|
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: 1078723-AFC (Adult Foster Care) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that when a supervisory staff person (SP) assisted a vulnerable adult (VA) into the facility, the VA sat on the ground and hit the SP on the arm. The SP then slapped the VA on his/her arm and grabbed his/her chin and told the VA that the VA hurt the SP when s/he hit the SP. Date of Incident(s): July 3, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision2, paragraph (b), clause (1): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 16, 2025; from documentation at the facility; and through four interviews conducted with a facility staff person (P), the VA’s therapist (T), the SP, and the VA’s guardian (G). The VA enjoyed listening to music, going on car rides, spending time outside, watching videos, going on community outings, and spending time with his/her family members. The VA’s diagnoses included severe developmental disabilities, Lennox-Gastaut syndrome, epilepsy, and idiopathic scoliosis. The VA was non-verbal and unable to communicate his/her wants and needs through speech. The VA’s Coordinated Service and Support Plan Preliminary Addendum stated that the VA had a high pain tolerance and sometimes grabbed, hit, and pinched others as a form of communication. The VA had no understanding of danger and might reach for items that were dangerous. The staff persons assisted the VA with walking by having one hand at his/her waist and the other by his/her arm in case the VA lost his/her balance. The staff persons could block or redirect the VA’s limbs or body for less than 60 seconds without holding or limiting the VA’s movement in order to interrupt a behavior that might result in an injury to him/herself or others. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA had a history of grabbing others and causing wounds, bruises, and scratches. When the VA became agitated, the staff persons were trained to try to remove the VA from the situation and remind the VA to be gentle and use appropriate actions. If it was not possible to stop the VA from hitting or grabbing, the staff persons could hold the VA’s hands or deflect the VA’s arms. The VA sometimes fell to his/her knees when s/he did not want to do something, causing scrapes and bruises to his/her knees. The VA’s Individual Resident Placement Agreement stated that the VA had an aversion to certain sounds and objects, such as vacuum cleaners, saws, cement mixers, post hole grinders, and lawn mowers. The staff persons were to assist the VA away from areas where those items were being operated. The T provided the following information: · On July 3, 2025, while the T was in the facility, s/he looked out a window and saw the VA and the SP walking “arm in arm” from the facility’s vehicle to the facility. The VA sat on the ground and the SP tried to get the VA to stand and continue walking. The VA walked a short distance and then sat on the ground again. When the VA and the SP were between ten and fifteen feet from the facility, the P opened the door to the facility so that they could enter. The T did not see the VA do anything to the SP, but s/he heard the SP say, “That hurt.” The SP also told the VA that “it’s not funny.” The SP “grabbed” the VA’s arm and “slapped” his/her left arm. The T heard the sound of the slap. The VA did not appear to react to the slap. The SP then held the VA’s chin and turned the VA’s head towards the SP while s/he talked to the VA. The SP “roughly” pulled the VA to a standing position and led him/her into the facility. · The VA sat in a chair and the SP brushed the VA’s hair with his/her hand and sang to the VA. The VA avoided making eye contact with the SP. The T then worked with the VA for approximately thirty minutes. The VA was not very engaged with the T and appeared “more shut down.” The T stated that the VA did not always make eye contact with the T or appear engaged, but sometimes laughed and smiled when s/he was having a good time. The P told the T that the incident was “unsettling to watch.” After the incident, the T did not see any mark on the VA’s left arm, but stated that s/he “wasn’t looking.” The P stated that on July 3, 2025, s/he was working at the facility when the SP and the VA returned to the facility from a community outing. There was a cement truck running in the driveway because construction workers were pouring concrete in the facility’s back yard for fence posts. The P stood at the facility’s door as the SP led the VA toward the facility. The VA sat down and hit the SP’s arm. The SP “batted” the VA’s hand away because s/he wanted to divert the VA and help him/her into the facility. The P did not believe the SP’s action was a “slap,” but rather an attempt to redirect the VA. The VA was “irritated and intrigued” by the loud noises made by the cement truck. The P had no concerns about the SP’s interactions with the VA. The SP provided the following information: · On the day of the incident, at approximately 12:15 p.m., the VA and SP arrived at the facility and walked up the driveway. There was a cement truck and a construction worker’s pickup truck in the driveway. The workers were putting a fence in the back yard and it was very noisy and “chaotic.” Loud noises often bothered the VA. The VA tried to grab the mirror on the pickup truck and then tried to get into the pickup truck while the SP attempted to move the VA away from the trucks. · The SP held the VA’s waist and turned the VA away from the trucks and toward the facility. The VA dropped to his/her knees and grabbed the SP’s arm with his/her left hand and tried to hit and pinch the SP with his/her right arm. The SP “pushed” the VA’s arms away, used his/her hand to move the VA’s face away from the construction workers and toward the SP, and told the VA to look at what s/he did to the SP’s arm. The SP did not recall telling the VA that “it wasn’t funny.” · The SP helped the VA to his/her feet and walked to the facility with his/her right hand on the VA’s back and his/her left hand on the VA’s waist or left arm. The SP stated that s/he did not slap the VA during the incident. · The VA was “really strong” and “liked to pinch.” The VA had a high pain tolerance and when s/he pinched or hit a staff person, they tried to show the VA what s/he did and help the VA understand that s/he caused pain. The VA did not like loud noises and the staff persons tried to redirect the VA away from tools or equipment like lawnmowers that made loud noises. The G stated that s/he had no concerns about the care the VA received at the facility. Facility documentation showed that the SP and the P 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. Conclusion: On July 3, 2025, the VA and the SP arrived at the facility and walked to the facility’s door. The VA became distracted by a cement truck and a pickup truck in the driveway and attempted to enter the pickup truck. The SP redirected the VA toward the facility and the VA dropped to his/her knees and hit the SP on his/her arm with one hand and attempted to hit and pinch the SP with his/her other hand. The T stated that the SP slapped the VA on his/her arm and that the T heard the sound of the slap. The P did not believe the SP’s action was a “slap,” but rather an attempt to redirect the VA. The SP stated that s/he pushed the VA’s hand away from him/her because the VA hit the SP and was attempting to do so again. Consistent information was provided that the SP held the VA’s chin and moved the VA’s head so that s/he looked at the SP rather than the trucks and told the VA that s/he hurt the SP. The SP stated that when the VA pinched or hit a staff person, they tried to show the VA what s/he did and help the VA understand that s/he caused pain. Although the T stated that the SP slapped the VA’s arm, given that the P and the SP each stated that the SP did not hit the VA’s arm, but instead pushed the VA’s arm away from the SP as the VA tried to hit and pinch the SP and that no information was provided that the VA sustained an injury during the incident, there was not a preponderance of the evidence whether all of the SP’s actions were therapeutic conduct or could reasonably be expected to produce physical pain or injury or emotional distress to the VA. 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 that the facility’s policies were adequate and were followed by the staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
