|
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: 1071953-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) became verbally aggressive and threatened another staff person (P1) and a vulnerable adult (VA). Date of Incident(s): April 1, 2026 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); and subdivision 17, paragraph (a): 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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on April 22, 2026; from documentation at the facility, law enforcement records, and medical records; and through four interviews conducted with facility supervisory staff persons (P1 and P2), the VA’s case manager (CM), and the VA’s guardian (G). The VA was not able to provide information for this investigation due to his/her abilities. The SP did not respond to phone or mail requests for an interview. The VA’s diagnoses included autism, mood disorder, intermittent explosive disorder, borderline intellectual functioning, and drug induced subacute dyskinesia. The VA enjoyed painting, going to movies, fashion design, and going on outings. The VA’s plans stated the VA had limited ways to express when s/he was angry or upset and used “inappropriate behaviors” including kicking, hitting, pulling hair, biting, etc. to him/herself and to peers and staff persons. The VA was “very routine focused” and changes to the routine caused maladaptive behaviors that put the VA and others at risk. The facility was a single-story residential home in a residential neighborhood. The main floor consisted of a bedroom, two offices, a kitchen, a living room, and two bathrooms. The lower level consisted of a bedroom, a laundry room, a living room, and a bathroom. The VA lived alone in the lower level but occasionally went upstairs to watch movies with client who lived on the main floor. The facility’s Internal Review showed that on April 1, 2026, at 2:09 p.m., P1 arrived for work at the facility. P1 greeted the SP and the SP did not respond. P1 completed administrative duties and at 2:35 p.m., went upstairs to meet the VA. The VA and P1 went downstairs and the VA took a bath and got his/her medication. P1 asked the SP if s/he was ready to take the VA to a gas station to get a snack and the SP did not answer. The SP had his/her eyes shut and appeared to be sleeping. P1 “shook” the SP several times to wake him/her up. The SP opened his/her eyes, his/her eyes “rolled back” and only the white part of the eyeballs were visible. The SP said, “Shut you bitch ass up, [n-word],” and “I’m gonna kill you bitch ass [n-word].” P1 asked the SP if s/he was okay and the SP responded, “Shut the fuck up before I kill you bitch.” The VA said, “It’s time. It’s time, it’s treat day.” The SP responded, “I’m gonna kill you too fat ass bitch. Shut up fucking bitch.” The VA repeated the name of the gas station and the SP said, “I told you to shut the fuck up, hoe ass bitch.” P1 directed the VA to his/her room and the VA hit the walls on the way to his/her room. Once in the room, the VA hit the closed door with his/her fists and banged his/her head. P1 called P2 and another staff person to come to the facility to fill the SP’s shift. The other staff person arrived and assisted P1 getting the VA out of the house and into the van in the garage to wait for P2 and law enforcement (LE). P2 and LE arrived and the SP was assessed and transported to a hospital to be evaluated. The VA exhibited verbal aggressions and property destruction due to not being able to leave for a snack due to the incident. Medical records showed the SP was seen in the emergency room (ER) on April 1, 2026, for “suicidal homicidal ideation threats.” The SP had a blood alcohol content level of 0.37%. P1 provided the following information: · On April 1, 2026, P1 arrived for work and the SP was sitting on the couch in the basement living room. The SP did not answer and P1 “though [the SP] was maybe having a bad day.” P1 did some work in the office and at 2:35 p.m., went upstairs to greet the VA when the VA returned to the facility from a work program. The VA and P1 went back downstairs, the VA bathed, and P1 administered the VA’s afternoon medication. The SP was wearing a hoodie and was slouched back on the couch. P1 asked the SP if s/he was ready to take the VA on an outing and the SP did not respond and appeared to be “sleeping.” P1 “shook” the SP a few times and when the SP did not respond, P1 was “concerned if [the SP] was alive.” P1 checked and saw the SP was breathing, so P1 shook the SP harder to wake him/her up. The SP opened his/her eyes, his/her eyes rolled back, and the SP said, “Back the fuck up [n-word], I’m going to kill you.” P1 backed away from the SP and asked the SP if s/he was okay. The SP said something similar to, “I’m going to kill you,” along with some curse words. The VA kept repeating the name of the gas station they were supposed to go to for the outing. The SP told the VA, “Shut the fuck up you fat bitch, I’m going to kill you too.” The SP had “slurred” speech when s/he spoke. · P1 believed the SP was under the influence