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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: 1070505-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070470-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: Allegation One: It was reported that three staff persons (SP1 – SP3) purposely antagonized a vulnerable adult (VA) to cause the VA to become upset so SP1–SP3 could discipline him/her. Allegation Two: It was reported that a staff person (SP2) pushed the VA and got into a physical altercation which caused the VA to have a sprained arm. Alleged Licensing Violation One: It was reported SP1 directed staff persons to withhold the VA’s van rides as punishment. Alleged Licensing Violation Two: It was reported SP1 and SP3 withheld the VA’s access to the kitchen, food, and drink. Date of Incident(s): Ongoing prior to May 14, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 8, 2024; from documentation at the facility and medical records; and through 13 interviews conducted with the VA, the VA’s guardians (G1-G2) who were also the VA’s family members, two supervisory staff persons (P1 and SP1), and seven staff persons (SP2, SP3, and P2-P6). The VA’s diagnoses included autism spectrum disorder and intellectual disability. The VA liked to be outside, go on van rides, play with water, watch YouTube, do puzzles, listen to music, eating, and spending time with his/her family members including G1 and G2. The VA The VA had a history of engaging in yelling and screaming, physical aggression towards others, property destruction, and self-injurious behaviors that included headbanging. The VA was prescribed an as needed (PRN) medication for agitation. Although the VA was interviewed, the VA did not provide information relevant to the allegations. Information obtained showed that there were interpersonal conflicts between staff persons. Facility documentation showed that SP1–SP3, and P1–P6 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 incident. Allegation One: It was reported that SP1 – SP3 purposely verbally antagonized the VA to cause the VA to become upset so SP1–SP3 could discipline him/her. P3 provided the following information: · SP1 “continuously corrected” and was “short tempered,” and “very stern” with the VA. P3 thought the SP ran the facility like a “boot camp.” SP1 swore to and about the VA “numerous times.” SP1 called the VA a “motherfucker” and told the VA to “keep your fucking hands off me.” SP1 also told the VA to “stop fucking grabbing” people. When talking in front of the VA, SP1 made comments about the VA such as how SP1 “didn’t give a fuck what that motherfucker gets” regarding the VA’s preferred snacks and, “That fucker is always going into the cupboards.” SP1 told others, “That motherfucker better stop.” “Once in a while,” SP1 “caught” him/herself and followed up with “just kidding.” · SP2 “swor[e]” at the VA, had a “horrible temper,” and “screamed in [the VA’s] face.” Both SP1 and SP2 “screamed” at the VA and “corner[ed]” him/her in his/her bedroom. P3 stated that during a staff meeting s/he overheard SP2 say that the VA got “agitated” and “antagonized” so the VA would “lunge” towards SP1. SP2 then “grab[bed]” the VA to “protect” SP1. SP1 later told others that SP2 “protect[ed]” him/her from the VA as “that motherfucker was going after me again.” · SP3 “nitpick[ed]” the VA about what the VA touched, where s/he was in the facility, and what s/he did. P3 stated that s/he “heard” that on one of SP3’s shifts, s/he “yell[ed]” at the VA who got “agitated” and “lunged” out. SP3 “got scared,” went downstairs, and locked him/herself in the medication room. “Finally” SP3 gave the VA a PRN and the VA went to bed. SP3 “yelled” at the VA “all the time.” SP3 “[sent]” the VA downstairs when s/he cooked in the kitchen as s/he said, “I don’t like [the VA] looking at me because it makes me uncomfortable.” SP3 told the VA, “You don’t get to look at me,” or “Don’t touch that, get out of here.” SP3 did/said this until the VA “freak[ed] out and grab[bed]” SP3 or did something else. SP3 would not leave the VA alone. · P3 believed that SP1-SP3 wanted to “punish” the VA for not doing what they thought s/he should do and each felt that the other staff persons were “babying [the VA] for not yelling at [him/her].” At a staff meeting, SP2 discussed “holding [the VA] accountable.” SP1-SP3 did not try to use other calming strategies for the VA such as using the VA’s sensory items or taking the VA on a walk. · SP1-SP3 redirected the VA’s behaviors “every five seconds” and “yelled” at him/her. SP1-SP3 also “screamed” at the VA that s/he “need[ed]” to go in his/her bedroom and “belittle[d]” the VA. SP2 told the VA s/he was “ridiculous.” The VA then repeated, “[SP2] says I am ridiculous.” SP1–SP3 each told the VA not to look at or touch items and not to say certain things. At times, the VA said, “I hate” and then SP1’s, SP2’s, or SP3’s name. SP1 told staff persons that when the VA said s/he hated a person it meant that the VA liked the person. · P3 said the VA enjoyed looking out the kitchen window to look at cows that were next door, but SP1-SP3 “screamed” at the VA “every five seconds” that s/he cannot be in the kitchen and to go downstairs. SP1-SP3 did not seem to think that their screaming at the VA caused the VA to engage in maladaptive behaviors. SP3 “yelled” at the VA “all the time” and “sent” the VA downstairs when s/he cooked in the kitchen because s/he said, “I don’t like [the VA] looking at me” because the VA “makes me uncomfortable.” P4 provided the following information: · SP1 treated the VA like “one of [his/her] kids” and told the VA, “You know better than this,” and “You know you should not be doing this.” At times SP1 swore but P4 did not remember the exact words SP1 used or whether SP1 swore at the VA or just in the presence of the VA, but the swear