|
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: 1128137-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Alice Percy Minnesota Department of Human Services 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at and swore at three vulnerable adults (VA1, VA2, and VA3). Date of Incident(s): October 13, 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 subdivision 2, paragraph (b), clause (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: 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 October 30, 2025; from documentation at the facility; and through fifteen interviews conducted with three facility staff persons (P1 – P3), four supervisory staff persons (P4 – P7), the SP, two clients (C1 and C2) who also lived at the facility, VA2, VA3, VA2’s guardian (G1), VA3’s guardian (G2), and VA3’s case manager (CM). VA1 declined to provide information for this report. VA1 enjoyed going out to eat, going shopping, going to church, and spending time with his/her family members. VA1’s diagnoses included schizophrenia – bipolar type, major depressive disorder, chronic obstructive pulmonary disease (COPD), and hypothyroidism. VA1 was not subject to guardianship. VA1’s Individual Abuse Prevention Plan (IAPP) stated that VA1 might struggle with how to leave a situation that was or could become abusive. VA1 might feel intimidated by someone who became verbally or physically aggressive with him/her. VA1 might easily become anxious or agitated. VA2 enjoyed watching television, going to church, going on community outings, and spending time with his/her family members. VA2’s diagnoses included mild intellectual disabilities, intermittent explosive disorder, adjustment disorder, polio, and depression. VA2’s IAPP stated that V2 might not independently defend him/herself from abuse. When others became aggressive, VA2 might become upset and begin to yell rather than leave the area. VA3 enjoyed playing video games, fishing, listening to music, going out to eat, going to the park, and spending time with friends and family members. VA3’s diagnoses included major depressive disorder, anxiety disorder, post-traumatic stress disorder, borderline personality disorder, and an intermittent explosive disorder. VA3’s IAPP stated that VA3 might not identify dangerous situations and would be unable to access resources for his/her safety. VA3 might “fight back” with an aggressor rather than leave the situation. The facility was a rambler style home that had five bedrooms, a bathroom, a living room, and a kitchen on the main level. The living room had a sectional couch that faced a television. A laundry room and storage areas not used by the clients were located on the lower walk-out level. Consistent information was provided that video cameras were located in the living room and kitchen and automatically deleted after five days. VA2 stated that s/he liked the staff persons and they took VA2 shopping. One of the other clients sometimes yelled at VA2. VA3 stated that the staff persons did not yell or swear at him/her and did not mistreat the clients. Although C1 and C2 were interviewed, they did not provide any information about the allegations. P4 stated that on a couple of occasions, VA1 told P4 that the SP “was always giving [VA1] trouble” and gave VA1 a “hard time.” VA1 did not provide additional information to P4 about the incidents. On an unknown date (maybe two to three weeks prior), the SP yelled at VA3 about making a mess in the bathroom and when P4 told the SP not to speak to VA3 in that manner, the SP told P4 s/he was “just joking.” VA3 did not react to what the SP said. On another occasion (October 13, 2025), after P4 told the SP that s/he was taking VA1 to pick up his/her new eyeglasses, the SP became upset with P4 because s/he wanted to drive VA1. When P4 asked VA1 to get ready to leave, the SP began to insult P4, swore at him/her in front of the clients, pushed P4, and yelled at him/her. P4 telephoned P5 and told him/her about the incident and P5 said s/he would talk to the SP. P4 was not aware of any other staff persons having any concerns with the SP’s interactions with clients. P5 stated that after P4 expressed concerns to P5 about how the SP talked to him/her, P5, P6, and P7 reviewed video recordings and saw that the morning of October 13, 2025, after P4 called and told the SP that P4 was taking the VA to pick up his/her eyeglasses instead of the SP, the SP became upset. After hanging up the telephone, the SP told VA1 to get his/her “punk ass” ready and then told VA1 to tell P4 that VA1 wanted the SP to take VA1 to pick up his/her eyeglasses. When VA1 refused, the SP told VA1, “Well fine. I’m not gonna do shit for you anymore. You can’t even do this one thing for me. And after I took you to get your fucking wallet.” The SP also told VA3 to go back into his/her bedroom because VA3 kept calling people “bitches.” VA1 told the SP to “calm down” and the SP began to swear at VA1. When VA2 helped VA3 get his/her walker, the SP asked VA2 why s/he helped VA3. The SP then lay on the couch and told VA2 to tell him/her when P4 returned to the facility. P5 stated that the SP typically spoke in a loud tone of voice. Prior to the incident, none of the clients expressed concerns to P5 about how the SP treated them and no staff persons had concerns with the SP aside from the SP having a “loud voice.” A video camera was located near the kitchen and showed both the kitchen and a hallway leading to the rear of the facility. A second video camera was located in the living room and showed the door to VA3’s bedroom. Both videos included audio. A review of two video recordings dated October 13, 2025, from 11:22:36 to 11:55:03 a.m. showed the following: o At 11:23:00, the SP was the only person in the living room and s/he was lying on one end of the couch looking at and scrolling through his/her cell phone. o At 11:27:21, VA2 entered the living room and sat on the other end of the couch. The SP asked VA2 to tell him/her when P4 returned to the facility. VA2 and the SP then watched television. During this time, VA3 was in his/her bedroom which opened into the living room and at times was visible on camera. o At 11:31:56, the SP’s phone rang as VA3 entered the living room from his/her bedroom and walked toward the kitchen with his/her walker. The SP answered and talked on his/her cell phone. o At 11:34:21, the SP sat up while still talking on the phone. o At 11:35:37 the SP