|
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: 1093318-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071943-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that a staff person (SP) placed a vulnerable adult (VA) in a restraint, and the VA was later diagnosed with a fractured arm. Date of Incident(s): On or around September 9, 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 site visits conducted on September 30, and October 5, 2025; from documentation at the facility, law enforcement (LE) records, and medical records; and through four interviews conducted with the VA, a facility supervisor (P1), the VA’s guardian (G), and the SP. Facility documentation showed the VA enjoyed socializing with peers and being out in the community. The VA had a good sense of humor and was able to articulate his/her wants and needs. The VA was diagnosed with developmental disabilities, autism disorder, and cerebral palsy. The VA had a history of verbal aggression such as swearing, yelling, name calling, or making loud generally negative comments for everyone to hear about a certain situation or person. The VA also had a history of physical aggression, property destruction, and self-injurious behaviors. The VA’s Individual Abuse Prevention Plan showed the VA was at risk for physical abuse. The facility’s Emergency Use of Manual Restraints (EUMR) Policy stated: · “Emergency use of manual restraint” means using a manual restraint when a person poses an imminent risk of physical harm to self or others and when it is the least restrictive intervention that would achieve safety. Property damage, verbal aggression, or a person’s refusal to receive or participate in treatment or programming on their own did not constitute an emergency. · The policy also provided strategies to de-escalate a person’s behavior, and techniques to complete restraints. The following information was consistent from medical records, law enforcement (LE) records, the facility’s Internal Review (IR), and interviews completed by this investigator: · A timeline of the VA’s pain/diagnosis:
o On September 5, 2025, the facility nurse completed a nursing assessment of the VA and there were no observed concerns. o On September 6, 2025, the VA complained of shoulder pain and the facility nurse was notified of the pain. Staff persons were instructed to provide the VA with pain medication, ice the area, and continue to monitor the pain. § P6 said s/he arrived at the facility on September 6, 2025, and the SP left the facility shortly after. The VA was in the kitchen with his/her pants down, and yelling. P6 waited until the VA was calm, and the VA complained that s/he had pain in his/her arm, and the VA said, "I think my arm is broke, my arm is broken." The VA was provided ice and pain medication. P6 talked with the VA and the VA said s/he had fallen, but also stated the SP had put the VA in a restraint. § P5 said the VA started complaining of his/her shoulder, arm, and fingers hurting. P5 explained it was difficult to understand where the pain was located, but the VA said the SP “did this,” and added the SP put the VA on the ground. However, the VA later stated s/he had hit “it” on a door and a dresser. P5 did not observe the VA fall while working at the facility on September 6, 2025. § P2 said s/he received a phone call on September 6, 2025, notifying him/her that the VA had shoulder pain. There was no observed swelling, and the facility nurse instructed staff persons to provide the VA with Tylenol, have the VA ice the area, and continue to monitor the area. o On September 7, 2025, the VA was in less pain, but did complain about pain in his/her hip. § On September 7, 2025, P5 and P6 said the VA continued to complain about being in pain, but the pain had transferred to the VA’s hip, and there was no observed swelling to the VA. § P6 said the VA had pain in his/her shoulder, wrist, and hip on September 7, 8, and 9, 2025. § The pain continued to be managed by pain medication and ice. o On September 8, 2025, the VA complained of pain in his/her head, shoulder, and arm. The VA was provided with pain medications, but there was no observed swelling. § P4 denied any knowledge of the VA having on-going pain or witnessing any falls. § P8 said the VA stated his/her elbow hurt, but the VA used his arm/elbow without issue. P8 did not observe any concerns with the VA’s arm. § P6 said the VA had pain in his/her shoulder, wrist, and hip. § P1 and P2 observed the VA at the facility and there were no observed concerns. o On September 9, 2025, the VA complained of pain in his/her hand, and there was opposing information related to observed swelling of the VA’s arm as at least one staff person observed swelling. § P7 said the VA complained of pain in his/her hand, and the VA told P7 that s/he had fallen. § P4 said the VA’s arm was swollen, but P4 was not aware of any incident that would have caused the swelling. P4 added that the VA was in pain when s/he moved the arm. § P9 observed the VA’s arm and did not observe anything abnormal. o On September 10, 2025, there was observed swelling of the VA’s arm. § P9 and P2 were at the facility and the VA said his/her hand hurt, and P2 observed swelling, and contacted the facility nurse. The VA was seen at a medical facility, and it was discovered the VA had a fractured arm. · Medical records showed the VA was seen at a hospital on September 10, 2025, due to swelling to his/her right upper arm, and was diagnosed with a spiral fracture. The fracture was an acute nondisplaced transverse fracture in the midshaft of the ulna, as well as an oblique nondisplaced fracture in the distal aspect of the ulna near the neck. While at the hospital the VA initially informed hospital personnel the injury occurred after s/he “rolled over in bed” on his/her arm, and denied the injury was caused by a fall. The VA later stated s/he was not aware of any trauma, but stated s/he was sleepwalking, and hit his/her arm on a bedroom door. While hospital personnel placed the splint on the VA, the VA said an overnight staff pulled him/her out of bed by his/her right arm, and put the arm behind the VA’s back. The VA added that the pain had increased since that alleged incident. While discussing the alleged incident with the overnight staff the VA mentioned that the G told staff persons to “hold" the VA like that when the VA was aggressive. Hospital staff attempted to have the VA explain the incident a second time, however, the VA said s/he “cannot remember." Medical records showed both examples (rolling over while in bed and a person causing the injury) could potentially cause a spiral fracture as there could be a rotational component to both potential causes of injury. The VA was provided a splint, and discharge instructions related to medication, pain management, restrictions, and instruction to follow-up with an orthopedic specialist. · LE records showed on September 10, 2025, LE observed the VA at the hospital. Upon collecting initial information, LE was advised that the VA told hospital personnel that the injury may have