words were used “pretty open[ly]” around other staff persons. When this happened, the VA got “quiet” and “[took] it.” At times, the VA said, “Sorry.” · SP1 and SP2 used a “raised voice” when redirecting the VA to his/her bedroom and when they had already told the VA things “multiple times.” At times, both SP1 and SP2 used “a little bit of yelling” at the VA. · P4 talked to P1 about his/her concerns with the language used in the house and towards the VA. Then at a staff meeting, P1 stated there was “no cursing” at the facility. At one point during a meeting, SP2 said the VA needed to be “held accountable” and “disciplined” for his/her behaviors but P1 told SP2 that was not an option with the VA and the reasons why. P2 thought afterwards that SP2 was “kind of understanding it after [P1] explained.” · P4 was not aware of any time when SP3 told the VA that s/he made SP3 uncomfortable, or times when the VA was not allowed to look at SP3, was not allowed to leave, or said something unkind about the VA. P6 provided the following information: · P6 heard SP1 and SP2 “raise their voices plenty of times” at the VA and they sounded “more angry” as opposed to trying to “divert” the VA’s attention from something s/he should not be engaging in. SP1 and SP2 told the VA to “shut up” and “knock it off.” SP1 and SP2 also told the VA, “You don’t need to be freaking out like that.” · SP1 told the VA in an “angry tone,” “We’re not doing this today.” SP1 also told staff persons not to provide the VA physical comfort such as holding his/her hand after s/he got upset because it was “babying [the VA]” and “rewarding [him/her] for bad behavior.” · While SP2 was typically just “loud,” s/he became louder at the VA when the VA physically went after SP1 because SP2 was “protective” of SP1. · P6 stated that s/he never heard SP1, SP2, SP3 or any staff persons swear at the VA and was not aware of any situations where SP3 told the VA that s/he made SP3 uncomfortable, was not allowed to look at SP3, was told to leave, or said something unkind about the VA. P6 had no concerns with SP3’s interactions with the VA. P2 said that at times some staff persons used a “loud voice” with the VA. P2 heard SP1-SP3 tell the VA to use an “inside voice” several times, but it was not done “to be mean” and did not redirect the VA “excessive[ly].” P2 never heard SP1, SP2, SP3 or any staff persons swear at the VA. P2 was not aware of any situations where staff persons talked about the VA being babied, not held accountable, or needed to be disciplined or when SP3 told the VA that s/he made SP3 uncomfortable, was not allowed to look at SP3, was told to leave, or said something unkind about the VA. P2 denied s/he or anyone else ever yelled, screamed, or swore at the VA to get out of the kitchen when staff persons were cooking. P1 said in January 2024. the facility addressed concerns with “almost all” staff persons about “overcorrecting” the VA such as telling the VA s/he was not allowed to look out the windows. The staff persons received correction action and there were no concerns since. SP1 was talked to about not using his/her “[parent] voice” with the VA. SP2 talked louder than others due to a hearing issue. SP3 “got along” with the VA and was “never heard to be rude” towards him/her. P1 stated that s/he never heard SP1, SP2, SP3 or any staff persons swear at the VA and was not aware of any situations where SP3 told the VA that s/he made SP3 uncomfortable, was not allowed to look at SP3, was told to leave, or said something unkind about the VA. P5 stated that s/he never heard SP1-SP3 or any staff persons swear at the VA. P5 was not aware of any situations where SP3 told the VA that s/he made SP3 uncomfortable, when the VA not allowed to look at SP3, the VA was told to leave, or said something unkind about the VA. G1 and G2 provided the following information: · G1 and G2 thought the facility did a “pretty good job” with the VA and when the VA was “aggressive” and had an “outburst” staff persons tried to avoid “increasing the situation.” When G1, G2, and the VA were together, the VA was “eager” to go back to the facility and was “fine” to go back as s/he “like[d]” the staff persons, “some more than others.” G1 and G2 thought the VA “like[d] it” at the facility. When the VA was redirected by a staff person, the VA might say “[staff person] bad” or “[staff person] mean.” However, the VA said that “about literally everyone [s/he] knows” and “everyone who worked with [him/her].” · Staff persons told G1 and G2 that the VA was “sweet” and that they “love[d]” him/her. G1 and G2 did not hear of any situations where staff persons were upset with the VA. G1 and G2 thought SP1 “genuinely care[d]” about the VA and SP2 took the VA on walks, spoke “kindly” about the VA, showed “a lot of love and affection” towards the VA, and spent time with him/her. G1 and G2 had “very few” concerns about the facility. G1 and G2 thought the program was “well ran” and they were “happy” with it. SP1 denied swearing and yelling at the VA. Staff persons were previously talked to about general swearing in the house and since that time it was “amazing” and SP1 “never heard” any ongoing swearing or yelling from staff persons. Staff persons had been told not to swear at the facility, but it was about swearing in general and not because staff persons were swearing at the VA. SP1 stated s/he was not aware of any concerns regarding SP3 including SP3 yelling at the VA, avoiding the VA, telling the VA that s/he made SP3 uncomfortable, not allowing the VA to look at SP3, telling the VA to leave, or saying something unkind about the VA. SP2 stated that s/he heard an overnight staff refer to the VA as a mother fucker, but the VA was not around. SP2 never heard any staff persons swear at the VA. While SP2 denied swearing at the VA, SP2 acknowledged swearing when talking