|
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: 1072298-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) made a vulnerable adult (VA1) go to his/her day program even though s/he was sick and that the SP also threw water on VA1’s face to wake VA1 up. It was also reported that the SP limited the amount of milk a vulnerable adult (VA2) was allowed to drink, that the SP did not take VA2 to the bank for over a month, and that the SP took items from VA2’s bag that s/he thought VA2 did not need. Date of Incident(s): Ongoing, prior to April 30, 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 May 8, 2025; from documentation at the facility; and through six interviews conducted with two facility staff persons (P1 and P2), an administrative staff person (P3), VA1, VA2, and VA1’s and VA2’s guardian (G). Attempts were made by telephone and mail to contact and interview the SP, but the SP did not respond to the requests. VA1 enjoyed listening to music, going on walks, working on crafts, baking, watching television, playing games, and spending time with friends and family members. VA1’s diagnoses included schizophrenia, major depressive disorder, asthma, and post-traumatic stress disorder. VA1 went to a day program four days each week. VA1’s Risk Assessment Detail stated that VA1 was at risk for physical and emotional abuse and was not consistently aware of potentially dangerous situations. VA1 struggled to manage his/her finances on his/her own and had a representative payee to help VA1 manage his/her money. VA2 enjoyed working on art projects, going on walks, and spending time with friends and family members. VA2’s diagnoses included asthma, diabetes, gastroesophageal reflux disease, hypertension, chronic kidney disease, major depressive disorder, borderline disorder, and generalized anxiety disorder. VA2’s Risk Assessment Detail stated that VA2 was not at risk for physical or emotional abuse or financial exploitation. However, when VA2 was dysregulated, s/he might exhibit behaviors that could provoke a reaction from others. At those times, staff persons were to redirect VA2 and encourage him/her to use his/her coping skills and calming strategies. Regarding VA1: VA1 stated that on several occasions the SP “made” VA1 go to his/her day program even though VA1 told the SP that s/he did not want to go. On an unknown date, VA1 told the SP that s/he was sick and did not want to go to the day program, but the SP told VA1 that s/he had to go. However, once VA1 vomited, the SP did not make VA1 go to his/her day program. On another occasion, the SP wanted VA1 to wake, so s/he pulled the blankets off VA1 and put water on his/her face. Sometimes the SP “teased” VA1 about loving another staff person, which made VA1 feel bad. On one occasion, when VA1 went to a doctor’s appointment, the SP told VA1 “not to talk about stuff” with the doctor, but the doctor told the SP to step out of the room and VA1 told the doctor that the SP made him/her want to run away. On one occasion, the SP told VA1 that s/he was fat. VA1 stated that the SP hurt him/her “mentally” because VA1 sometimes heard “voices” because of what the SP said and did to VA1. VA2 stated that the SP sometimes made VA1 go to his/her day program even when VA1 did not want to go or was “feeling like crap.” P1 – P3 provided the following information: · P1 stated that the SP sometimes made VA1 go to his/her day program even when VA1 did not want to go. The day program opened at 9 a.m., but the staff persons typically drove VA1 to the day program around 10 a.m. On several occasions, P1 heard the SP yell at VA1 that s/he had to go to his/her day program and “didn’t have an option” to stay at the facility. P2 stated that on multiple occasions, the SP told VA1 that s/he “had” to go to his/her day program even though VA1 did not want to go. On one occasion, VA1 told the SP that s/he was ill and vomiting and the SP told VA1 that s/he was “fine” and could go to the day program. P2 stated that on the following day when s/he was at the facility, VA1 was upset, cried, and wanted to leave the facility. P2 stated that there was no reason VA1 had to go to his/her day program if s/he did not want to. · P1 stated that the SP told P1 that s/he sometimes dipped his/her hand in water and pressed it onto VA1’s face in order to wake VA1. P2 stated that VA1 told P2 that the SP sprinkled water on VA1’s face in order to wake him/her. · P1 stated that the SP frequently did not allow the clients to visit their family members. The SP told VA1 that s/he could not visit his/her family members until s/he was “100% well.” P1 stated that VA1 was “never going to be 100% well” because of his/her health issues. P3 stated that on one occasion, VA1 told his/her physician that s/he had “bad thoughts” about hurting him/herself so the SP told VA1 that s/he could not visit his/her family members if s/he was having those thoughts. P3 told the SP that s/he could not prevent VA1 from seeing his/her family members. The internal review provided the following information: · P3 provided information that when the SP was not at the facility, VA1 told P3 that it was “so nice to have people that don’t make me go to my day program if I’m tired.” · The SP provided information that s/he encouraged the clients to make their own decisions about attending their day programs. The SP woke the clients by tapping their shoulders and never placed water on the clients’ faces to wake them. The G stated that VA1 did not talk to the G about the incidents and s/he learned about