of a substance and his/her behavior was not typical behavior for the SP. P1 remained with the VA and the SP at the facility from the time the VA got home until LE arrived, around 3 p.m. · P1 worked with the SP for two to three weeks and did not have any previous concerns. The SP previously worked at the facility and was good with the VA. The VA was excited when the SP worked. · P1 took the VA to his/her room and called P2 and another staff person to come to the facility to assist with the VA. The VA typically went to the gas station on Wednesdays to get “treats” and had behaviors when his/her routine was disrupted. Outings to the gas station occurred at 3 p.m. and due to the SP’s behavior, the outing that day was delayed. The VA started having behaviors and pounded on walls with his/her fists. · The other staff person arrived and assisted P1 with getting the VA upstairs and out of the house. P1, the VA, and the other staff person waited in the facility vehicle in the garage. The VA continued to have behaviors in the vehicle. · P2 and LE arrived and the SP was transported by ambulance to the hospital. · P1 did not believe the VA understood the situation and was not affected by the SP’s actions, other than having behaviors due to being late for the outing. · P1 showed this investigator a text message from the SP dated April 6, 2026. In the text message, the SP stated, “I had a couple drinks like 3 hours before work, and my back was thrown out, so I had a bunch of Tylenol PM. No excuses. The nurses said that’s why I blacked out.” P2 provided the following information: · On April 1, 2026, around 2:55 p.m., P1 called P2 and said the SP seemed to be under the influence of something and threatened P1 and the VA. P2 called LE and went to the facility. P2 stood by while LE assessed the situation and the SP was transported to the hospital. · The SP was a “good employee,” did a “tremendous” job with the VA, and P2 had not seen that type of behavior from the SP in the past. · The VA was a “high behavior” individual and required a staffing ratio of 2:1 during awake hours. The VA did not seem to be affected by the SP’s actions and was more worried about going on his/her outing. The G and CM said the VA had “high behaviors” and had lived at the facility for many years. There were no concerns with the facility or any other staff persons at the facility. P1, P2, and the SP were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion: Consistent information showed that on April 1, 2026, P1 arrived for work at the facility and saw the SP sitting on the couch and appeared to be sleeping. The SP failed to respond to multiple attempts by P1 to wake the SP up. The SP opened his/her eyes, his/her eyes rolled back, and the SP made threatening statements to P1, which included, “Shut yo bitch ass up, [n-word],” “I’m gonna kill you bitch ass [n-word],” and “Shut the fuck up before I kill you bitch,” and told the VA, “I’m gonna kill you too fat ass bitch. Shut up fucking bitch.” P1 was able to get the VA into his/her room until an additional staff person arrived to assist. The VA was then taken to the facility vehicle until LE arrived. The VA had behaviors that included head banging and pounding on walls and a door with his/her fists due to his/her outing being delayed due to the SP’s behavior. The SP was transported to the ER for suicidal and homicidal ideation threats. The SP had a blood alcohol content level of 0.37%. The SP sent P1 a text message five days later and stated s/he had consumed “a couple drinks 3 hours before work.” Regarding neglect: Although the SP was under the influence of alcohol and sleeping and/or passed out during his/her shift given that the SP did not give medications or drive the VA, that P1 was also at the facility to provide supervision to the VA, and that there was no harm to the VA, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services which were reasonably necessary to obtain or maintain the VA’s physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding emotional abuse: Although the SP called the VA names and threatened the VA which was inconsistent with the role of a professional caregiver in a facility licensed by the Minnesota Department of Human Services and was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), given that it was a single incident, and that there was no information to show that there were any similar incidents, there was not a preponderance of the evidence whether the SP’s conduct was repeated and/or rose to the level of emotional abuse. It was not determined whether emotional or 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: 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 policies and procedures were adequate but not followed, the VA’s plans were not implemented as applicable, and there was a need for corrective action. P1 was retrained on policies and procedures and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Given the facility took immediate action to address the violation outlined in this report, a Correction Order was not issued.
|