to the VA about whether G1 and G2 would put up with “that shit.” At times, staff persons “raise[d]” their voices so the VA could hear over his/her vocalizations. SP2 thought that yelling at the VA would only make him/her “mad” so it was “dumb” for staff persons do so. SP2 was not aware of any situations when SP3 told the VA that s/he made them uncomfortable, that the VA s/he was not allowed to look at them, that s/he did not want the VA around, telling the VA to leave, or saying something unkind about the VA. SP3 was only aware of one overnight staff person who swore at the VA. P1 was notified and it was taken care of. SP3 denied yelling or swearing at the VA and stated s/he was not aware of any staff persons including SP1 and SP2, yelling or swearing at the VA. SP3 denied that s/he wanted to “set [the VA] off.” SP3 stated that s/he did not know any staff persons who “disciplined” the VA. There was an unknown staff person who “lecture[d]” the VA about his/her interactions with staff persons that were “not nice” and asked the VA to “apologize” to staff persons for his/her behaviors. SP3 denied s/he told the VA s/he was now allowed to look at SP3 or that the VA needed to “get out” of the area. Conclusion for Allegation One: Regarding SP1’s interactions with the VA: Information from P3, P4, and P6 was consistent that SP1 yelled and/or swore at the VA. However, P1, P2, P5, SP2, and SP3 each denied hearing SP1 yell or swear and SP1 denied the allegations. While it was possible that P3, P4, and P6 witnessed different interactions SP1 had with the VA that were not observed by others, given the interpersonal conflicts between staff persons, the credibility of the information provided was not able to be determined. Therefore, there was not a preponderance of the evidence whether the SP1’s interactions with the VA produced or could reasonably be expected to produce emotional distress to the VA. Regarding SP2’s interactions with the VA: Information from P3, P4, and P6 was consistent that SP2 yelled and/or swore at the VA. However, P1, P2, P5, SP1, and SP3 each denied hearing SP2 yell or swear and SP2 denied the allegations. While it was possible that P3, P4, and P6 witnessed different interactions SP2 had with the VA that were not observed by others, given the interpersonal conflicts between staff persons, the credibility of the information provided was not able to be determined. Therefore, there was not a preponderance of the evidence whether the SP2’s interactions with the VA produced or could reasonably be expected to produce emotional distress to the VA. Regarding SP3’s interactions with the VA: P3 stated that SP1 yelled and swore at the VA. However, P1, P2, P4, P5, P6, SP1, and SP2 each denied hearing SP3 yell or swear and SP3 denied the allegations. While it was possible that P3 witnessed different interactions SP3 had with the VA that were not observed by others, given the interpersonal conflicts between staff persons, the credibility of the information provided was not able to be determined. Therefore, there was not a preponderance of the evidence whether SP3’s interactions with the VA produced or could reasonably be expected to produce emotional distress to the VA. It was not determined whether emotional abuse occurred (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). Allegation Two: It was reported that SP2 pushed the VA and got into a physical altercation which caused the VA to have a sprained arm. SP1 provided the following information: · On May 14, 2024, the VA had behaviors “all day” including screaming and biting. Around 2:30 to 3 p.m., the VA was in his/her room yelling. SP1 went downstairs to tell the VA it was time for a snack. SP2 was downstairs in the medication room on the opposite end of the hallway from the VA’s bedroom. At that time, the VA’s bedroom did not have a door because the VA recently “ripped” it off. · As SP1 approached the VA’s bedroom doorway, the VA’s left arm “came around the door” and “grabbed” SP1’s sweatshirt. As the VA “[tried]” to grab SP1, s/he incidentally “punched” SP1 in the face. The VA grabbed SP1’s “chest,” and attempted to “yank” SP1 into the VA’s bedroom. SP1 put his/her feet “against the wall” on the other side of the door frame and braced him/herself from going into the VA’s bedroom. The VA continued to “pull” on SP1. · SP1 either called out for “help” or for the VA to “let go” and SP2 came out of the medication room towards them. SP2 approached SP1’s right side and went into the area of the door frame. SP2 put his/her arms “up between” the VA’s arms and the doorframe in an attempt to get the VA to loosen his/her grip on SP1’s sweatshirt and release it. SP1 denied that SP2 pushed, pulled, or hurt the VA. · When the VA let go of SP1’s sweatshirt, the VA “sprang backwards” into the bedroom, in the direction the VA was pulling SP1. In the process, the VA “grab[bed]” onto SP2 and they “tumbled” into the bedroom and “slipped” on a pair of pants that were on the floor. The VA “fell” at the foot of the bed “kind of hitting [his/her] head.” landing with “all [of his/her] weight on [his/her] arm.” SP2 landed towards the VA’s feet. SP1 said it happened “superfast.” · When SP1 and SP2 tried to help the VA up, the VA “kick[ed]” at them, so they “backed up.” Around this time, P2 came downstairs to see what was happening. “Shortly thereafter” the VA stood, s/he was “pretty agitated” and screamed and bit him/herself so s/he was offered a PRN. The VA said his/her arm hurt so the VA was administered Tylenol and ice for it. Throughout the afternoon, the VA continued to complain about arm pain, so SP1 and SP2 took the VA to the emergency room. The VA’s medical records stated that the VA did not have any fractures and s/he was instructed to take Tylenol or ibuprofen for “discomfort” and use ice for “swelling.” SP2 provided the following