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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: 1069193-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady/Heidi Murphy Scott.broady@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP1) refused to give a vulnerable adult (VA) space, called the VA names, refused to allow other staff persons to take the VA to medical appointments, did not allow the VA to go on outings, denied the VA snacks, and entered the VA’s room without permission. It was also alleged that a staff person (SP2) raised his/her voice to the VA, accused the VA of lying, called the VA names, and threatened to press charges against the VA. Date of Incident(s): Multiple dates 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 May 20, 2024; from documentation at the facility; and through seven interviews conducted with the VA, the VA’s guardian (G), facility staff persons (SP2 and P3), and facility supervisory staff persons (P1, SP1, and P4). The facility had two common living areas on the main floor, an office, and a kitchen/dining area. The VA’s bedroom was on the second level, along with another client’s bedroom. A third bedroom was unoccupied. A third client used of a wheelchair for mobility and had a bedroom on the main level, with access through the office. The facility had a basement, which was not used by the clients. The VA was diagnosed with major depressive disorder, attention deficit hyperactivity disorder predominately hyperactive type, fetal alcohol syndrome, reactive attachment disorder, and post-traumatic stress disorder. The VA enjoyed shopping and spent time on his/her computer and cell phone. The VA provided the following information: · On April 19, 2024, the VA got into a “heated” argument with SP2. SP2 got frustrated with another client and banged on that client’s door. The VA told SP2 “not to do that” as loud noises have caused medical issues for the client. SP2 said the client “was fine.” The VA and SP2 continued to argue over SP2’s actions. SP2 called the VA “whiny” and “a liar” and accused the VA of “twisting stories.” The VA called a community person (CP) who worked at the facility in the past and had the call on speaker phone. The CP told SP2 that SP2’s behavior toward the other client was “wrong.” P1, P2, and P4 were told about the incident. P4 was upset with the VA for calling the CP. · An unknown licensor was at the facility on an unknown date in April 2024 and the VA shared concerns with the licensor. · On an unknown date between January and April 2024, the VA and SP1 had a conversation about a rent bill. The VA realized s/he was wrong and apologized to SP1. The VA was in a bad mood and asked to be left alone. SP1 kept talking to the VA and called the VA a “bitch, brat, and whiny” and said, “You’re such a big shot using the F word.” The VA asked SP1 to “get out of [the VA’s] face.” SP1 got closer and the VA pushed SP1. The VA felt “verbally attacked” and that SP1 was “antagonizing” him/her. The VA went to a different nearby facility location and told staff persons there. Staff persons had the VA call P4. · The facility bought food for the clients and snacks were available for all the clients. The VA was looking for chips and found them in another client’s bedroom. The VA told SP1 that food cannot be hidden in clients’ bedrooms. · The VA worked overnights and arrived back at the facility after around 1-2 a.m. When the VA arrived, s/he ate food and put dishes in the sink with the intention to clean them in the morning. The VA did not want to wake up anyone else at the facility doing dishes in the middle of the night. SP1 put a sign on fridge that stated the kitchen was closed after dinner. The VA told SP1 that s/he was going to call P1 and SP1 said, “No, no,” and took the sign down. · The VA told SP1 that s/he did not want SP1 to participate in a phone appointment and SP1 said, “I’m not going to take you to anymore appointments then.” Staff persons typically drove the VA to appointments. The VA had a medical appointment in St. Cloud and SP1 said medical transportation would take the VA. The VA stated that made him/her uncomfortable. SP1 told the G and a family member there was no other option but the VA felt there was. P3 volunteered to drive the VA. · The VA felt that s/he was treated differently than the other clients by staff persons. · SP1 accompanied the VA to a medical appointment. The VA filled out paperwork that asked about a “stable diet.” SP1 laughed and said, “No you definitely do not have a stable diet.” The VA struggled with food and eating and the VA’s feelings were hurt by the comment. · On November 7, 2023, the VA received a text from SP1 that said, “Just want to give you a heads up I went in your room to get dirty dishes, etc.” The VA told SP1 to ask permission before going in the VA’s bedroom. On November 21, 2023, SP1 went into the VA’s bedroom again. The VA told SP1 that was a violation of VA’s rights. SP1 apologized and said s/he was trying to clean up. A previous staff person had stolen a bracelet from the VA and VA didn’t want staff persons in his/her bedroom.