them from the facility. Regarding VA2: VA2 stated that at times the SP was “verbally abusive” to VA2 and sent text messages to VA2 saying that s/he could not go to the movies because of VA2’s “attitude.” The SP delayed VA2 in getting his/her paycheck by telling VA2 that the check was going to be mailed to him/her and not letting VA2 go to his/her workplace to pick up the check. On one occasion, the SP refused to take VA2 to a store until VA2 paid off a bill. The SP wanted to drive VA2 when s/he visited his/her family and asked VA2 to call his/her family members to ask if they would buy the SP’s meal if s/he drove VA2 to their home. The SP told VA2 that s/he could only have one glass of milk each day and when VA2 took a second glass of milk, the SP “flipped out.” None of VA2’s doctors told VA2 that s/he should not drink milk. The SP also told VA2 that if s/he purchased sugary cereals, the SP would not take VA2 to Walmart. On one occasion, while VA2 was at a nursing home rehabilitation center, the SP “cleaned” VA2’s bedroom and several of VA2’s items “went missing,” including perfumes, lotion, and a Swiss army knife. The SP told other staff persons that VA2 was sleeping with a staff person, which was not true. P1 – P3 provided the following information: · P1 stated that the SP frequently told VA2 that s/he could only have one glass of milk. On one occasion, VA2 poured a second glass of milk and the SP told VA2 that s/he could not drink it. The SP told VA2 that s/he would find an “alternate milk” for VA2 to drink and would make sure VA2 only had one glass. P2 stated that when VA2 took a second glass of milk, the SP told VA2 to stop drinking milk and s/he was going to purchase almond milk for VA2 even though VA2 did not like almond milk. P1 told the SP that s/he could not limit the amount of milk VA2 drank and the SP told him/her that they were running out of milk “too quickly.” P1 and P2 each stated that the SP frequently drank the milk and “blamed” VA2 for drinking it. P3 stated that VA2 had no restrictions on how much milk s/he drank. · P1 stated that recently the SP refused to take VA2 to a store because s/he was “unhealthy.” P1 believed that going on community outings would help VA2 become healthier. · P3 stated that when VA2 wanted to move to a larger bedroom in the facility, the SP told him/her that s/he could not do so and told VA2 that s/he was “not moving your shit.” There was no reason that VA2 could not move to the other bedroom. · P1 stated that on one occasion, the SP told VA2 that s/he talked to VA2’s employer and they were going to mail VA2’s paycheck to VA1. After three weeks, VA2 called his/her employer and learned that the SP did not call the employer and VA2 had to pick up his/her paycheck at his/her workplace. When VA2 asked to be driven to his/her workplace to get his/her paycheck, the SP told P1 not to take VA2 to his/her workplace and that if s/he did, the SP would “write up” P1 for doing so. P1 called P3 to ask if s/he could take VA2 to pick up his/her check and P3 told P1 that s/he could. When P3 told the SP that P1 could take VA2 to get his/her check, the SP “hung up the phone” on him/her. P1 then took VA2 to get his/her paycheck because VA2 needed money to purchase personal items. · P2 stated that on one occasion, the SP refused to administer medications to VA2 and “threw” VA2’s insulin and needle at VA2 and told VA2 to “figure it out.” The SP then sent VA2 to his/her work program without administering the medications to VA2. The SP later told P2 to take VA2’s medications to him/her at the day program. · P1 stated that the SP’s tone of voice was “always aggressive” when s/he talked to the clients and that his/her comments were very “demeaning.” P2 stated that when VA2 asked to do something, the SP typically gave VA2 “an automatic no.” When P1 told a supervisory staff person (P4) that the SP was speaking to the clients in an inappropriate manner, P4 told P1 that s/he was working with the SP on how to interact with the clients and asked P1 to “hold on.” P2 stated that if the staff persons told the SP that s/he could not restrict the clients’ rights, the SP told them that s/he was a supervisor and what “I say goes.” · P2 stated that when VA2 was at the hospital, the SP cleaned VA2’s bedroom and threw away perfume, clothing, and other items, even though s/he did not have permission to do so. · P1 stated that after a client passed away, the client’s family member told the other clients that they could take anything they wanted from the client’s bedroom. The SP took three bags of clothing and a guitar that one of the other clients had requested. The G stated that VA2 did not talk to the G about the incidents and s/he learned about them from the facility. VA2 was diabetic, but was allowed to make “poor choices” regarding his/her diet. The internal review provided the following information: · While the facility’s health care professional (HCP) was at the facility, VA2 asked to move to an unused bedroom, but the SP told VA2 that s/he could not move to the other bedroom because the SP “was not moving your shit.” · The HCP also saw the SP go through VA2’s bag while VA2 was at a rehabilitation center and take out items the SP “didn’t think [VA2] should have.” P1 saw the SP place some of VA2’s clothing, shoes, and personal items in boxes in the living room to be thrown away, but P1 did not allow the boxes to be thrown away. · The SP provided information that while s/he went into VA2’s bedroom without permission, it was only to clean the room