information: · On the day of the incident, at 3 p.m. when SP2 arrived at the facility, the VA was in his/her bedroom so SP2 went downstairs to be near the VA. The VA was “anxious” for snack and was “loud… biting [him/herself], [and] pound[ing] on the wall.” SP2 reassured the VA that “snack was coming” and s/he tried to “distract” the VA by talking about the evening’s plans. · Around 3:30 p.m., the VA was in his/her bedroom and SP2 was on a couch when SP1 came downstairs and walked towards the VA’s bedroom. As SP1 got close to the VA’s bedroom, s/he said, “It’s time for snack.” · Shortly after, SP2 heard SP1 called out for “help.” SP2 went to the VA’s bedroom and saw that the VA was in his/her bedroom “around the corner,” and s/he had reached with both hands and “grabbed” onto SP1’s sweatshirt on the chest area. · SP1 was in the hallway “against the wall,” using “one hand on the wall as leverage” to stop the VA from pulling him/her into the bedroom and his/her other hand to try to “push” the VA’s hands off of SP1’s sweatshirt. The VA “pull[ed]” on SP1 and “planted [his/her] feet” which was not typical for the VA. SP2 asked the VA, “What are you doing?” and then went around SP1 into the VA’s bedroom to approach them from the side. SP2 then tried to “separate[e]” the VA from SP1 by “spreading them apart.” · SP2 tried to get in his/her hands between the VA’s fist and SP1’s sweatshirt but the VA had a “death grip” on SP1. SP2 “tr[ied] to do a pressure point” on the VA’s fingers using his/her thumb to get the VA to release. SP2 “pushed on everything” until s/he pushed “in between one of [the VA’s] knuckles” and the VA “let go” of SP1 hitting SP1 in the face. The VA then took his/her free hand and grabbed on to SP2's shirt and “latched” on while the VA’s other hand still pulled on SP1. · “For the 100th time,” SP1 told the VA to “let go” and the VA did causing SP1 to go backwards away from them. The VA then reached to grab SP2 with his/her other hand. When the VA let go of SP1, SP2 was “off balance” so they “shot backwards” as if “slingshot[ted]” by the VA’s body movement and “momentum.” · As they fell further into the VA’s bedroom, the VA “tripped” on clothing that was on the floor and the VA and SP2 landed on the foot of the VA’s bed, with SP2 falling into the VA’s lap. The VA and SP2 then “bounced” off the bed and the VA landed “against the wall” on his/her side “bumping” his/her head on the wall. SP2 landed by the bed near the VA’s feet. The VA and SP2 were “tangled up . . . in a pile” on the floor. · SP2 stood and the VA “tried to kick” him/her. SP2 then tried to help the VA stand but s/he kicked at SP2 again. SP2 asked the VA if s/he was okay, and the VA stood. SP1 and SP2 left the bedroom and got the VA a PRN medication and administered it to the VA. After the VA calmed s/he said his/her arm hurt. SP1 and SP2 took the VA to the emergency room where the doctors said the VA was fine. P2 provided the following information: · On the day of the incident, P2 worked with SP1 and SP2. Around 3:30 p. m., P2 was on the main level of the facility documenting and about to leave when s/he heard a “loud bang” and his/her name was called from downstairs. P2 went downstairs and saw SP1 by the VA’s doorway, but did not see the VA or SP2. · P2 walked to the VA’s bedroom and saw the VA lying on the floor, but P2 did not recall how the VA was lying. SP2 was standing next to the VA leaning over him/her, trying to help the VA stand and the VA kicked at SP2. SP2 was eventually able to help the VA stand and the VA “calmed” and went upstairs. P2 thought the VA might have been administered a PRN. Once upstairs, the VA said s/he had pain in a location P2 could not remember and the VA was given an ice pack. · SP1 and SP2 then each told P1 information about the incident that was consistent with the information each provided during their interview. When P2 left the facility, the VA was “okay” and was sitting on the couch next to SP2. P3 provided the following information: · On May 15, 2024, at 7 a.m., P3 arrived at the facility and SP1 was working. At that time, P3 read that the previous day the VA got into an “altercation” with SP1 and SP2 and was taken to emergency room. SP1 then asked P3 to take the VA to urgent care to re x-ray the VA’s arm because the night before the emergency room said it was “too swollen” to get a “proper x-ray.” P3 had concerns that the VA’s injury was not accidental and that SP2 went into the bedroom and “restrain[ed] [the VA] or push[ed] [him/her] down on the floor” “smashing” the VA’s. · As P3 got the VA ready to go to urgent care, the VA said, “[SP2] pushed me down” and that his/her shoulder and arm hurt. · P3 never saw SP2 push the VA, but “twice” in meetings SP2 talked about doing so. SP3 stated that on May 15, 2024, s/he worked at the facility with SP1. SP1 was “upset and crying” about what happened the previous day with the VA. SP1 provided information about the incident to SP3 that was consistent with the information SP1 provided during his/her interview. SP3 did not have concerns regarding SP1’s or SP2’s physical interactions with the VA. P4 said the VA and SP2 got along “pretty good,” and s/he never saw SP2 be “aggressive” or “confrontational” with the VA. P5 thought SP2 was “gentle and calm” with the VA. P5 “never” saw SP2 be aggressive towards the VA. G1 and G2 provided the following information: · When the VA physically aggressed towards a person it was best to block, “shield yourself,” and “push to deflect [the VA] to one side.” While the VA did not make untrue statements, s/he might “piece items together” from different events, so it should be “corroborated.” If something did happen to the VA, s/he would say it “a lot,” repeat it, and “obsess” on it. I · On an unknown date in May 2024, SP1 called and said the VA had a “fit,” but did not provide additional details