· The VA isolated him/herself, did not like how staff treated him/her, was not comfortable going downstairs, did not feel liked by staff persons, and felt like every time VA went downstairs, s/he got “harassed” by staff persons. · Around April 19, 2024, P4 called a meeting with SP1 and the VA. P4 asked what had been going on. The VA explained the s/he had been disrespected by staff persons. P4 disagreed with the VA and said, “No you haven’t.” SP1 was “practically yelling at [the VA] the whole time” and the VA “broke down crying.” SP1 made remarks, laughed and “snickered” at the VA, which hurt and upset the VA. P3 was also in the room with another client. P4 told SP1 to stop multiple times but SP1 did not stop the behavior. The VA felt that the G should have been present during the meeting. P3 provided the following information: · SP1 went in the VA’s bedroom without permission and got trash and dishes, after the VA had told the SP1 not to go in the bedroom without the VA’s consent. No other staff persons went in the VA’s room without permission. · The VA would not eat with the group while the SP1 worked at the facility. After SP1 left, the VA would eat with others. · There was an incident in which the VA had an appointment and had a ride scheduled. SP1 got mad at the VA for an unknown reason and cancelled the ride and told the VA to “figure out your own stuff.” P3 offered to give the VA a ride and SP1 said, “No,” that the VA needed to figure it out. P3 disagreed and drove the VA to the appointment. · P3 stated SP1 put signs “all over the place.” There were four signs total. One sign referred to cleaning up your mess, that it does not clean itself. Another sign was about cleaning dishes. P3 did not remember what the other two signs said. P3 believed the signs were not meant for the clients but for staff. SP1 said the signs were meant for the VA. · Food was stored in rooms, not hidden. The VA had two boxes of crackers. No one else in the house ate them. They were the VA’s favorites. They were in the VA’s room. · SP1 tried to “assert [his/her] authority” and expected the VA to do whatever s/he said. If P3 was there, s/he would get in “between the two of them” during disagreements. The CP provided the following information: · The CP was on the phone with the VA and heard SP2 “yell and scream” at the VA. SP2 called the VA a “liar,” and a “manipulator,” and told the VA to “mind [his/her] own business.” The CP was put on speaker phone and told SP2 to calm down and to stop talking to the VA in that way. SP2 continued to yell and scream and then slammed a door. · The VA told the CP s/he was emotionally drained, and “this” was “messing” with the VA’s self-harm urges. · The CP talked to P4 about the incident and was told to “stay out of it” and it “was no longer any of [the CP’s] concern.” P1 provided the following information: · Staff persons used to transport the VA to medical appointments. The G approved medical rides through medical assistance. · P1 was not aware of staff going into the VA’s room when the VA was not home or of food stored in clients’ bedrooms. The VA never brought any concerns to P1. · The VA got upset due to the “way we react and talk to people” and was “usually pretty easy to de-escalate.” SP1 provided the following information: · Some of SP1’s job duties included prompting the VA to take showers, ensuring the VA’s bedroom was clean, and ensuring the VA paid rent. · The VA struggled to take medications on time, to clean up after him/herself, and to finish laundry. · When conflict happened, SP1 would try to answer the VA’s questions and tried to figure out why the VA was upset. SP1 stated, “I need to learn how to just walk away.” · SP1 denied the s/he ever antagonized the VA or called the VA “slob,” “whiny,” or a “bitch.” SP1 denied that food was stored in clients’ bedrooms. SP1 did not have any concerns over other staff persons interactions with the VA. · The VA did not have rides set up for work originally and staff persons were not supposed to transport the VA to work. SP1 felt bad and let one staff person transport the VA a couple times. SP1 was told not to do that and told the VA that staff persons were not allowed to drive the VA to and from work. SP1 felt