|
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: 1071773-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Beth Virden Christine.Cavanaugh@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) slapped a vulnerable adult’s (VA) face during an altercation. Date of Incident(s): October 12, 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 October 22, 2025; from documentation at the facility; and through six interviews conducted with the VA, the VA’s guardian (G), the VA’s case manager (CM), a facility staff person (SP), a supervisory staff person (P1), and an administrative staff person (P2). Attempts were made by telephone and email to contact and interview the VA’s in-home support staff person (IHS). The IHS scheduled an interview but then did not answer at the time of the interview or reschedule. The IHS provided information for the facility’s Internal Review, which was included in this report. The VA’s support plans, including Action Plan, stated the following: · In 2022, the VA moved into the facility seeking services and support relating to his/her diagnoses, including developmental and intellectual disabilities. The facility provided staff, who helped with the VA’s activities of daily living, medications, and appointments. · The VA also received services from an in-home support agency. The agency provided the IHS, who worked most days with the VA at the facility and in the community. The IHS was not employed by the facility. When the IHS was working, s/he was the VA’s primary (1:1) staff person and supplied the VA’s care and supervision. · The VA had a history of agitation and verbal and physical aggression toward others. Staff were supposed to keep the VA engaged to avoid boredom and provide “clear and calm” instructions when needed. Staff used “first/then language,” offered choices, and avoided saying, “no.” If the VA started to posture or make fists, staff remained neutral and did not verbally engage with the VA. If the VA started pacing or shaking, staff gave him/her space and blocked any attempts by the VA to hit or pinch. The facility was a single-family home where the VA lived with two housemates. [Note: The VA’s housemates were not present for the incident on October 12, 2025, and so, they were not interviewed for this investigation.] The facility’s Internal Review included an interview with the IHS. The IHS stated that on October 12, 2025, the VA had “constant behaviors,” including slapping, hitting, and chasing others. Around 6 p.m., the VA picked up and threw the SP’s cellphone and the SP responded by slapping the VA’s face. The IHS was standing behind the VA when the interaction occurred and did not see which hand the SP used to slap the VA’s face or where the SP’s hand contacted the VA’s face. The VA started crying and the IHS led him/her outside. The IHS did not see any marks or injuries on the VA’s face and had never had prior concerns with the SP’s conduct. The G said that on October 12, 2025, around 5:30 or 6 p.m., the IHS called and stated that the VA threw the SP’s cellphone and “[the SP] got upset and hit [the VA].” The G could each hear the SP “yelling” in the background of the call. The IHS handed the phone to the SP and the SP talked to the G “fast and loud” and appeared “highly agitated.” The G had a hard time understanding the SP and told him/her to take “a deep breath.” At some point after, the IHS left the facility with the VA removing him/her from the situation. On October 13, 2025, the SP left a “yelling” voicemail for the G stating that the IHS was “wrong” about what happened. P1 and P2 each said that they did not have prior concerns with the SP’s conduct and that there were no marks or injuries on the VA’s face following the incident. The SP said that on October 12, 2025, the VA threw the SP’s cellphone and moved toward the SP appearing ready to hit. The SP grabbed the VA’s hands and pushed them together, which made a clapping sound. The SP released the VA’s hands after about one second and walked away. The IHS was standing behind the VA and could not see the SP’s hand movements. The IHS left shortly after with the VA and the incident concluded without further incident. The SP said that s/he did not slap the VA, and the VA did not sustain any injuries. The CM said that s/he did not have concerns with the facility’s overall care and supervision of the VA. The VA said that the facility was “good,” and that staff never slapped his/her face. Facility documentation stated that the SP, P1, and P2 received training on the Reporting of Maltreatment of Vulnerable Adults Act, and that the SP and P1 received training on the VA’s support plans, including Action Plan. Conclusion: The IHS and the SP each said that on October 12, 2025, the VA threw the SP’s cellphone. The IHS said that in response, the SP slapped the VA. The SP said that s/he did not slap the VA but that the VA moved toward him/her and to prevent being hit, the SP grabbed the VA’s hands, which made a clapping sound. The VA said that staff never slapped him/her. Given that the VA did not have injuries consistent with being slapped and that the IHS’s view was obstructed in that s/he could not state which hand the SP used to slap the VA or where the SP’s hand contacted the VA’s face, there was not a preponderance of the evidence whether the SP slapped the VA and produced 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 policies and procedures were adequate but not followed regarding the VA’s “as needed” medication administration. The facility updated protocols and the VA’s support plans, and trained staff on the changes. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