but stated the VA “tripped” and “fell” on his/her arm. Because the VA complained of pain, staff persons were taking the VA to the emergency room. SP1 said at that time, the VA’s arm appeared “fine” and “not broken.” The VA’s arm was not broken, but “might have been a “muscle pull or ligament sprain.” · The following Sunday, G1 and G2 saw the VA and at that time the VA had no bruises that looked unusual or that someone had grabbed him/her. The VA still complained about his/her arm “hurting” and it appeared as if it were “sore” because the VA avoiding using it or lifting things and had “trouble bearing weight on it.” When G1 and G2 asked the VA what happened, the VA said s/he “fell down.” The VA continued to “complain for a couple of weeks” about his/her forearm hurting. Conclusion for Allegation Two: Information was consistent that on May 14, 2024, in the afternoon, the VA physically aggressed towards SP1 and then SP2 resulting in a physical incident between SP1, SP2, and the VA, which caused the VA and SP2 to fall to the floor. After the incident, the VA complained of arm pain and was taken to the emergency room where his/her x-rays showed no fractures. Although P3 said that the VA told him/her that s/he was pushed by SP2, P3 was not at the facility during the incident and SP1’s and SP2’s accounts of the incident to multiple people at different times were consistent and were consistent with the others account. It was also reasonable that the VA might interpret parts of the incident as being pushed as SP1 and SP2 attempted to remove the VA’s hands from SP1’s and SP2’s respective clothing. Given that the VA was physically aggressive towards SP1 and SP2 it was reasonable and necessary for them to intervene with the VA’s actions. In addition, despite having fallen to the floor, their consistent accounts of their actions during the incident were reasonable and SP3, P4, and P5 had no previous concerns regarding SP2’s physical interactions. Therefore, there was a preponderance of the evidence that SP2 did not push the VA or engage in actions that were not therapeutic conduct. It was determined that 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). Alleged Licensing Violation One: It was reported SP1 directed staff persons to withhold the VA’s van rides as punishment. G1 and G2 said if the VA had a “bad day or bad morning” or was being physically aggressive, staff persons did not bring him out into the community. If the VA was upset while in the van, s/he could make it “dangerous” and try to “grab” the staff person driving. At times, the VA was able to “instantly” stop his/her behaviors, but other time it could take an hour. P1 said that the VA was “not restricted” from van rides due to his/her maladaptive behaviors, the VA needed to have one hour of not having behaviors for the “safety” of persons in the van. In May or June 2023 SP1 texted staff persons that the VA was not able to go on a van ride because s/he was “naughty over the weekend.” P1 told SP1 that the VA’s van rides were not to be restricted that way and P1 believed it was no longer an issue. P2 said the VA went out on a van ride almost daily. When the VA had a maladaptive behavior prior to a ride, staff persons waited an hour for the VA to calm before they left. P2 was not aware of any situations where the VA was to wait longer than an hour or a time when van rides were withheld due to the VA’s behaviors one to two days prior. P3 said that during a staff meeting, SP2 told others that the VA needed to be “held accountable” and when the VA was “naughty” s/he should not get van rides for three days. When the VA was “crabby” towards SP2 over the weekend, s/he was not allowed to go on a van ride on Monday. P4 was not aware of any amount of time the VA needed to have between demonstrating a maladaptive behavior and going on a van ride. Typically P4 asked SP1 for approval prior to taking the VA on a van ride and if the VA had hit walls or bitten him/herself that day, SP1 said they would not be able to do a van ride because the VA’s behaviors usually got “worse” when they came back. P4 said, “Every couple months,” or “every so often” SP1 said no to van rides if the VA grabbed staff “a day before” or “a few days before.” SP1 told P4 that s/he thought if the VA went on van rides it caused “more behaviors” that week. P5 said that staff persons were to wait one hour after the VA demonstrated a maladaptive behavior to ensure s/he was calm and safe before going on a van ride. P5 was not aware of any situations where staff persons denied the VA a van ride due to behaviors the previous day. P5 took the VA on a van ride “every day I work” and there were only two days a week P5 did not work. P6 said s/he did not deny the VA a requested van ride unless s/he was demonstrating a maladaptive behavior. P6 waited “twenty minutes” after the VA’s maladaptive behavior to ensure the VA was calm prior to taking the VA in the van. At times, P6 was told by SP1 that the VA would not go out on a van ride today because s/he had “behaviors” earlier that day, even though the VA appeared calm at the time. P6 was never told the VA was not able to go on a van ride for a behavior that happened a previous day. SP2 said that the VA was not able to go on a van ride if s/he had a maladaptive a behavior within the previous hour and had not yet “calm[ed] all the way.” Once an hour passed and the VA was calm, the VA could go on a ride. SP2 was not aware of the VA being denied van rides for behaviors on previous days. SP3 said the VA might not be able to go on a van ride if s/he had a “situation,” but it “depend[ed] on the circumstances” and it might be denied for “safety[’s] sake.” The VA needed to be calm for one hour before going on a van ride. SP3 was not aware of the VA being denied van rides for behaviors that happened a day or so prior. SP1 provided