|
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: 1090406-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Lindsay Arth Lindsay.Arth@state.mn.us Suspected Maltreatment Reported: It was reported that after a vulnerable adult (VA) displayed behaviors towards a staff person (SP), the SP did not de-escalate the situation and instead, engaged in behaviors towards the VA, including pushing and hair pulling. Date of Incident(s): April 21, 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 subdivision2, paragraph (b), clause (1): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 21, 2025; from documentation at the facility and law enforcement records; and through seven interviews conducted with the VA, a facility client (C), a facility supervisory staff person (P1), three staff persons (the SP, P2, and P3), and the VA’s case manager (CM). The facility provided short term intensive residential treatment services to adults diagnosed with mental illness. The facility had two floors, with client bedrooms, a living room, and staff offices on each. The clients had their own bedrooms. The nursing office and VA’s bedroom were both on the second floor. The facility had cameras in the main areas of the facility. There was an alarm in the nursing office that staff persons could press that sounded throughout the facility to alert other staff persons that they needed assistance. The VA was diagnosed with schizoaffective disorder bipolar type, borderline and antisocial personality disorders, and post-traumatic stress disorder. The VA enjoyed exercising and listening to music. The VA was not subject to guardianship. The VA’s Crisis Plan said that “warning signs” that the VA’s mental health symptoms may be getting “worse” included delusions, hallucinations, increased anger, and decreased medication compliance. When these things occurred, staff persons were to encourage the VA to go on a walk. The VA’s Abuse Assessment and Plan said that the VA was at risk of abuse, including due to his/her impaired judgement and current mental status. Staff persons were to provide frequent check-ins with the VA. The VA had a history of missing “several doses” of his/her prescribed medication which impacted his/her mental stability. Staff persons were to provide medication education for continued medication consistency. The VA also had a history of physical aggression towards others, including “assault.” Staff persons were to teach the VA appropriate socialization through communication skills and role play. Information showed that on the overnight of April 20 to 21, 2025, the SP, P2, and P3 worked at the facility. P1, P2, P3, facility video footage, the General Progress Notes completed by P2 and P3, and the Investigative Summary provided the following information: · On April 21, 2025, at approximately 4:30 or 4:45 a.m., the SP called P1 and was crying. The SP told P1 that s/he was “assaulted” by the VA and that the VA had been “elevated all night.” The SP told P1 that 9-1-1 was already notified. P1 told the SP to wait for law enforcement to arrive and that s/he would also come to the facility. · At 5 a.m., P1 arrived at the facility and saw that the VA, the SP, P2, and P3 were in the nursing office. P1 was “confused” why they were together due to the SP telling P1 that the VA “assaulted” him/her. However, the SP was “calm,” and the VA was putting lotion on his/her feet. P1 then asked the VA what was going on and the VA said, “What do you want bitch?” The VA was “very escalated” but at times, would also be “very calm.” · Law enforcement then arrived and asked the SP if s/he wanted to “press charges” against the VA and the SP said, “Yes.” The VA continued to “escalate” so law enforcement “restrained” and handcuffed the VA and then took the VA to a nearby hospital where s/he was admitted for a “mental health evaluation” and “stabilization.” The SP initially declined medical attention but then sought medical attention at some point after due to sustaining a bump on his/her head, scratches, and stating that his/her scalp hurt due to the VA pulling his/her hair during the incident. · P2, P3, and the SP each said that on the date of the incident, throughout the overnight, the VA was experiencing “psychosis symptoms” and elevated behaviors including flipping future. P3 said that the VA was “not doing well at all” and was “hysterically giggling,” had “facial and body spasms,” and displayed “five emotional states” in a “span of a few seconds.” P2, P3, and the SP attempted to redirect and “de-escalate” the VA and “mitigate” harm to the VA but were not able to do so and the VA’s behaviors continued throughout the night. · P2, P3, and the SP also observed the VA smoking marijuana in his/her bedroom and P2 and the SP each asked the VA to “please” not smoke in his/her bedroom or at the facility. At some point after, the