hung up his/her phone, looked at VA2 and said, “Lawsuit.” The SP then around the room and said, “Give me the fucking . . . I’m sick of fucking looking at this shit every [unintelligible] fucking 24 hours a day. Where’s, where’s the remote? Is it on the counter over there?” and VA2 then stood and walked in the direction the SP pointed. “[Inaudible] of this shit. How can you like the same fucking show all the goddamn fucking day? You know what I mean?” VA2 told the SP s/he did not see it and the SP looked in the other direction at the TV and said, “It’s right there,” and pointed. VA2 then walked to get the remote and then gave the remote to the SP. The SP said, “I don’t know what [his/her] fucking problem is this morning?” VA2 responded, “Who? [inaudible].” The SP said, “Yeah.” o At 11:36:48, VA3 walked through the living room with his/her walker and into his/her bedroom. VA3 was in his/her bedroom with the door open and visible on camera when the SP sang, “What you gonna do? What you gonna do cuz you smell like poop? [VA3, VA3], what you gonna do, what you gonna do cuz you smell like poop?” VA3 then returned to the living room and stood near VA2. The SP sang something that was inaudible. o At 11:37:40, the SP looked at VA3 and said with a raised volume, “Hey, we don’t want you in here. Go in your room. All you do is call women bitches and be an asshole. Go be an asshole by yourself. Thank you.” VA3 then turned and walked to his/her bedroom and the SP said, “Thank you.” [Note: Up to this point, VA3 had not said anything.] o At 11:38:16, the SP told VA3 to close his/her bedroom door and then told VA2 to close VA3’s bedroom door and VA2 did so. The SP left the living room and went to the kitchen. o At 11:38:46, the SP walked to the kitchen and said, “Fucking dirt bag. [S/he] didn’t even eat. eat.” “[Inaudible] Do you think I give two popsicles about [his/her] punk ass.” VA2 then walked toward the kitchen and stopped to ask VA3 if s/he was going to eat and said, “Get your walker.” o At 11:39:13, the SP told VA2, “Hey, don’t be trying to help [him/her] out. Let [him/her] fall on [his/her] face and break it.” o At 11:40:16, VA3 walked into the kitchen and sat at the kitchen table as the SP washed dishes. o At 11:44:00, the SP sat at the kitchen table with VA3. o At 11:52:37, the SP said loudly, “Don’t put that right there. Put that in the trash, if you’re done,” and VA3 complied by pulling the trash can closer to his/her chair. When VA3 was done throwing the items away, the SP stated, “[Inaudible] your bitch ass up and put it in the sink.” The SP then kicked the trash can moving the trash can. VA3 then moved the trash can back in place. o At 11:53:12, VA3 pushed his/her chair back from the table and the SP grabbed a plate from VA3’s hands and loudly told VA3, “Beat it.” The SP then tossed the plate into the sink and again told VA3, “Beat it.” VA3 said, “I’m trying to get up.” VA3 then stood and used his/her walker to return to the living room. P2 stated that s/he did not often work with the SP but when s/he did the SP often spoke loudly so it was hard to know if s/he was upset or “just loud.” On one occasion, the SP was upset and spoke to P2 loudly, but later called P2 to apologize for how s/he spoke. P2 never heard any of the staff persons, including the SP, yell at the clients or tell the clients to shut up. None of the clients told P2 about any concerns they had with how staff persons treated each. P3 stated that several years ago, the SP told VA3 to be quiet when VA3 talked about his/her feelings. P3 told the SP not to speak to VA3 in that manner and the SP became upset with P3. On another occasion, the SP told VA3 to change the television channel because VA3 always watched the same channel. P3 told the SP that the clients could choose which channel to watch and the SP became angry with P3. P3 never heard the SP yell at the clients or tell the clients to shut up but at times gets mad at staff persons. P6 stated that after learning about the incident, P6 talked to the SP, who told P6 that s/he was upset and “on edge” about a family situation. After talking to the SP, P6 reviewed the video and provided information that was consistent with the above video. P6 was not aware of any previous concerns regarding the SP’s interactions with clients but the SP had conflicts with other staff persons. P7 stated that the video recording showed that after VA3 refused to tell P4 that s/he wanted the SP to take him/her to pick up his/her eyeglasses, the SP told VA3 that in the future s/he was “not going to do shit for you.” On an unknown date, VA2 told P7 that the SP was a “good guy” but got on VA2’s “nerves.” P7 was not aware of any previous concerns regarding the SP’s interactions with client but the SP “blew up” at staff persons. P1 stated that s/he never heard any staff person speak to any of the clients in a way that concerned P1. P1 did not hear any of the staff persons yell at the clients, swear at the clients, or tell the clients to shut up. Sometimes the clients yelled at the other clients. The SP provided the following information: · On one occasion, VA2 told the SP that VA3 repeatedly called VA2 a “bitch.” The SP then told VA3 that s/he did not want to sit by anyone who called VA2 a bitch and told VA3 to watch television in his/her bedroom. VA3 then went to his/her bedroom to watch television. The SP did not tell VA3 to close the bedroom door and VA3 frequently watched television in his/her bedroom. · The SP did not lie on the couch to nap or tell VA2 to tell him/her when P4 arrived at the facility. The SP was recently in a car accident and sometimes lay on the couch to straighten his/her leg. The SP never told VA2 to not help VA3 with his/her walker and to let VA3 “fall on their face.” The SP never “yelled” at the clients, but may have raised his/her voice when speaking to them from another room. The SP never swore at any of the clients. The SP never told a client that s/he “smelled like poop,” although on one occasion s/he suggested that a former client take a shower because s/he smelled bad since they had not showered for several days. The SP never called a client a fucking piece of shit or a fucking dirt bag. The SP believed s/he called VA1 a “punk ass” on one occasion, but did not mean to be derogatory toward VA1. The SP believed s/he may have commented about watching the same television show repeatedly, but did not recall swearing when s/he talked about it.