the following information: · Staff persons tried to get the VA out in the community daily including going on van rides. · If the VA was upset, there was a risk to him/herself and others if they were in the van because the VA had previously “grabb[ed]” onto the steering wheel. The VA was to be without maladaptive behaviors for “15 to 30 minutes” prior to going in the van. SP1 said it was up to the staff person’s “judgement or comfort zone,” but was not aware of any specific information in the VA’s plans. (Note: A review of the VA’s plans showed that there was nothing in the VA’s plans regarding this.) · SP1 denied not allowing the VA to go into community when s/he had behaviors the previous day and denied that van rides were being withheld longer than 30 minutes after a behavior. SP1 did not think s/he sent text messages stating as such, but if s/he did, it was “a long time ago… months” when s/he did not know staff could not deny such things. Once SP1 was told that withholding van rides was not allowed they no longer were withheld. A text message dated June 7, 2023, from SP1 sent to staff persons stated, “Until further notice we will not be doing van rides for [the VA]. Due to [him/her] grabbing staff and having many behaviors. Thank you.” One staff person responded, “Thank you for letting us know!” and another staff person responded, “Sounds good.” On November 16, 2023, SP1 sent a text stating, “[the VA] will not be going tomorrow… [s/he’s] not been good the last 2 days.” Relevant Rules and/or Statutes: Minnesota Rules, part 9544.0060, subpart 2, item J, states in part that using punishment of any kind is prohibited. Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (15), states that a person’s protection related rights include the right to engage in chosen activities. Conclusion for Alleged Licensing Violation One: While it was reasonable for the safety of staff person and the VA that staff persons wait a period of time (20-60 minutes as described) after the VA had a maladaptive behavior for the VA to be calm prior to going in the van, information showed that on more than one occasion SP1 text staff persons that the VA was not to go on a van ride because s/he had maladaptive behaviors that day and/or prior days. P1 was aware of the first text (June 7, 2023) and stated s/he addressed it with SP1, yet a second text was sent on (November 16, 2023). SP1’s instructions to withhold van rides/activities from the VA due to his/her behavior, after the VA had been calm for a period of time, were violations of Minnesota Rules, part 9544.0060, subpart 2, item J and Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (15). A licensing violation was determined. Alleged Licensing Violation Two: It was reported SP1 and SP3 withheld the VA’s access to the kitchen, food, and drink. G1 and G2 said the VA was unable to control his/her food intake so a rights restriction was put into place. The VA was able to go into and out of the kitchen as s/he wanted and got “regular snacks.” The VA used a cup by the kitchen sink for water and there were no limits on his/her intake. P1 andSP1, and the VA’s facility documentation, provided information that the VA did not have any rights restrictions in place. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b), clauses (3), (5), and (6) states in part that a person’s protection related rights include the right to: · have use of and free access to common areas in the residence; · have access to three nutritionally balanced meals and nutritious snacks between meals each day; and · have freedom and support to access food and potable water at any time. Regarding the VA’s access to the kitchen: P3 said the VA enjoyed looking out the kitchen window at the cows next door and when the VA did so, SP1 to SP3 “screamed” at the VA “every five seconds” that s/he cannot be in the kitchen and to go downstairs. SP3 “[sent]” also the VA downstairs when s/he cooked because s/he said, “I don’t like [the VA] looking at me” because the VA “makes me uncomfortable.” P1 said that because the kitchen was “small,” when the VA went into it, staff persons were to exit because staff persons could be “cornered real quick.” In the past, staff persons had told the VA s/he was not allowed in the kitchen, but when P1 learned of this, staff persons were told that the VA was allowed in the kitchen and P1 thought it no longer occurred. After informing staff persons, P3 continued to tell P1 that staff persons were not allowing the VA in the kitchen. P1 thought P3 misheard heard staff persons so did not follow up with other staff persons. P2 said when staff persons made food in the kitchen, they “tried not to let [the VA] look into the kitchen.” The VA “stared” at the cooking food from the “outer edge” of the doorway but did not enter the kitchen on his/her own. At times as staff persons cooked, the VA got “louder and louder,” so staff persons asked the VA to “calm” and that they would let him/her know when the food was “ready.” P4 said when staff persons cooked the VA food, staff persons redirected him/her to “not look” in the kitchen and to go watch TV. P4 had not heard staff persons tell the VA s/he could not be in the kitchen. If the VA came into the kitchen, s/he was asked to “have a seat” while the food was being prepared. P5 said the VA and staff person were not to be in the kitchen at the same time because it was “very easy” for a staff person to be “trapped” by the VA due to the layout. P5 was not aware of staff persons keeping the VA out of the kitchen and telling the VA s/he was not allowed in there. P6 said that due to the VA’s “food obsession” and attempts to grab and eat food out of hot pans, the VA was not allowed in the kitchen while staff persons cooked. When P6 cooked, s/he asked the VA to “step out.” The VA handed it “sometimes very well” or might “kind of blow