VA went into the nursing office where P2 and the SP were and became physically “aggressive” towards the SP. The VA threw or “smashed” a container of Rice Krispie bars at the SP’s face, scratched the SP’s face, and punched the SP in the face two times. P2 said that the VA then grabbed and pulled the SP’s hair. The SP “repeatedly” told the VA to “let go” and was “calm and neutral” when s/he was talking. P2 then used an “alarm” in the office to alert P3 who was downstairs and called 9-1-1, which staff persons were trained to do when a client displayed physical aggression and because the incident was “beyond” P2’s and the SP’s “ability to manage.” The VA then pushed” the SP’s head towards the floor and the SP “pushed [the VA] off.” The VA and the SP were pulling one another’s hair, and the SP said, “Bitch, let go.” P2 used “physical intervention” to separate the VA and the SP. P2 then saw a scratch and “red marks” on the SP’s face and a welt or bump on the SP’s forehead and the VA’s face was “scratched” and red. P2 did not know if either required medical attention. · P3 said s/he heard the “alarm” sound and went upstairs arriving at the end of the incident. P3 saw that things were “thrown around” including a bookshelf and “smashed Rice Krispy treats” in the office. P2 and the SP were “frantic,” and the VA was “really heightened, escalated, flushed, and frazzled.” The VA then returned to his/her bedroom. · P2 said that there were no “events” to “trigger” the VA throwing the Rice Krispies at the SP and said that the SP’s interactions with the VA were “self-defense at first.” During the incident, P2 was concerned for both the VA and the SP and said it was a “tough situation” because the VA was physically aggressive towards the SP. The VA and the SP were both “distressed and retaliating” and the SP became “escalated” during the incident. · P3 said that at some point during the incident, the SP and P3 were in the office and the SP was “panicking” and told P3 that the VA had his/her “fucking phone.” The SP left the office and P3 followed the SP out of the office towards a main area. P3 described the SP as “behaving frantically” and stating that s/he “had to get [his/her] phone back” and “fuck that bitch.” During this time, the VA was in his/her bedroom, so P3 did not think that the VA heard the SP say those things. · P3 then went downstairs to lock a door to an office due to the VA’s “unpredictability” and then “ran back up.” When P3 returned upstairs, the VA’s bedroom door was closed but s/he heard noises coming from the VA’s room. P3 opened the VA’s bedroom door and saw the SP “on top” of the VA in the VA’s bed and the SP and the VA were “gripping” or “pulling” one another’s hair. The SP asked P3 to grab his/her phone, which was on the bed, and P3 did so. P3 also told the VA and the SP to “breathe” and to “let go of each other.” They then each let go and both were “noticeably battered and scratched up.” P3 and the SP then left the VA’s room. · P3 said that the SP’s “reaction” was “unexpected” but that the SP had recently purchased a new iPhone and the VA taking his/her phone may have “struck a nerve.” The SP took the incident with his/her phone “very personally” and did not “seem to fully recognize” his/her “position as care providers with a power imbalance over a vulnerable adult experiencing severe mental illness symptoms.” P2 did not see the incident with the SP’s cell phone. · The C told a supervisory staff person (P4) that at some point during the incident, s/he heard “someone” state from the VA’s bedroom, “Give me my phone back,” and “let go of my hair.” The C could see people on the VA’s bed but thought it was another client and the SP. The SP was on top of the client trying to get his/her phone back, but the C did not “see [any] fighting.” Prior to the incident, the VA was “tipping stuff over.” · The SP told P4 that at some point during the incident, the VA walked into the nursing office and was “loud and speaking aggressively.” The VA “switched between giggling and laughing to shouting.” The SP and P2 began asking the VA how s/he was doing when the VA picked up a “box” of treats and “smacked” the SP in the face and then grabbed the SP’s hair. The SP attempted to grab the VA’s hand to get his/her hair released, but the VA had a “good grip.” As the SP was “trying to get [his/her] hair released,” the SP got a “bit” of the VA’s hair. The SP then asked P2 for assistance and P2 did so, including “checking on” the SP. The SP said that his/her scalp “hurt” but that overall, s/he was “fine.” At some point after, the VA was in his/her bedroom when the VA opened the door and had his/her hand out for the SP to “shake.” The SP asked the VA if s/he was “okay” and the VA said that s/he needed “help” finding his/her phone. The VA then grabbed the SP’s hair and pulled the SP into his/her room. During