· Recently the SP and P4 had a disagreement, which P4 told P5 about and P5 then told the SP to leave the facility, which the SP did. The SP did not believe that P5 understood that s/he had close relationships with VA2 and VA3 because s/he worked with them for years. The SP stated that s/he and P5 had interpersonal conflicts and P5 did not want the SP to work at the facility. G1 stated that VA2 was “pretty accurate” at providing information about events. VA2 did not talk to G1 about having concerns about the staff persons. Prior to the incident, G1 had no concerns about the care VA2 received at the facility. G2 stated that s/he did not hear the SP make negative comments to the clients when s/he was at the facility. In the past, VA3 sometimes made negative comments to the other clients. Prior to the incident, G2 had no concerns about the care VA3 received at the facility. G2 stated that VA3 was “sometimes accurate and sometimes not” at reporting events. The CM stated that VA3’s ability to provide accurate information about events was “limited at best.” Prior to the incident, the CM had no concerns about the care VA3 received at the facility. The facility’s Policy and Procedure Regarding Employee Professionalism and Conflicts of Interest stated that the staff persons were to build positive and supportive relationships with the clients and other staff persons. The staff persons were not allowed to make comments or community about the clients in a manner that was vulgar, obscene, threatening, intimidating, harassing, libelous, or discriminatory. Facility documentation showed that the SP, P1, P2, P3, P4, P5, P6, and P7 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VAs’ plans prior to the incidents. Relevant Rules and Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (b), state that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: The SP stated that s/he never yelled at or swore at the clients, never called the clients names, never told VA3 that s/he “smelled like poop,” and never told VA2 to not help VA3 with his/her walker. However, video dated October 13, 2025, showed the SP engaging in such actions. Two video recordings reviewed, showed the SP repeatedly swearing while talking to VA2; and singing to VA3, “What you gonna do cuz you smell like poop? [VA3, VA3], what you gonna do, what you gonna do when you smell like poop?” and telling VA3, “Hey, we don’t want you in here. Go to your room. You just call women bitches and be an asshole. Go be an asshole by yourself. Thank you.” In addition, when VA2 was heard telling VA3 to use his/her walker, the SP told VA2, “Don’t be trying to help [VA3] out. Let [him/her] fall on [his/her] face and break it.” When the SP and VA3 were both in the kitchen, the SP told VA3, “[Inaudible] your bitch ass up and put it in the sink.” The SP then kicked the trash can moving the trash can. Neither of the video recordings provided for this investigation, showed an interaction between the SP and VA1. However, P5, P6, and P7 stated that the video each reviewed showed that after P4 telephoned the facility and told the SP that s/he was taking VA1 to pick up his/her new eyeglasses, the SP became upset because s/he wanted to drive VA1 and called VA1 a “punk ass” and told VA1 that s/he was “not gonna do shit for you anymore.” P4 stated that VA1 also told P4 that the SP “was always giving [VA1] trouble” and giving VA1 a “hard time.” The SP’s actions as observed on video and outlined above were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, were a violation of Minnesota Statutes, section245D.04, subdivision 3, paragraph (b). Although the SP’s actions were not accidental or therapeutic conduct and that the SP had a history of talking loudly which was likely interpreted by some as yelling, information showed that this was the sole day that the SP engaged in swearing at and/or calling VA1, VA2, and/or VA3 names. Despite the consistent information provided that the SP yelled at, became upset, and/or swore at other staff persons, P1, P2, P3, P5, P6, and P7 provided consistent information that prior to this incident there were no concerns regarding any staff persons’, including the SP’s, interactions with clients. Therefore, there was not a preponderance of the evidence whether the SP’s oral language on the single day was repeated and would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing or threatening and could reasonably be expected to produce emotional distress to the VAs. It was not determined whether emotional 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: 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but the SP did not follow the policies. The SP 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, a Correction Order was not issued for the violation outlined above.
|
