around 5 p.m., P3 was not working, but came to the facility to bring the clients cupcakes. P2 was in the kitchen with the VA. SP1 walked into the kitchen and the VA said, “Fuck you” to SP1. SP1 then twice said, “I know you want to fuck me.” SP1 thought of it as “joking,” but the VA was “taken aback” and said, “No. No. No. I don’t like that.” SP1 then left the kitchen. P2 did not say anything to SP1 but told P1 and P11 about it. · On an unknown date in March 2024, there was a “bad smell” in the living room, but P3 did not know the reason for it. SP1 and SP2 made comments to the VA such as asking the VA if s/he “shit [his/her] pants.” The VA was not “as upset” as s/he was when previous comments were made to him/her, but repeatedly said, “No, I wouldn’t do that.” P2 provided the following information: · P2 worked at the facility for two years and over the last six months was concerns with how several staff persons interacted with the VA including SP1, SP2, P4, P5, and P9. Those staff persons “poked,” “mocked,” and “teased” the VA until the VA got “angry.” P2 stated that it was “like a group thing.” On unknown dates, P2 heard SP1, SP2, P4, P5, and P9 ask the VA things such as if s/he was “gay” or if the VA thought someone was “sexy” or “hot” and then laughed about it. P2 said it happened “so frequently.” · On an unknown date in March 2024, around 7 p.m., P2, P3, and the VA were in the kitchen. At some point SP1 walked into the kitchen and the VA said, “Fuck you,” to SP1. SP1 responded to the VA and said, “Oh, you want to fuck me? I bet you want to fuck me. Yeah, you want to fuck me, don’t you.” The VA said, “No, I don’t. No. Fuck you.” P2 and P3 said, “Let’s cool it down,” and SP1 said, “Yeah, I don’t want you to start playing with me [the VA’s name].” The VA said, “Whatever,” and SP1 left the kitchen. · P2 stated you could hear “everything throughout the whole house.” On unknown dates and times, P2 heard SP1 and SP2 say things to the VA such as, “Do you think [SP1 or SP2] looks hot?” or “Do you want to have sex with [SP1 or SP2]?” P2 heard SP1 and SP2 make comments of a similar nature to the VA about twenty times over the last six to seven months. SP1 and SP2 thought they were “joking” with the VA, but they also “found it funny” when the VA became upset. · Around mid-March 2024, there was a “weird smell” in one of the living rooms at the facility and P2, who was in another area of the house at the time, heard P5 and SP1 ask the VA if s/he “shit [his/her] pants,” and was “sitting” in his/her “own shit.” SP2 was also there and laughed at their comments. · On a Wednesday in mid-March 2024, P2 told P1 about his/her concerns with how staff persons were treating the VA. P2 previously told prior supervisory staff persons about his/her concerns but had “issues” because the supervisory staff persons were friends with the staff P2 had concerns with. The facility had a “big atmosphere” about “snitching” and staff persons got a “target” on their backs if they reported staff persons to management. P1 provided the following information: · On April 2, 2024, P2 told P1 “vague” information about concerns with SP1’s and SP2’s interactions with the VA and that they were “kidding around a little too much” with the VA which “upset” the VA. P2 said that SP1 and SP2 teased the VA and made comments to the VA such as s/he “pooped” his/her pants and/or that s/he “stinks.” At that time, P1 thought that it was just “joking around.” Then, two days later, April 3, 2024, P3 told P1 the same story information but with more details. P3 said that the day prior, SP1 and SP2 called the VA names including “gay” and “fag” and told the VA that the VA “liked it up the butt.” At one point when SP1 entered the kitchen that day, P3 heard the VA said, “F-you,” to SP1 and SP1 said to the VA, “Yeah, I know you want to F-me.” P1 stated that the VA liked “pretty much everyone,” but if s/he did not like someone, s/he said, “F-you.” P1 was not entirely sure what specific comments were said by SP1 or SP2, but the majority of the comments came from SP1 with SP2 laughing at what was said. · SP1 and SP2 were “best friends.” P1 talked to SP1 and SP2 separately about the allegations and each were both “shocked” and denied “everything.” P1 told them that if they were “joking around” with the VA to upset him/her, that it “needed to stop.” · After P1 talked to SP1 and SP2, P4, who knew about the allegations, then talked to P1, and tried to “defend” SP1 and SP2 referencing their age. P1 told P4 that age was not an excuse for their concerning interactions with the VA. · There were no prior concerns with SP1 or SP2 that P1 was aware but P1 had only been in the facility fulltime for approximately one month. Anytime P1 saw/observed SP1 or SP2, they were “sweet” and “quiet.” P1 thought SP1 and SP2 were “great” staff persons until P1 was made aware of the concerns. P1 had no concerns with P2 or P3 and had no reason not to believe their information. However, there was “definitely” interpersonal conflicts between SP1, SP2, P2, P3, and other staff persons because P2 and P3 brought up previous concerns to supervisory staff persons so staff persons referred to P2 and P3 as “snitch bitches.” · P1 did not talk to the VA regarding the allegations because of the VA’s diagnoses/short-term memory loss. However, after P2 initially told P1 his/her concerns, but before P3 told P1 his/her information, P1 asked the C, who according to P1 was an accurate reporter, if s/he had seen any staff persons “be mean” to the VA. The C said that s/he had and then named SP1, SP2, and P5. P1 had no other information that P5 said anything concerning to the VA, but that when the VA was “worked up” from what SP1 and SP2 had said to him/her, P5 told the VA to “calm down.” However, when P1 asked P5 about the allegations, P5 denied any staff persons being “mean” to the VA. P1 thought the staff persons “covered for each other.” The C said s/he heard staff persons including SP1 and SP2 “joke around” with the VA and call the VA names “too many times.” The C did not remember the specific details of the incidents or what was said. However, the VA was “mad” when the comments were made to him/her. P4 stated that s/he heard about the allegations from P8 who talked to P3. P4 had no concerns with SP1, SP2, or P5, and worked with them “quite often.” P4 never saw/heard any staff persons provoke, swear, or inappropriately joke at or with the VA. Staff persons were “respectful” and treated the VA “like family.” P5 stated s/he never heard staff persons joke/interact in an inappropriate way with the VA. P5 never heard any staff persons tell the VA s/he “smelled like poop” and denied doing so him/herself. P6 said the VA swore a lot including, “fuck you,” but P6 usually did not “take it seriously” and the VA was “just joking.” Staff persons “always joked” with the VA to help get the VA out of a “mood,” but not in a way that concerned P6. P6 never heard staff persons swear at the VA. At times, the VA made sexual comments, but P5 just “ignored” them and redirected the VA. P6 never heard any staff persons make sexual comments to the VA, call the VA “gay,” or say the VA smelled or was incontinent. P6 had no concerns with how staff persons treated the VA. When the VA was “angry,” it was the staff persons job to redirect the VA to help the VA calm. P6 had no concerns with SP1 or SP2 and how they interacted with the VA. P7 said s/he had no concerns with how staff persons interacted or spoke to the VA. P8 said s/he heard about the allegations and stated that they were “lies.” P8 never heard staff persons swear at the VA, joke in an inappropriate way, or make remarks about the VA being incontinent. Staff persons “light-heartedly joked” with the VA to make the VA laugh or smile. P8 stated that SP1 and SP2 were “caring” and “some of the kindest people” P8 knew, so P8 “didn’t believe” that they would treat the VA in a disparaging way. P9 said s/he had no concerns with how staff persons interacted with the VA. P10 said s/he had no concerns with how staff persons treated/interacted with the VA. P11 said that P1 told him/her about the allegations and provided consistent information that P1 said in his/her interview regarding P3’s concerns. P11 was with P1 when s/he talked to SP1, SP2, and P5, who denied all of the allegations. P11 never heard any of the concerning comments and stated that they usually occurred when management was not at the facility. The G said the VA was really “good natured” unless someone “ordered [him/her] around.” The VA was “triggered” by persons telling the VA what to do or asking him/her what s/he was doing and when that occurred, the VA became “upset” or “angry.” The VA did not have a good short-term memory and might forget something that happened “a minute later.” The G was concerned staff persons were not trained properly on persons with traumatic brain injuries especially regarding the VA’s “triggers.” SP1 denied the allegations including swearing, calling the VA names, and making inappropriate comments that were sexual in nature. SP1 thought maybe a staff person overheard him/her using the word “gay” with another staff person, but denied using it towards the VA. SP1 heard the VA use the “f-word” or staff persons saying, “Oh, fuck,” but denied saying that word to the VA or using it in a sexual comment towards the VA. SP2 said that s/he heard staff persons swear, but not towards the VA. Staff persons “joked around” with the VA, but not in a way that was sexual in nature and stated that the joking was “harmless.” SP2 denied using the word “gay” in reference to the VA. SP2 heard about the time where the living room smelled and comments were made, but did not have additional information as to who said what. SP2 stated that it was not okay for staff persons to make comments that were sexual in nature to the VA and was “frustrated” when P1 told him/her that s/he was part of the accusations because s/he would “never” do or say those things. The facility’s personnel files showed that P1-P6, P8-P11, and SP1 were trained on the VA’s plans. P1-P11, SP1, and SP2 were trained on the Reporting Maltreatment of Vulnerable Adults Act. The facility did not have records to show P7 or SP2 were trained on the VA’s plans which was a violation of Minnesota Statutes, section 245D.095, subdivision 5 which states in part that the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation, and training that includes orientation to individual service recipient needs. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights included the right to be treated with courtesy and respect. Conclusion: P2 and P3 provided consistent information that on multiple dates they heard SP1 and SP2 say things to the VA such as calling the VA “gay,” that s/he “liked it up the butt,” and asking the VA if s/he “shit [his/her] pants,” or wanted to “have sex with [SP1 or SP2]?” The C stated s/he heard SP1 and SP2 “joke around” with the VA and call the VA names “too many times,” but did not remember what was said. However, P4, P5, P6, P7, P8, P9, P10, and P11 each had no concerns or had not seen/heard any inappropriate remarks/interactions by staff persons to/with the VA. Given that the information from P2 and P3 conflicted with the information provided by P4-P11; that there were interpersonal conflicts between staff persons at the facility including P2, P3, P5, SP1, and SP2; and that SP1 and SP2 each denied the allegation, there was not a preponderance of the evidence whether SP1, SP2, or any other staff persons engaged in repeated oral language toward the VA or treatment of the VA, that a reasonable person would consider disparaging, derogatory, humiliating, harassing or threatening, and produced or 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 stated that their policies and procedures were not adequate or followed and that TBI training would be assigned to all new staff persons. Additionally, the G would come to the facility to speak on the VA’s behalf and teach staff persons the best way to speak to the VA. Action Taken by Department of Human Services, Office of Inspector General: On June 27, 2025, the facility was issued a Correction Order for the violation outlined in this report.
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