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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: 1120661-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070806-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that on April 25, 2024, a vulnerable adult (VA) had bruising and scratches on his/her back and thereafter video recording at the facility was reviewed and it was also reported that: · On April 20, 2024, from approximately 1:30 p.m., until after 11:59 p.m., the VA was not provided food by a staff person (SP1). At around 9:30 p.m., the VA was observed picking up crumbs off the floor and putting the crumbs in his/her mouth. · On April 24, 2024, the recording showed the VA was lying on a beanbag chair and a staff person (SP2) stepped over the VA, and “kicked” the VA’s right ankle. · On April 24, 2024, at 3:46 p.m., the recording showed SP2 went upstairs with the VA, and a loud noise was heard. The VA was seen walking down the stairs with his/her her head down and both hands on the back of his/her head. SP2 was behind the VA and SP2 was holding an item in his/her hands. Date of Incident(s): April 20 and 24, 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), clauses (1) and (2); and subdivision 17, paragraph (a): 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. · 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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 10, 2024; from documentation at the facility, medical records and law enforcement records; and through five interviews conducted with facility supervisors (P1-P2), the VA’s guardian (G), SP1, and SP2. An interview with the VA was attempted, however an interview was unable to be completed due to the VA’s limited verbal communication skills. During the site visit this investigator observed the VA in a wheelchair and a staff person was taking the VA on a walk. While in the wheelchair the VA was observed to bounce him/herself against the backrest. Facility documentation showed the VA enjoyed going on car rides, playing in water, and going to the movie theater. The VA was described as happy and giggly when in a good mood, but on “bad days” the VA would grab staff persons. The VA was diagnosed with developmental disabilities, Angelman syndrome, attention-deficit hyperactivity disorder, as well as multiple physical health conditions. The VA was able to understand verbal conversation and used a pictograph to communicate. The VA had a G-tube and received 1:1 staffing 24 hours a day. The VA’s Self-Management Assessment (SMA) stated the VA may become upset, uncomfortable, or overstimulated and would engage in behaviors such as biting, grabbing, or pulling the hair of other people. Due to the VA’s limited verbal communication s/he may not always be able to communicate his/her needs and wants. The VA’s Coordinated Service and Support Plan Addendum (CSSPA) showed the VA received supports, including but not limited to, meal preparation, eating, grooming tasks, hygiene tasks, medication management, community involvement, dressing, bathing, social skills, appointment management, and G-Tube care. Staff persons assisted the VA with eating. Staff persons would prepare and cut food into bite-sized pieces to ensure easy swallowing. The VA’s Individual Abuse Prevention Plan (IAPP) stated the VA was susceptible to physical abuse. The VA did not have a history of engaging in self-injurious behaviors but had a history of becoming physically aggressive toward others. The following information was collected through the VA’s progress notes, facility video recordings, interviews, and the facility’s Internal Review (IR). It should be noted the below concerns were found after SP1 made a progress note on April 25, 2025, and thereafter camera recordings from April 19 to April 25, 2025, were reviewed by facility administration. It was alleged that on April 20, 2024, the VA may not have been provided food for approximately eight hours. SP2 was the staff person working with the VA during the shift: · At 1:39 p.m., the VA was sitting on his/her bean bag chair in the living room and thereafter went into his/her bedroom at 1:50 p.m. At 7:04 p.m., video recording showed SP2 talking on a phone for about an hour while in the kitchen. During the time SP2 was in the kitchen the VA sat on his/her bean bag chair, rocked back and forth, and made noises. · The VA went into the kitchen at 7:51 p.m., after SP2 said, “Come eat.” The VA left the kitchen at 7:55 p.m. While the VA was in the kitchen SP2 could be heard talking on the phone and there was a faint noise of a person eating. · Around 9:30 p.m., the VA was observed eating crumbs off the floor. · At 2:01 a.m., the VA was heard making a loud yelling noise, and a different staff person provided the VA with food. · There was conflicting information provided by P1-P4, and SP1-SP2, related to whether the VA would have been able to eat a meal within five minutes. However, all persons said there were no prior concerns with the VA being provided food. SP1, P3, and P4 did not express any concerns related to staff persons not feeding the VA. · SP2 denied not providing the VA with food during his/her shift. It was alleged the VA had a bruise on his/her left arm, and scratches on his/her back: · On April 24, 2024, SP1 observed bruising on the VA’s left arm and scratches on the VA’s back. SP1 made a progress note documenting the injuries. SP1 said s/he was not aware of the