and place dirty laundry outside the bedroom door to be washed. The SP did not know what happened to VA2’s missing items. Prior to getting VA2’s paycheck, the SP wanted to check with VA2’s rep payee. The SP asked the clients to limit how much milk they drank only if s/he needed milk for meal preparation. Facility documentation showed that the SP and P1, P2, and P3 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on VA1’s and VA2’s 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: A. Maltreatment: Regarding VA1: VA1 stated that when the SP wanted VA1 to wake, s/he pulled the blankets off VA1 and put water on his/her face. P1 stated that the SP told P1 that s/he sometimes dipped his/her hand in water and pressed it onto VA1’s face in order to wake VA1. P2 stated that VA1 told P2 that the SP sprinkled water on VA1’s face in order to wake him/her. VA1, VA2, P1, and P2 provided consistent information that the SP made VA1 go to his/her day program even when VA1 was ill or did not want to go. P1 and P3 provided consistent information that the SP sometimes restricted VA1 from visiting his/her family members. VA1 stated that sometimes the SP “teased” VA1, told VA1 that s/he was fat, and made VA1 feel bad. VA1 told his/her physician that the SP made him/her want to run away. The SP hurt VA1 “mentally” because VA1 sometimes heard “voices” because of what the SP said and did to VA1. The SP did not provide information for this investigation but denied the allegations during the Internal Investigation. The SP’s actions of pulling off VA1’s blankets and sprinkling water on VA1 to wake him/her; “making” VA1 go to his/her day program even when s/he was ill or did not want to go; restricting VA1’s visits with family members; and calling VA1 fat and “teasing” him/her about loving a staff member, were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; and a violation of Minnesota Statutes, section245D.04, subdivision 3, paragraph (b). Given the consistent information provided by VA1, P1, P2, and P3 regarding the SP’s interactions with VA1; that the SP’s actions caused VA1 to feel bad and to want to run away from the facility; and that the SP’s aforementioned actions were not accidental or therapeutic conduct, there was a preponderance of the evidence that the SP’s actions were treatment which would be considered by a reasonable person to be disparaging, derogatory, humiliating or threatening and produced or could reasonably be expected to produce emotional distress to VA1. It was determined that 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). Regarding VA2: Consistent information was provided that on multiple occasions the SP told VA2 that s/he could only have one glass of milk each day and when VA2 took a second glass of milk, the SP threatened to purchase almond milk, which VA2 did not like. None of VA2’s doctors told VA2 that s/he should not drink milk. The SP told VA2 that his/her paycheck was going to be mailed to VA2 and did not let VA2 go to his/her workplace to pick up the check for several weeks even though VA2 needed the money to buy personal items. When P1 offered to take VA2 to get his/her paycheck, the SP told P1 not to take VA2 to get his/her paycheck and if s/he did, the SP would “write up” P1 for doing so. VA2 stated that at times the SP was “verbally abusive” to VA2 and sent text messages to VA2 saying that s/he could not go to the movies because of VA2’s “attitude.” P1 stated that the SP’s tone of voice was “always aggressive” when s/he talked to the clients and that his/her comments were very “demeaning.” P2 stated that if staff persons told the SP that s/he could not restrict the clients’ rights, the SP told them that s/he was a supervisor and what “I say goes.” P3 stated that when VA2 wanted to move to a larger bedroom in the facility, the SP told him/her that s/he could not do so and told VA2 that s/he was “not moving your shit.” There was no reason that VA2 could not move to the other bedroom. P2 stated that on one occasion, the SP refused to administer medications to VA2 and “threw” VA2’s insulin and needle at VA2 and told VA2 to “figure it out.” The SP then sent VA2 to his/her work program without administering the medications to VA2. The SP later told P2 to take VA2’s medications to him/her at the day program. The SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, were not therapeutic conduct, and were in violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b). Given the consistent information provided by VA2, P1, P2, and P3 regarding the SP’s interactions with VA2 and that the SP’s aforementioned actions were not accidental or therapeutic conduct, there was a preponderance of the evidence that the SP’s actions were treatment which would be considered by a reasonable person to be disparaging, derogatory, humiliating or threatening and produced or could reasonably be expected to produce emotional distress to VA1. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on VA1’s and VA2’s plans prior to the incidents. The SP was responsible for maltreatment of VA1 and VA2. A. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated emotional abuse for which the SP was responsible was not serious, given that VA1 and VA2 did not sustain an injury but was recurring because the SP was responsible for the emotional abuse of two vulnerable adults. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. The facility was not issued a Correction Order for the violations outlined in this report because they took immediate corrective action.
|