up.” SP1 said staff persons were to “limit” the VA being in the kitchen when they cooked food because there was a concern due to the layout of the kitchen that if the VA was physically aggressive while in the kitchen, a staff person could be “trapped” in the corner. SP1 said that even with risk when staff persons were cooking, the VA was able to come in and get water if s/he wanted. If the VA came in, staff persons were to move out of the VA’s way and have a route to leave if needed. SP1 was now aware of any staff persons telling the VA s/he could not be in the kitchen. SP2 said when staff persons prepared “hot” food items, it was “preferred” for the safety of staff persons and the VA, that the VA was not near the oven or drawers with sharp items. The VA got “irritate[d]” when s/he was in the kitchen and was not able to eat food and the VA could come into the kitchen for something to drink. If staff were cooking, after the VA got a drink s/he was then “ask[ed]” to step out while staff persons cooked. The VA responded to this “fine” and SP2 never saw the VA get mad or “react negatively” when asked to step out of the kitchen. SP3 said when meals were being prepared, the VA might get “fixated” on the food so staff persons tried to “distract” and keep the VA “busy” away from the kitchen. When SP3 cooked, s/he “redirect[ed]” the VA out of the kitchen for his/her and the VA’s safety. The VA was usually “fine” with it and “walk[ed] away.” Regarding the VA’s access to food: P3 provided the following information: · The VA was “short[ed]” on meals which caused him/her to be “angry.” Despite the facility having “plenty” of the VA’s favorite snack, when the VA was “loud… stomped… or punched the wall,” SP1-SP3 “refused” to give the VA a snack. SP1-SP3 told staff persons the VA “does not deserve it” because s/he was “yelling” and being “loud.” · SP3 did not want to give the VA his/her food on schedule and s/he said, “I don’t think it’s right,” despite it causing the VA to become upset. SP3 also tried to give the VA “smaller rations of everything” despite the portion size being listed on the menu. P3 thought SP3 limited the VA’s food “out of spite.” · When the VA wanted multiple dipping sauces for his/her food, SP3 told other staff persons the VA was only allowed “one or the other.” SP3 said, “[The VA] doesn’t deserve or need it,” and SP1 and SP2 agreed. At one point, there was a meeting about the VA’s food and portion sizes and the expectations for staff persons was clarified that staff persons could not change the “rules” about the VA food and portions. · SP1 told staff persons that the VA needed to be “sugar free” because sugar caused the VA to have maladaptive behaviors and so SP1 planned to “just stop buying [it]” which included the VA’s “favorite snack.” P1 provided the following information: · The VA was “obsessed” with food and received three snacks and three meals a day. The VA was “always hungry” and ate the point of stomach pains and at times became constipated. The VA also ate uncooked items like raw meat if able. In between meals and snacks, staff persons encouraged the VA to wait to eat and offered the VA activities to do. Staff persons used “portion control” with the VA based on the package serving sizes and the VA received seconds on “veggies and fruit.” · P1 was not aware of any staff persons limiting the VA’s access to food or denying the VA his/her desired food as a result of his/her maladaptive behaviors. · On one occasion, P1 heard that SP3 limited the number of sauces the VA received at mealtimes. SP1 talked with SP3 about it and SP3 said it was a “fluke” and that it happened “one time.” P1 was not aware of it happening since. · P1 said that while the VA had no rights restriction for food, there “was no sugar” at the facility because sugar increased the VA’s maladaptive behaviors. There was no medical order for this, but G1 and G2 agreed because they noticed it too. P2 was not aware of any staff person denying the VA his/her preferred snacks or limiting the VA’s portions due to his/her maladaptive behaviors and denied doing so. P2 “heard something” a “he said, she said” that the VA would not get jelly because it “cause[d] behaviors,” but did not hear anything about the VA not getting sugar. P4 was not aware of staff persons limiting the VA’s access to food or that sugar caused the VA to have maladaptive behaviors. P4 heard from P3 about staff persons withholding food, but never saw it occur.
P5 said the VA was “always hungry” and was given fruit in-between meals and snacks so his/her “hunger doesn’t upset [him/her].” P5 was not aware of the VA being denied food due to maladaptive behaviors. The facility did not have sugar in the house and was not aware of staff persons denying the VA sugar items due to it causing maladaptive behaviors. P6 said that one time the VA was eating at the table when SP1 told the VA that s/he was “done hooting and hollering” and then threw away the VA’s food. P6 was not aware of any staff persons limiting the VA’s portion sizes. P6 heard from others about the VA not having sugar because it “amped” the VA up but P6 never heard about a no sugar rule. P6 was not aware of any staff persons withholding snack or food from the VA due to his/her maladaptive behaviors. SP1 provided the following information: · The VA had a “very bad obsession with food.” When the VA smelled food cooking, s/he expected it to be available to eat at that moment. Staff persons explained to the VA that s/he cannot eat raw meat and tried to distract the VA with an activity including a van ride or walk. · SP1 was not aware of any staff persons denying the VA food or snacks due to his/her maladaptive behaviors. One time, a staff person asked SP1 if the VA should have a snack “even though” s/he had a maladaptive behavior, and SP1 said, “Always, yes.” SP1 denied telling staff