this, the VA also grabbed the SP’s phone so the SP used “Siri” to call P3. P3 then came into the room and the SP asked P3 to help him/her get the VA’s “hand” off his/her hair and told P3 that the VA had his/her phone. The SP said that the VA’s fingers were in his/her “scalp” and that the VA was not “letting up” so P3 “grabbed” the VA’s fingers to remove them from the SP’s hair. · According to the Investigative Summary and video footage, which this investigator watched, showed that on April 21, 2025, at 4:41 a.m., the VA walked towards the nursing office. The incident was not directly visible but was seen through a reflection on a clock in the living room which showed an “altercation” between the VA and the SP in the office. The VA was observed punching the SP “twice” and then the SP pushed the VA and remain in the office. P2 was seen attempting to intervene. (Note: There were no video cameras in the hallway in front of the VA’s bedroom.) · There were no prior concerns with the SP’s interactions with the clients and P3 described the SP as “sweet.” However, when P1 heard about the incident, P1 had concerns that there was a “lot” of “reengagement” by the SP with the VA that “should not have happened” and some of the incident “probably could have been prevented.” The SP was trained on and should have “disengaged” and “consulted” with other staff persons when the VA was “escalated.” The SP should have removed him/herself and not pushed the VA after the VA pushed him/her. Staff persons were also trained to be “calm.” Additionally, P1 said that the SP’s statements were not person centered and did not “align” with the facility training. When the VA took the SP’s phone, the SP should have asked another staff person for help or given the VA “time to regulate.” However, P2 and P3 each said that the SP did not do so. · The VA had a history of “declining” to take his/her medications, including around the time of the incident. When this occurred, staff persons were trained to prompt the client to take their medications and the nursing staff persons worked with the client to figure out why they were declining, which staff persons did with the VA. However, staff persons could never “force” clients to take their medications but “encouraged.” · P1 did not know if the VA would recall the incident due to the VA being “symptomatic” and “in and out of coherence” at the time of the incident. The VA did not recall the date of the incident but said that there were “three separate altercations” on the night of the incident but that s/he “did not really remember anything.” When this investigator asked the VA if s/he had any concerns with staff persons interactions, the VA said that s/he “did not know.” When asked if any staff persons were physically aggressive with him/her, the VA said a “little bit,” but the VA did not recall which staff person and did not “remember” any additional details. The VA also said that at some point, an unknown staff person grabbed his/her sweatshirt and the VA “pushed [the staff person] off” him/her. The VA did not receive any injuries while at the facility. The VA also said that s/he was not taking his/her medications around the time of the incident and that staff persons “reminded” him/her to take them “over and over again.” The Incident Report Saint Paul Police Department provided the following information: · On April 21, 2025, at approximately 4:45 am., law enforcement was called to the facility for an “assault” by the VA. When law enforcement arrived, they spoke to P2, P3, and the SP who told them that the VA approached the SP, and the SP asked if s/he could do “anything” for the VA. The VA then became “super aggressive” towards the SP and began throwing things such as tables, chairs, and other items in the main area of the facility. The SP, P2, and P3 attempted to calm and deescalate the VA, by giving the VA space and staying “hands off” so that they did not “agitate” the VA further. P2 told law enforcement that s/he saw the VA “harass,” follow, and “assault” the SP, including throwing things at the SP, including a “large Rice Krispie treat bar” which hit the SP in the face, causing a small scratch underneath the SP’s eye. The VA also grabbed and pulled the SP’s hair and held it “tightly” which caused the SP some “pain.” P2 and P3 told the VA that s/he needed to get his/her hands off the SP’s hair. · P2, P3, and the SP also told law enforcement that around April 11, 2025, the VA began refusing his/her medications and the VA’s “symptoms” became worse and “more aggressive.” · Law enforcement arrested the VA and issued a citation to the VA for fifth degree assault. Law enforcement also spoke to the VA who was acting “strangely” by asking to smoke marijuana and kept referring to an unknown staff person to assist him/her. The VA said that staff persons “starved” him/her