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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: 1072443-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy Minnesota Department of Human Services 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) threatened to post a vulnerable adult’s (VA’s) criminal record on a public bulletin board. The SP also followed the VA to his/her friend’s (F’s) house, where the SP engaged in a verbal altercation with the F, which scared the VA. The SP then sent text messages to the VA calling him/her names. Date of Incident(s): November 11 - 13, 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 December 5, 2024; from documentation at the facility and court records; and through six interviews conducted with two facility supervisory staff persons (P1 and P2), the SP, a client (C) who also lived at the facility, the VA, and the VA’s case manager (CM). The VA enjoyed spending time outside, taking walks, and spending time with his/her friends and family members. The VA’s diagnoses included major depressive disorder, anxiety disorder, post-traumatic stress disorder (PTSD), schizophrenia, and cannabis dependence. The VA was not subject to guardianship. The VA stated that s/he moved into the facility in August 2020 and s/he liked living there. On one occasion, when the SP had been drinking alcohol, s/he followed the VA to his/her friend’s (F’s) home and then told the F about the VA’s criminal past. The VA was hiding in the bathroom while the SP was at the F’s home but heard what the SP was saying. [Note: The VA provided the F’s first name and stated that the F would not provide information for this report.] The same day, the SP sent the VA text messages where s/he threatened to “take pictures” and “post it everywhere” in the community. The VA never saw any information posted in the community. However, the VA did not feel safe and took out a restraining order against the SP. The C stated that the SP was “mean” to the clients and wanted to “separate and categorize” them. The SP told the clients stories about “alien abductions.” The SP “did absolutely nothing” at the facility. The SP was “loud” and the clients frequently stayed in their bedrooms when the SP was at the facility. The SP sometimes “talked trash,” but the C did not listen to him/her. A Harassment Restraining Order dated November 14, 2024, stated that there were reasonable grounds to believe that the SP “engaged in harassment which has or is intended to have a substantial adverse effect on safety, security or privacy” of the VA. The SP sent harassing text messages to the VA, frightened the VA with threatening behavior, and called the VA abusive names. The VA did not feel safe to leave the facility because s/he was afraid the SP would confront the VA in the community. The VA was also afraid that the SP would damage the VA’s reputation by threatening to share the VA’s criminal background with the community. On November 13, 2024, the SP sent three abusive text messages to the VA that referenced the VA’s criminal background. Copies of the text messages the SP sent to the VA were obtained and reviewed. Given the graphic nature of the messages that were related to the VA’s criminal history, details of the text messages are not included in this report. P1 and P2 provided the following information: · P2 stated that the SP began to send “inappropriate” texts to P2 where the SP “seemed to be intoxicated.” The SP was upset with “how things were going in the world” and then changed his/her focus to the VA. The SP also text that s/he was going to put a posting on the bulletin board in the town’s grocery store about the VA’s criminal record and would also go door-to-door and tell every resident in the town about the VA’s criminal record. On November 11, 2024, P2 removed the SP from the facility’s work schedule. On November 13, 2024, the SP followed the VA in the community and had a verbal confrontation with the F, but did not interact directly with the VA because the VA hid in a bathroom. After the SP left the F’s home and the VA returned to the facility, the SP sent threatening text messages to the VA. The VA told his/her case manager (CM) about the text messages. · P1 stated that the clients began to stay in their bedrooms during the SP’s work shifts. When the SP talked about the clients, s/he sometimes used racial slurs and referred to the clients as “losers” and “criminals.” None of the clients told P1 that the SP made those comments to them until after the VA received text messages from the SP. · P1 stated that the SP told the C stories about alien abductions, which caused the C to have difficulty sleeping at night. The C told P1 that s/he did not want the SP to talk about aliens. P1 believed the SP talked about alien abductions in order to upset the C because s/he continued to talk about it even after P1 asked him/her to stop. · The SP sometimes did not cook meals for the clients and told them they could make meals for themselves because s/he was not a cook and refused to cook. The SP documented that the clients “did not eat” and when P1 asked the clients why they did not eat, they told P1 that the SP did not cook anything. P1 talked to the SP about his/her job responsibilities numerous times. P1 stated that the staff persons were trained to “keep it professional” and not have a relationship with any