persons s/he planned to stop buying the VA preferred snacks and the VA “never goes without” those items. · SP1 talked to G1 and G2 about a pattern s/he observed that when the VA drank soda s/he did not sleep and was “screaming at three in the morning sometimes.” There were conversations about tracking the VA’s sugar intake and comparing it to behaviors, but there were no attempts to reduce or eliminate sugar. · On one occasion, SP3 said there was an issue with the sauces that the VA given, either it was out or “something happened,” so the VA did not get both sauces s/he wanted. There was a “big uproar” about it and the facility now portioned out the sauces to avoid the issue happening again. SP2 provided the following information: · The VA had set food times and SP2 was not aware of any staff intentionally ignoring or not following it. At time when the VA’s food might be a few minutes late, SP2 explained to the VA and let the VA know when the food would be ready. The VA responded “pretty well.” · The VA’s food was portioned but SP2 thought the VA should have more due to his/her size. At times, the VA said, “It hurts,” and SP2 thought it was possible this was hunger pains and the VA did not know how to express it. SP2 was not aware of any staff persons withholding the VA’s food and denied withholding food from the VA. SP3 provided the following information: · The VA “lov[ed]” food, was “hungry all the time,” and was never “satisfied” even when s/he had just eaten a full meal. The VA was offered gum, fruit, and Veggie Straws in between meals and snacks. · SP3 was not aware of staff persons limiting the VA’s portions or withholding food from the VA due to maladaptive behaviors and denied having done so. Sugar caused the VA to be “all hopped up” and caused an increase in maladaptive behaviors, so “less is better.” Regarding the VA’s access to drinking water: P3 said s/he was told by SP1 that the VA drank “too much water” and the VA was put on a “fluid protocol,” which was actually to keep the VA out of the kitchen and away from the sink. The VA was given smaller glasses of water and juice but had no medical order to restrict fluid. P1 felt the VA might be “flushing out [his/her] meds” due to the amount of water s/he drank. When the VA drank “a lot” of water s/he had “more behaviors.” P1 said that when staff persons “limited” the VA’s water intake the VA had “less behaviors.” P1 also said that staff persons did not “restrict water,” but “monitored” the VA’s water intake. P1 denied that the VA was intentionally given smaller cups. P2 said the VA often went into the kitchen to drink water. P2 only saw staff persons try to limit the VA’s water intake when s/he was “uncontrolled going and going for water.” P4 was not aware of any staff persons telling the VA s/he was not able to drink water when s/he wanted some. At one point, SP1 told staff that s/he thought with the amount of water the VA drank, that the water “washed out” the VA medications but after the VA had a doctor appointment, they were told that the VA would need to drink a gallon of water a day for the water to impact the VA’s medications. P5 did not see any staff person prevent the VA from drinking water. The VA went into the kitchen to drink water “all day.” P6 did not see staff persons limit the VA’s water intake, but at times staff persons suggested to the VA to wait a while because s/he drank “a lot” of water at one time. SP1 said the VA “slammed a lot of water.” At one point, SP1 questioned whether this “flushed” out the VA’s medications, so the VA’s doctor was consulted and there were no concerns. SP1 was no aware of any staff persons denying the VA access to drinking water. SP2 was not aware of any staff persons preventing the VA from drinking water when s/he wanted. SP3 said the VA drank milk and juice at mealtimes and drank as much water as s/he wanted. Conclusion for Alleged Licensing Violation Two: Regarding the VA’s access to the kitchen: Although P3 said that SP1-SP3 did not allow the VA in the kitchen, all other information obtained showed that the VA was redirected out of the kitchen when staff persons prepared food for the safety of the VA and the staff person preparing food and that the VA was able to come into the kitchen for drinks during the times staff persons were cooking. Given that the VA had a history of physical aggression towards staff persons and the tight space of the kitchen it was reasonable that while staff persons were cooking, they might redirect or encourage the VA away from the kitchen. Therefore, a licensing violation was not determined. Regarding the VA’s access to food: Although P3 stated that at times the VA was not given enough food, was denied food as a result of maladaptive behaviors, and/or was not allowed sugar, all other information obtained showed that the VA was given meals and snacks and fruits/vegetables in between meals and snacks and that the VA was not denied food when s/he had a maladaptive behavior. In addition, P1 stated that G1 and G2 were in agreement to limit the VA’s sugar intake because it was noticed that sugar increased the VA’s maladaptive behaviors which was reasonable. Therefore, a licensing violation was not determined. Regarding the VA’s access to drinking water: Information obtained showed that while at times the VA’s water intake was monitored, there was no information provided that showed the VA was not allowed access to drinking water when s/he wanted it. Therefore, a licensing violation was not determined. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed, and that there was no additional action needed to protect the health and safety of the VA. Action Taken by Department of Human Services, Office of Inspector General: On December 4, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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