injuries prior to April 24, 2024, and had not worked the previous two days. SP1 believed the bruise on the VA’s arm was from someone grabbing the VA, but SP1 did not believe staff persons at the facility would intentionally harm the VA. SP1 spoke with other staff persons, and no one was aware of any injuries to the VA. · Pictures were taken of the VA’s injuries. The pictures showed a faint yellow bruise on the VA’s right upper shoulder blade, which was roughly the size of a quarter. The shape of the bruise was oval, and there were also a few red dots that were the size of mosquito bites. The VA’s upper back had a few small scratches which appeared red. The VA had a bruise on his/her left bicep, that was about the size of a quarter and round in shape. · P2 observed the bruise and believed it looked like a “thumbprint,” but did not know the cause of the bruises or scratches. · P3 said SP1 informed him/her of the bruising on the VA, but P3 was not aware of what caused the bruising. P3 stated s/he did not have concerns of any physical abuse occurring in the facility. · P4 observed a bruise on the VA arm but was not aware of any scratches or bruising on the VA’s back. P3 stated s/he did not have concerns of any physical abuse occurring in the facility. · SP1 denied causing any bruising on the VA. · P3-P4, SP1, and SP2 all provided plausible explanations such as the VA rubbing his/her back on the ground which would have caused the scratch marks. There was no information to how or when the bruise on the VA’s left bicep occurred. · The VA’s progress notes from April 25 to April 27, 2024, showed the scratches and bruise had improved. It was alleged on April 24, 2024, SP1 “kicked” the VA in the foot: · A video recording from April 24, 2024, at 3:21 p.m., showed the VA was sitting on his/her bean bag in the living room and was observed rocking and making noise. The VA moved toward the kitchen door, and at 3:27 p.m., SP1 opened the door while the VA was next to the door. SP1 directed the VA to return to the bean bag chair. At 3:35 p.m., SP1 exited the kitchen and stepped over the VA legs while walking toward the stairs. SP1 turned around, walked back toward the VA, and again stepped over the VA’s legs. After stepping over the VA, SP1 turned around and SP1 used his/her foot to make physical contact the VA’s foot/ankle. SP1 then made an inaudible statement to the VA before SP1 used his/her foot to touch the VA’s feet a second time. The VA responded by bringing his/her legs inward to get out of the way and SP1 proceeded upstairs. During the recording the VA did not appear to be in pain or have an emotional response to the interaction. · The IR, P1, and P2 described the physical contact SP1 had with the VA as a “kick.” P2 also said SP1 slammed the kitchen door which “almost” hit the VA’s hand, and SP1 later yelled, “Hey,” to get the VA to stop crying. P2 did not observe any injury to the VA and the VA was able to walk without any issues. · SP1 provided consistent information within an interview with this investigator and the facility’s IR. SP1 said it was bad luck in his/her culture to step over someone's feet, and said s/he walked back over the VA’s feet, and did not mean to kick the VA’s feet, but rather SP1 was attempting to shift the VA’s legs in order to walk by the VA. It was alleged on April 24, 2024, the VA walked downstairs holding his/her head after a loud noise was heard from off camera view: · On April 24, 2024, at 3:46 p.m., a video recording showed the VA walked downstairs and appeared to have his/her hand on the back of his/her head. The VA walked back upstairs, and a loud noise could be heard which sounded liked “dishes banging against something.” The VA then moved back downstairs with both hands on his/her head. The cause of the loud noise was not in camera view. Shortly after the loud noise occurred SP1 walked into camera view holding what appear to be a plate or pan and put the dish in the kitchen. · The IR stated a plate had potentially been used to “hit/intimidated” the VA. · P1 observed the VA on May 1, 2024, and the VA was not in any pain or discomfort. P1 said there were no known injuries to the VA’s head. · SP1 watched the video recording which included the loud sound that was off camera. SP1 said the noise was a plate that fell when s/he was upstairs and denied intimidating or hitting the VA with an object. SP1 reported that the VA’s head was very soft and that any marks would have been visible. The facility reviewed all the alleged incidents and determined SP1 “kicked” the VA in the ankle on April 24, 2024. The facility determined SP2 used his/her personal cell phone while working. The facility also determined SP1 and SP2 spoke to the VA with stern/aggressive voices and did not engage the VA, and SP1 failed to report the VA’s unexplained injuries within 24 hours of discovering the injuries. Medical Records from April 29, 2024, showed the VA was seen at an emergency room due to a health concern unrelated to the allegations, and there were no observed injuries to the VA’s head. Law enforcement (LE) records provided the following information: · LE reviewed the video recording and described the incident with the VA laying on a bean bag chair with his/her legs spread out straight on the floor. SP1 stepped over the VA legs, walked toward the stairs, turned around and stepped over the VA’s legs again. The SP then turned around and “kick(s)” the VA right