that was when the VA started “being pissed off” and disrespectful. Clients did not even say hello to the VA. One client was “scared off” by the VA and moved out. · SP1 did not invade the VA’s personal space. On an unknown date, SP1 walked toward the VA to get an item that was behind the VA and the VA pushed SP1. · Staff persons provided transportation for the VA to the VA’s appointments that were near the facility. The VA also qualified for free transportation, which was used for long distance appointments. SP1 set up those transports. · A staff person was willing to drive the VA but “why should [s/he] use [his/her] personal vehicle and ask for reimbursement when [the VA] is allowed free transportation.” The VA expected to go shopping after appointments and that needed to be planned. · When the VA wanted to go out on community outing, to go out with friends, that needed to be verified with the G and the VA needed to find his/her own transportation. Shopping needed to be planned but if SP1 was going to the grocery store, SP1 asked the VA if s/he wanted to go along. When the VA requested to go shopping, it depended on how many staff persons were working, which clients were at the facility, and if appointments were planned. SP1 stated, “I can’t say I’ve ever denied [the VA] of going shopping or anything like that.” When SP1 went shopping, the VA was asked to go with and the VA usually said, “No.” · SP1 went shopping and bought boxes of crackers. SP1 went into the VA’s room to look at the window screens for maintenance personnel and noticed the boxes of crackers in there. SP1 asked the VA to bring the boxes of crackers downstairs and put them back in the cupboard but the VA never did. When the VA went to work, SP1 went in the VA’s room and retrieved the crackers. The facility paid for the crackers and everyone should have access to them. SP1 went in the VA’s room on one occasion to grab dirty dishes. · The facility had a communal dinner every day and the VA was called for dinner. The VA waited until the overnight shift started at 10 p.m. and would go to the kitchen and started “making a mess.” The VA did not clean up after him/herself. SP1 put a sign on the refrigerator that said, “The kitchen closes at [unknown time].” The sign was taken down by the end of SP1’s shift. · SP1 denied laughing about the VA’s diet while filling out medical forms. SP1 never talked to the VA about his/her diet and only asked what the VA wanted from the store. SP2 provided the following information: · The VA did not allow anyone in his/her bedroom. Staff persons tried to get the food dishes and trash out of the bedroom. The VA’s bedroom was a “pig stye.” There were piles of laundry by the door and the VA got mad when staff did his/her laundry. SP2 stated, “We do the best we can with [the VA].” · The VA “doesn’t want to be messed with and doesn’t want to be around people.” · There was an incident with another client screaming on an unknown date. SP2 knocked on the door to get the client’s attention and to let the client know staff persons were there and not going anywhere. The VA went downstairs and yelled not to bang on the door as the client had startle seizures. SP2 told the VA to “mind your own business.” The VA went down the stairs “charging” SP2. SP2 told a staff person to call 9-1-1 if anything happened. The VA called SP2 inappropriate names. The VA called the CP and talked to the CP about cutting him/herself. SP2 did not see any cuts in the VA. SP2 told the CP that the VA was “telling [his/her] lies.” The VA “slapped” SP2’s jacket strings. SP2 told the VA, “If you’re not happy here, why don’t we look for a different place.” · SP2 did not recall calling the VA “whiny” and was not aware of any signs in the kitchen. SP2 stated that s/he yelled to the CP on the phone that the VA was telling lies and not to worry about it. · Staff persons took the VA to medical appointments and the VA sometimes took medical transportation to appointments in St. Cloud. · SP1 went to store and put crackers in the closet. The VA took all of crackers and SP1 said, “No,” as the other client liked them too. Some food for another client was put in his/her room because it disappeared too fast. P4 provided the following information: · The VA did not like anyone going into the VA’s bedroom. · On April 30, 2024, a meeting was held about VA’s room being a “fire hazard.” The VA vaped marijuana and did not take medications on schedule. The VA had been disrespectful to staff persons and called them “bitches.” A meeting was held with the VA, the G, P2, SP1, a nurse and P4. · P4 heard of concerns but never personally witnessed any concerns between the VA and staff