and the VA made “accusations” such as “suing the city.” Due to the VA’s “diminished” mental health, law enforcement took the VA to the hospital. The SP provided the following information: · On April 21, 2025, around 12 or 1 a.m., the VA appeared “agitated” and “upset.” The VA was not his/her “regular self” and began shouting and appeared “erratic,” including moving furniture in the living room area, which P2, P3, and the SP thought might interrupt the other client’s sleep. When this occurred, P2 spoke to the VA. · At approximately 3 or 4 a.m., the VA came into the medication room where the SP and P2 were working. The SP and P2 were “polite” when interacting with the VA when the VA grabbed Rice Krispie bars and “smacked” the SP in the face with them and then grabbed the SP’s hair. The SP tried to get his/her hair out of the VA’s hands, but the VA had a “good grip.” P2 then “intervened” and the SP and the VA “released” and then P2 and the SP called 9-1-1 and P1. · At some point prior to law enforcement arriving, the SP was in the hallway, near the VA’s bedroom door, walking to the office when the VA took the SP’s phone. The SP asked for it back and the VA said that s/he could have it back if s/he could find the VA’s phone, which the VA said was missing. The SP told the VA that was “no problem.” However, the VA “smacked” the SP and pulled the SP into his/her bedroom by the hair. The VA then pulled the SP onto his/her bed and the SP asked the VA to let go of his/her hair and to give the VA his/her phone. The VA was trying to “roll over” onto the SP so the SP “pushed” the VA down so the VA would “let go” of his/her “grip.” The SP denied pushing the VA at any other time. The SP used Siri to call P3 for help and P3 came into the VA’s room. The SP asked P3 to grab the VA’s hand from his/her hair so the SP could be “released” and P3 did so. The SP then grabbed his/her phone and left the room. · The SP had two “knots” on his/her temple and a “mark” on his/her face” from the incidents. The following day, the SP sought medical attention due to the “injuries” s/he sustained. The SP was not aware of any injuries to the VA but said that the VA had a “red” face. · Throughout the incident, the SP was communicating with P1, a group chat with staff persons, and law enforcement. When clients displayed behaviors, staff persons were trained to notify the on-call staff persons and de-escalate the situation, which the SP, P2, and P3 were doing. The SP said s/he did not “initiate” the incidents with the VA and did the “best [s/he] could” during the incident. The SP “tried” to stay away from the VA, which staff persons were trained to do when a client displayed behaviors. The C did not recall the incident and stated that s/he “did not witness anything.” The C did have any concerns with the facility. The CM said that on April 21, 2025, around 6:10 a.m., P1 notified him/her of the incident. The CM did not have any concerns with the facility. The VA could provide accurate information but it depended on the situation and the VA’s “mental state.” The IRTS Supervision of People Served said that if there was a concern during the overnight, staff persons were to stay calm, attempt to de-escalate the situation, seek support from others, and call 9-1-1 as needed. The IRTS Consumer Bill of Rights said that clients had the right to be treated with courtesy and respect. Clients were to be free from abuse. The Standards of Conduct Policy said that staff persons were not to fight with, be abusive, or display threatening conduct or speech towards any clients. The Disengagement Skills said that staff persons were to be “calm” and use “appropriate non-verbal communication in approach.” Facility documentation showed that the SP, P1, P2, and P3 were trained on the VA’s plans, the facility policies including client rights, and on the Reporting of Maltreatment of Vulnerable Adults Act. The SP, P1, and P3 were also trained on “disengagement.” Conclusion: A. Maltreatment: Information from P2, P3, and the SP showed that throughout the overnight April 20 to 21, 2025, the VA displayed behaviors including shouting and flipping furniture. P2, P3, and the SP attempted to redirect the VA and “mitigate” harm to the VA but were not able to “de-escalate” the VA and the VA’s behaviors continued throughout the night. P2 and the SP each said that at some point, the VA came into the office and threw a container of Rice Krispie bars at the SP’s face, scratched the SP’s face, and punched the SP in the face. The VA then grabbed the SP’s hair. P2 said that the SP was “calm” and repeatedly told the VA to “let go.” P2 called 9-1-1 and alerted P3, who was downstairs. The VA also pushed the SP’s head towards the floor and the SP pushed the VA off. The SP and the VA were then pulling one another’s hair and P2 separated them. Although P2 said that the