leg “intentionally” and the SP proceeded to “kick(s)” the VA again “lightly as if to move” the VA’s feet/legs out his/her way. [The VA] did not appear to be injured and continued to lay on the bean bag chair. · LE charged the SP with a formal complaint but the county attorney dismissed the case. The G was aware of the concern, but did not have relevant firsthand information. P1, P2, SP1, and SP2 completed training on Reporting of Maltreatment of Vulnerable Adults Act and the VA’s client specific programming. Relevant Rules and/or Statutes: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: Regarding the allegation that on April 20, 2024, the VA was not provided food: There were concerns the VA was not provided food while SP2 worked on April 20, 2024. Video recordings showed SP2 was in the kitchen and directed the VA to come into the kitchen and eat at 7:51 p.m. SP2 denied not providing the VA food, and there was no other information that showed the VA was not provided food in a timely manner. Therefore, there was a preponderance of the evidence that SP2 did not fail to provide the VA with care or services, which were reasonable and necessary to maintain the VA's physical or mental health or safety. It was determined that neglect did not occur (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding the allegation that the VA had a bruise on his/her left arm, and scratches on his/her back: On April 25, 2024, SP1 observed the VA had a bruise on his/her left arm, and scratches on his/her back. There was no information which showed the bruise was caused by a staff person, or whether the bruise occurred while personal cares had been completed. Additionally, there was also information the VA had poor balance and staff persons assisted the VA with personal cares, and at times the VA required physically guidance from staff persons. Multiple staff persons provided plausible explanations related to the scratches on the VA’s back. For these reasons, and without additional information or witnesses, there was not a preponderance of the evidence that SP1 engaged in non-accidental conduct that would be reasonable expected to cause pain or injury or how the VA obtained the injuries. It was determined physical abuse did not occur (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). Regarding the allegation that SP1 “kicked” the VA in the foot on April 24, 2024: A video recording from April 24, 2024, at 3:35 p.m., showed SP1 exited the kitchen and stepped over the VA legs and SP1 walked toward the stairs. SP1 turned around, walked back toward the VA, and again stepped over the VA’s legs. After stepping over the VA, SP1 turned around and SP1 used his/her foot to make physical contact the VA’s foot/ankle. SP1 then made an inaudible statement to the VA before SP1 used his/her foot to make physical contact with the VA’s feet a second time which was a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). The VA responded by bringing his/her legs inward, away from SP1, and SP1 walked back toward the stairs. During the recording the VA did not appear to be in pain or have an emotional response to the interaction. Although it was reported that SP1 kicked the VA and video showed SP1 had contact with the VA’s feet, given that SP1 denied kicking the VA, that video showed SP1 moving the VA’s foot and not using a kicking motion, there was not a preponderance of the evidence whether SP1’s conduct was therapeutic or could be reasonably expected to cause pain or injury. It was not determined whether 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). Regarding the allegation that on April 24, 2024, the VA walked downstairs holding his/her head after a loud noise was heard from off camera view: A video recording from April 24, 2024, at 3:46 p.m., showed the VA walked downstairs and appeared to have his/her hand on the back of his/her head. The VA walked back upstairs, and a loud noise could be heard which sounded liked “dishes banging against something.” The VA then moved back downstairs with both hands on his/her head. Shortly after the loud noise occurred SP1 walked into camera view holding what appear to be a plate or pan and put the dish in the kitchen. There was no information the VA was injured during the alleged incident; however, the IR stated the dish that caused the loud noise had potentially been used to “hit/intimidated” the VA. SP1 said the sound was caused by the dish falling, and added the dish was not used to hit or intimidate the VA. Given that there was not video of SP1 using the dish to do this, that SP1 denied the allegation, and that there was no further information or witnesses to support the allegation, there was not a preponderance of the evidence whether SP1 engaged in conduct that would reasonably be expected to cause the VA pain or injury. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were adequate but not followed. The facility provided staff persons additional training regarding the incident regarding the care and services of the VA. The report was not similar to past events. The facility took corrective action including SP2 not working at the facility in the future and installing cameras in the kitchen and stairwell. SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action to address the violations outlined in this report, a Correction Order was not issued. No further action was taken.
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