of the clients. The SP provided the following information: · During the time the SP was employed by the facility, s/he was often “extremely intoxicated,” but was not intoxicated during his/her work shifts at the facility. · The VA “didn’t have any rules” at the facility and the SP “gave up” on enforcing the rules. The clients made drug deals in front of the facility and smoked marijuana inside the facility. The SP stated that there was no programming that the clients had to remain drug free. The SP documented when drug use occurred and P1 told the SP not to say “anything bad” about the clients. The SP was also upset that the clients did not have to work. At one point, the VA told the SP that s/he was “mean” and the VA wanted to hurt him/herself. · The SP stated that “everyone” in their small town knew about the VA’s criminal record. The SP “checked records” about the VA and believed that P1 and P2 should have told the SP “about who I was taking care of.” · The SP said s/he did not follow the VA to the F’s home, but went to the F’s home because the F was also the SP’s friend. The SP did not believe that s/he “argued” with the F, but they “were talking.” The SP did not believe the VA was at the F’s home at the time and “it was ridiculous” that anyone said the SP followed the VA. [Note: When asked about the F’s contact information, the SP stated that s/he had changed phones and no longer had the F’s phone number.] · The SP did not recall sending inappropriate messages to P2. Because the SP was “very intoxicated” s/he also did not recall sending text messages to the VA that referred to his/her criminal background. When shown copies of the text messages, the SP stated that it was “terrible evidently that I said that, but I can’t remember any of that.” The SP was aware that the VA took out a restraining order on the SP and the SP “never went around” the VA. The CM stated that the VA told him/her about the SP’s text messages, but the CM had no additional information to provide. The facility’s Professional Boundaries policy stated that the staff persons were trained to not seek unnecessary information from the client that was not relevant to the therapy process. The staff persons were to maintain their objectivity with the clients and to maintain the clients’ privacy and confidentiality. The staff persons were to ensure that the clients’ care needs were of primary importance. The staff persons were not to discuss any of the clients’ personal or medical information with anyone other than those designated in the clients’ plans. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Relevant Rules and Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (b), state that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: The VA stated that on one occasion, when the SP had been drinking alcohol, the SP followed the VA to the F’s home and then told the F about the VA’s criminal record while the VA hid in the F’s bathroom. The same day, the SP sent the VA text messages that were reviewed for this report but given the graphic nature related to the VA’s criminal history details were not included in this report. In addition, the SP told P2 that s/he was going to post the VA’s criminal record on the bulletin board in the town’s grocery store and would also go door-to-door and tell every resident in the town about the VA’s criminal record. While the VA never saw any of his/her personal information posted in the community, the VA did not feel safe and was granted a court ordered restraining order against the SP because of the SP’s actions and threats. Although the SP denied engaging in the actions described by the VA and stated s/he was also friend’s with the F, that s/he did not believe that the VA was at the F’s house when s/he talked to the F, and that s/he did not remember texting the VA, when shown copies of the text messages, the SP stated that it was “terrible evidently that I said that, but I can’t remember any of that” and that s/he was intoxicated at the time s/he sent the text messages to the VA. Given that the VA’s accounts were consistent with the text messages provided and that the VA was granted a restraining order against the SP, it was most likely that the VA’s accounts were more credible. The SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6); and were not accidental or therapeutic conduct. Therefore, there was a preponderance of the evidence that the SP used malicious oral language toward the VA that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing or threatening and could reasonably be expected to produce emotional distress to the VA. 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 trained on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans. 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 statutory criteria to be determined as recurring or serious because the repeated nature of the SP’s actions were considered a pattern of behavior that was a single incident and it did not meet the definition of serious. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. After the incident, the staff persons were retrained on the policies. 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. Given that the facility took immediate correction action, a Correction Order was not issued for the violation outlined in this report.
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