SP initially acted in “self-defense,” P2 also described the SP as “retaliating” and said that the SP became “escalated.” Video footage showed the VA punching the SP “twice” and then the SP pushed back but did not remove him/herself from the situation. At some point after the incident, the VA took the SP’s cell phone but it was unclear how this occurred or whether in the office, hallway, or the VA’s bedroom. P3 described that after the VA took the SP’s phone, the SP was “behaving frantically” and the SP said, “Fuck that bitch,” but P3 did not think the VA heard the SP say this, because the VA was in his/her bedroom. P3 went downstairs and a short time after, came upstairs and went into the VA’s bedroom where s/he saw the SP on top of the VA, in the VA’s bed, and the SP and the VA were pulling one another’s hair. According to the VA’s plans, the VA had a history of physical aggression towards others and staff persons were to teach the VA appropriate socialization through communication skills and role play. In addition, the facility’s policies and procedures said that staff persons were not to fight with, be abusive, and not display threatening conduct or speech towards any clients. If there was a concern during the overnight, staff persons were to stay calm, attempt to de-escalate the situation, seek support from others, and call 9-1-1 as needed. Information from P2, P3, the SP, and law enforcement showed that the SP was initially “calm” and that when the VA displayed behaviors, staff persons called 9-1-1 and communicated with one another. Although P2 said that the SP initially acted in self-defense, information also showed that at some point, the SP’s actions were no longer therapeutic and were inconsistent with the VA’s plans and the facility policies and procedures. The VA did not recall many details from the night of the incident but said that an unknown staff person grabbed his/her sweatshirt, and the VA pushed the staff person off. The VA did not receive any injuries from this. The SP said that s/he was trying to get his/her hair out of the VA’s grip and that P2 “intervened.” Additionally, the SP said that s/he was trying to get his/her phone from the VA when the VA “smacked” him/her and pulled him/her into his/her bedroom by the SP’s hair. Although the SP said that s/he did the “best” s/he could during the incident and did not “initiate anything,” the SP’s conduct of stating, “What do you want bitch?” and “Fuck that bitch,” was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and with facility policies and procedures and at one point the SP also pulled the VA’s hair. While it would be reasonable and necessary that when the VA was physically aggressing towards the SP in the office, that the SP take actions to prevent harm to him/herself. However, after the initial incident in the office, the VA had removed him/herself from the situation and staff persons by going to his/her bedroom. P2 and P3 each said that the SP did not ask them for help with getting his/her phone back until after the VA and the SP were in a physical altercation in the VA’s bedroom. When P3 went into the VA’s bedroom, s/he saw the SP pulling the VA’s hair. The SP’s act of pulling the VA’s hair and pushing the VA was not accidental or therapeutic conduct and was inconsistent with his/her training. Although the VA did not sustain an injury, it was reasonable to expect that pulling the VA’s hair could reasonably be expected to produce pain. Therefore, there was a preponderance of the evidence that the SP’s actions could reasonably be expected to produce physical pain or injury. It was determined that 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).
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. At the time of the incident, the SP was responsible for the care of the VA. The SP received training on the VA’s plans, the facility policies including client rights and “disengagement,” and on the Reporting of Maltreatment of Vulnerable Adults Act. 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 maltreatment for which the SP was responsible was not recurring or serious. It was a single incident for which the VA did not sustain a serious injury. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by the SP. The SP did not follow CPI/disengagement regarding a client “crisis,” and also did not follow the facility policies regarding interventions in crisis situations. Between the VA and the SP, there was hair pulling, pushing, and punching. The SP no longer worked at the facility. Additionally, following the incident, P2 and P3 participated in “coping” sessions regarding “what could have [been] done differently.” 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. On July 30, 2025, the facility was issued a Correction Order for failing to affiliate P2’s background study under the correct roster.
|
