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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: 1116303-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Beth Virden Gessner.Rivas@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) called a vulnerable adult (VA), “Gay bastard.” Date of Incident(s): October 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 November 21, 2024; from documentation at the facility; and through six interviews conducted with the VA, the VA’s guardian (G), facility staff persons (the SP, P1, and P2), and a supervisory staff person (P3). The DHS investigator called the VA’s case manager (CM), but the CM did not respond by the completion of this investigation. The VA’s support plans, including Individual Abuse Prevention Plan, provided the following information: · The VA liked being creative and writing poems and wanted to live independently someday and work with children. · The VA was susceptible to abuse from others and had a history of engaging in self-injurious behaviors. The facility provided at least one staff person 24-hours a day for the VA’s care and supervision. Staff reported suspected or known abuse on the VA’s behalf. · At times, if the VA believed s/he was not receiving attention from staff, s/he might become “upset” and might “make inaccurate reports against staff.” Staff helped the VA develop direct communication skills through role-playing and modeling. Staff also helped with the VA’s activities of daily living and independent living skills, transportation, health care, and leisure and recreation. · The VA’s diagnoses included bipolar disorder. The facility was a single-family home where the VA lived with his/her housemates. The VA provided the following information: · In early October 2024, the VA ran away from the house with the SP chasing after him/her. The SP grabbed the VA’s fanny pack and when the VA stopped running, the SP said, “Let’s go, [the VA’s nickname]. Let’s go.” “You know you want to play these games.” The VA started “banging” his/her head and the SP raised his/her fist and struck/punched the VA’s right hand, which the VA had raised in self-defense. “If I hadn’t blocked it, [the SP’s] hand would’ve went right by my eye.” The VA sustained scratches on his/her chest and back, which were “superficial” and had since healed. · On October 16, 2024, the VA “yelled” at the SP for killing the VA’s plant by overwatering it. The VA started walking to his/her bedroom but heard the SP “mumble … under [his/her breath,” “Gay bastard.” The VA turned around to question the SP and started audio recording on the VA’s cellphone. The VA said that the SP can be heard on the recording “yelling” and “antagonizing me.” “[The SP] wouldn’t leave me alone when I asked for space.” There was no one else around during this incident. The VA provided two audio recordings to the DHS investigator, which were not dated or timestamped, and included the following conversations with unidentified staff persons: · Audio recording 1 – The staff person was talking about the VA’s upcoming medical appointment. The VA said that the staff person was avoiding talking about the “abuse” at the facility, which included scratches. The staff person said that staff were not abusing the VA. The VA’s scratches were sustained when the VA ran to a bridge. · Audio recording 2 – The VA told the staff person that s/he should repeat what s/he said, which was call the VA, “Gay bastard,” and the staff person responded that s/he did not say that. The VA told the staff person to stop checking on him/her and the staff person said that it was his/her job to check on and engage with the VA. The SP provided the following information: · On a day in October 2024, the SP arrived at work and the VA was “going through a manic (phase)” and asked to be left alone in his/her bedroom. The SP agreed but told the VA that s/he would check on him/her every so often and the VA was “fine with that at first.” · Later, the SP heard the VA “banging” on his/her walls and dresser and went to the VA’s bedroom. The VA called the SP “a bunch of derogatory names.” The SP walked away, and the VA called out, “What did you call me? Homophobic bastard?” The SP was “thrown off” and did not understand if the VA was calling the SP, “Homophobic bastard,” or if the VA was talking to someone on his/her cellphone. The SP did not call the VA, “Homophobic bastard.” · The SP left the area and gave the VA time alone in his/her bedroom. However, at some point after, the VA approached, calling the SP “racial slurs,” and stating the SP killed the VA’s plant. The SP stopped engaging with the VA but remained sitting nearby to ensure the VA did not harm him/herself. · “Minutes later,” the VA walked out of his/her bedroom and ran out of the house. The VA had a history of “eloping.” The SP followed the VA. When the VA returned to the house, s/he called 9-1-1 for “self-sustained injuries while hitting the dresser and walls prior to [his/her] elopement.” The VA later “accused” the SP of “putting [the SP’s] hands on” the VA, which the SP did not do. P3 said that on October 7, 2024, the SP worked with the VA and called P3 stating that the VA was “struggling” and the SP tried offering support and the VA’s “as needed” medications but nothing was helping. The SP said that the VA “was trying to record [the SP] to get [the SP] in trouble.” P3 told the DHS investigator that the VA had a history of making “false reports” about staff “almost daily.” P3 “investigated” all the VA’s reports, but “none were substantiated.” The VA was “very challenging” to work with. The SP was a “spectacular staff. Engaging and cares about the clients.” P1 said that s/he worked “upstairs” with the VA’s housemate on October 16, 2024. P1 heard the VA “angry” and using “racial slurs” toward the SP. P1 did not hear the SP say anything to the VA. P2 said that s/he worked “upstairs” with the VA’s housemate. P2 said that the VA had a history of recording parts of a conversation but not the full conversation in order “to make it seem like [the VA] is being targeting” by staff. The G said that the VA had a history of “false reporting.” The VA played his/her audio recordings for the G and the G did not hear the SP call the VA “gay bastard.” Facility documentation stated that the staff persons interviewed for this investigation received training on the VA’s support plans, including Individual Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The VA said that the SP called him/her “Gay bastard” and scratched him/her. The SP denied the allegations and the audio recordings provided by the VA did not include information consistent with the VA’s account. P1-P3 did not have information to support the VA’s account and P3 said that the SP was a “spectacular staff.” For these reasons, there was not a preponderance of the evidence whether the SP’s conduct included repeated or malicious language or treatment, which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 determined that policies and procedures were adequate and followed. The VA had a history of similar incidents. There was not a need for additional staff training or corrective action. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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