persons. The VA had not brought any concerns directly to P4. · Around April 19, 2024, P4 heard that VA was yelling. P4 did not inquire because “I wasn’t there.” P4 told “them” to make sure things were documented. · Staff persons took the VA to appointments. The VA began taking another form of transportation that was approved by the G. · P4 was not aware of staff persons going in the VA’s bedroom. P4 only heard about P2 taking pictures from outside the door due to an odor coming from the bedroom. · P4 was not aware of any signs in the kitchen. · Potato chips and other overflow of food was stored in the office until the rest was eaten and everyone had access to the office. · The VA told P4 s/he was upset over staff not driving him/her to and from work. The facility’s Internal Reviews stated that P4 received a telephone call from the CP on April 20, 2024, and was told of the incident involving the VA and SP2 on April 19, 2024. P4 stated s/he would look into the incident and denied telling the CP to “stay out of it.” P4 described the April 19, 2024, incident as a “screaming match” and confirmed that SP2 called the VA “spoiled” and told the VA s/he was acting like a “child.” The CP heard SP2 tell the VA to “mind [his/her] own business” and called the VA a “liar” and a “brat.” The CP stated the VA was very emotional during the verbal exchange. The CP stated P4 told him/her the matter was not his/her concern. SP1, SP2, and P4 were trained on the VA’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Conclusion: Regarding SP1: The VA stated that SP1 went into the VA’s room without the VA’s permission for things like gathering dirty dishes, put signs in the kitchen that stated the kitchen was closed after a specified time, did not let the VA go on outings, called the VA names, hid snacks in another client’s room, and told the VA s/he had to take alternative transportation to medical instead of having staff persons drive the VA to appointments even though P3 offered to drive the VA and staff persons were allowed to transport clients to appointments. P3 stated SP1 went in the VA’s room without permission, cancelled transportation for the VA after SP1 “got mad” at the VA and told the VA to “figure it out,” and put four signs up in the facility about cleaning up after yourself and SP1 stated they were meant for the VA. SP1 gave explanations for entering the VA’s room without permission, took down the signs in the kitchen during the shift they were put up, denied calling the VA names, stated outings needed to be verified with the G and the VA needed to arrange for transportation and if those things were done, the VA was allowed to go, snacks that were paid for by the facility were taken out of the VA’s room so that all clients could have access to the snacks, and that the VA had access to free transportation to medical appointments. Although the VA stated SP1 called the VA names, given that SP1 denied doing so and there was no further information to confirm or dispute either account, and that the VA was not denied access to food and received transportation, there was not a preponderance of the evidence whether SP1 engaged in conduct that rose to the level of emotional abuse. 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). Regarding SP2: The VA stated that during an argument on April 19, 2024, SP2 called him/her a “liar” and “whiny” and accused the VA of “twisting stories” to the CP. The CP stated s/he heard SP2 call the VA a “liar” and a “brat” and told the VA to mind his/her own business. The CP stated the VA was very emotional during the incident. SP2 stated s/he yelled into the phone when the VA was talking to the CP and told the CP that the VA was lying and not to worry about it. SP2 denied calling the VA names. Although SP2’s behavior was inconsistent with the standard of a professional caregiver in a facility licensed by the Department of Human Services, given there was no information there were other incidents similar, there was not a preponderance of the evidence whether SP2 actions were repeated and or malicious and rose to the level of emotional abuse. 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’s Internal Review stated policies were adequate but not followed. SP1, SP2, P1, P3, and P4 were retrained on Maltreatment of Vulnerable Adults Reporting Policy and Procedure-Definitions of Abuse, Home and Community Based Service Provider Attestation Policy, Employee Conduct and Discipline Policy-Prohibited Employee Conduct, and De-escalation techniques and strategies for avoiding power struggles. SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action.
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