happened from “rolling over” in bed. Additionally, the VA had informed staff persons that his/her arm was hurt on Saturday, and the facility nurse instructed the VA to be seen at the hospital. LE spoke with the VA, without staff persons in the room, and the VA said the SP grabbed him/her and placed him/her in a restraint that included pulling the VA’s his arm behind his/her back. The VA described it as dislocating his/her shoulder. The VA said the incident occurred on September 9, 2025, between 2 and 10 p.m., after the VA became “argumentative,” with the SP. The VA said P1 was present for the incident. o There was no other information that P1 was present for an alleged incident. · LE asked the VA why s/he said the injury occurred while rolling over in bed, and the VA explained s/he had a difficult time remembering things, but added the incident with the SP was real. The VA made a statement to LE indicating some information was made up. LE asked the VA if the information related to the SP hurting the VA was made up, and the VA stated, “that part was real.” LE attempted to ask the VA additionally questions regarding the made-up information, however the VA was unable to provide any additional context. LE noted a previous criminal investigation was completed involving the VA having a black eye, and the VA said the SP punched the VA. That investigation resulted in no criminal charges. · P3, who was an asleep overnight staff person, did not recall any incidents during the above timeframe in which s/he woke up. P3 added the VA was loud when s/he walked, or had a behavior, or bumped into things. · P2 was not aware of any incident of the VA falling, being involved in a restraint, or any other incident which could have likely caused the injury. P2 said s/he was contacted by P7 and informed the VA’s shoulder hurt and the nurse was contacted for instruction. P2 said it was common for the VA to provide the SP’s name when s/he was upset or when the VA made statements of being hurt. P2 followed up with the SP and P3 and there were no incidents or behaviors that required a restraint on the days the SP worked. · P4 denied any knowledge of the VA’s complaining of being in pain or falling until September 8, 2025. P4 did not observe any swelling, but the VA did complain of pain on September 8, 2025. P4 said on September 9, 2025, the VA had swelling to his/her arm, and the VA had said, “Ouch” a couple times, but there was no known incident that would have caused an injury. · P5 said the VA informed him/her that s/he had slept wrong, or s/he hit his/her arm on something. P5 said the VA originally complained of pain in his/her elbow, and then shoulder, wrist, and hip, but was not consistent with the location of the pain. P5 said the VA was consistent that when s/he woke up his/her wrist was hurting. When the VA was seen by hospital personnel the VA said s/he was sleepwalking and hit his/her hand on a door. However, the VA does not sleepwalk and uses a walker to move around the facility. · P7 worked asleep overnights on September 6, and 8, 2025, did not hear anything suspicious either of the nights, but the VA said his/her hand hurt on September 8, 2025, and the VA said s/he had fallen. · There were no progress/shift notes that showed the VA engaged in any behaviors which required a restraint or that could have resulted in any form of injury. · The SP denied using a restraint, or having any physical contact with the VA which could have resulted in the injury. The SP said the VA fell while chasing his/her cat, but the SP did not observe the VA to be in any pain or sustain an injury. The SP added that the VA completed exercises on the days s/he worked and only expressed his/her arm hurt on the morning of September 7, 2025. The SP said during his/her shifts there was nothing that occurred that could have caused the VA to have broken his/her shoulder (as that was the injury that the SP was initially told had occurred). LE informed the SP that the VA had a broken wrist, to which the SP said there was nothing that happened that would have caused the VA to have a broken wrist. The SP again denied implementing a restraint. The SP said if an incident occurred the asleep staff working that day would wake up as the VA was loud. The SP added the VA chooses to not use his/her walker and has had falls due to mobility issues. · The VA said s/he was not sure how the injury to his/her wrist occurred when speaking with this investigator. Whereas the VA made multiple different statements above to LE, medical personnel, and other staff persons. During the facility’s Internal Investigation, the VA said the SP “Did it,” and the SP put the VA’s arm behind his/her back when they were in the hallway. The G said s/he was not present for the incident, but was concerned because this was the second alleged incident that involved the SP, and both incidents were related to physical abuse. The SP and P1 received training on the VA’s client specific plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on September 10, 2022, the VA was diagnosed with a broken wrist. However, based on the information obtained it was unclear when the initial injury occurred. The first time the VA stated s/he was in pain was on September 6, 2025. The VA made multiple opposing statements about how the injury occurred, including that the SP restrained the VA, that s/he fell, that s/he slept on the arm wrong, and that s/he bumped into a wall. The differing statements occurred on multiple days, and the statements were made to staff persons, medical personnel, LE, and this investigator. Additionally, according to P1 the VA had a history of making statements about the SP hurting him/her. Due to this information the credibility of the VA was unable to be determined. The SP denied implementing a restraint on the VA, or causing any harm to the VA. There were no staff that witnessed the SP harm the VA, and no documentation of a restraint completed. There was consistent information that the VA was loud, and asleep overnight staff persons would have likely woken up if there was an incident, however there was no information which showed an incident occurred between the VA and the SP.
Although the VA was diagnosed with a broken wrist, given that the VA provided inconsistent information regarding how the injury occurred and whether the SP caused the injury, and that there was no information that showed that the VA’s injuries were sustained due to an altercation or incident with the SP, there was not a preponderance of the evidence whether staff persons engaged in conduct that would cause the VA pain or injury. It was not determined whether 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 policies and procedures were adequate and were followed. The facility found the VA’s programming was not implemented. The facility completed additional staff training to ensure documentation of the VA’s falls and other incidents, and updated the VA’s programming to include a risk that the VA was not an accurate reporter. The SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
|
