|
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: 1071646-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) pushed a vulnerable adult (VA) into his/her wheelchair and told the VA s/he was going to bed. The SP assisted the VA into his/her bed “hastily” and the VA’s legs were left hanging off the bed. After the incident, the VA had red marks on his/her left shoulder. Date of Incident(s): July 10 - 11, 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), clauses (1) and (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: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · 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 July 31, 2026; from documentation at the facility; and through twelve interviews conducted with two facility supervisory staff persons (P1 and P2), five staff persons (P3 - P7), the SP, three residents (R1 – R3), and the VA’s case manager. Although the VA was interviewed, s/he did not provide information about the incident. The VA enjoyed going on community outings, working on craft projects, watching television, listening to music, smoking cigarettes, and going out to eat. The VA’s diagnoses included anxiety, depression, traumatic brain injury, substance abuse, and diabetes. The VA was not subject to guardianship. The VA used a walker or wheelchair for mobility. The VA’s bed was low to the floor to help prevent slipping off the bed when seated on the edge. The VA’s Risk Assessment Detail stated that the VA was susceptible to physical abuse due to his/her limited mobility. The staff persons were trained to check the VA for signs of abuse such as bruises or scrapes. The VA’s bedroom was located next to the staff office, which is where the overnight sleep staff person was able to sleep when not needed to assist the awake staff person. R1 stated that the staff persons worked hard and treated the residents well. R1 never heard any of the staff persons yell or swear at the residents. R2 stated that he enjoyed living at the facility and never heard the staff persons yell at the residents or act aggressively with the residents. R3 stated that the staff persons were sometimes “loud,” but R3 never heard them swear or scream at the residents. R3 did not see any of the staff persons act aggressively with the residents. P1 provided the following information: · P1 typically worked twice a week from 10 p.m. to 7 a.m. as an “asleep overnight” staff person. An awake staff person also worked that shift. The VA rarely said more than one or two words to P1. The VA used a walker to move around the facility and liked to go outside, smoke cigarettes, and then return. The VA needed assistance getting into bed because s/he was unable to lift his/her legs onto the bed. During the night, the staff persons checked on the VA every 15 minutes. Between 3 and 4 a.m., the VA usually woke and sat on his/her bed or the floor. P1 and the other staff person then helped the VA get up, change clothing, and go to the kitchen for breakfast. The staff persons also checked the VA for injuries or marks when they assisted him/her with dressing. · On July 10, 2026, at 10 p.m., P1 arrived at the facility and worked with the SP. The SP told P1 that s/he did not need assistance with getting the VA to bed. P1 told the SP to wake P1 if s/he needed assistance and P1 went to sleep. P1 heard “a lot going on” during the night, which was typical since R1 and R2 were frequently moving around and the VA listened to a radio during the night. At approximately 4 a.m., P1 woke and heard “blaring and screaming” so s/he got up and walked into the VA’s bedroom, where s/he saw the VA standing by his/her dresser next to his/her wheelchair and the SP standing about two feet from the VA. The VA was only wearing underwear. The SP “yelled” at the VA to “sit the fuck down, sit down right now, sit down.” P1 asked the SP what was happening and the SP turned and “got a look on [his/her] face,” but did not answer P1. P1 tried to calm the SP and VA, but the SP “grabbed” the VA’s left arm and pulled the VA into his/her wheelchair. P1 told the SP to stop and then noticed that the VA had three marks on his/her back that looked like scratch marks. When P1 asked about the marks, the SP “got quiet.” Neither the VA nor the SP answered P1. The VA was shaking and “distraught” and P1 believed the VA felt intimidated. P1 stated that the VA had the marks prior to when the SP pulled the VA into his/her wheelchair. · The VA’s radio was very loud, so P1 turned away from the SP and VA to turn off the radio. As s/he tried to turn down the volume, the SP took the VA’s wheelchair to the VA’s bed and moved the VA partially onto his/her bed and walked out of the room. When P1 turned back to the VA, the VA’s upper body was on the bed, the VA’s legs were off the bed, the VA was shaking, and his/her eyes were red and watering. P1 moved the VA fully onto his/her bed and asked what was wrong. The VA told P1 that the SP “does this to me all the time.” The VA also said that the SP was “mean” to him/her and “hurt” him/her. When P1 questioned the VA, the VA repeated what s/he had already told P1. P1 had never had such a long conversation with the VA before. P1 wiped the VA’s nose and face and told the VA that s/he would sit with him/her until s/he fell asleep. P1 believed it was approximately an hour before the VA slept. When P1 left the VA’s bedroom, s/he did not see the other residents, but the SP was sitting in the living room. P1 did not talk to the SP. P1 was unable to find the paperwork to document the marks on the VA. When another staff person arrived for their work shift, P1 left and called P2 to tell him/her about the incident. P2 – P7 provided the following information: · P2 stated that on the morning of the incident, P1 contacted P2 to let him/her know about what s/he saw. The SP was taken off the work schedule. · P3 stated that on one occasion, s/he arrived for his/her work shift and saw a red mark on the VA’s side and three marks on his/her back that resembled scratches from fingernails. The marks were one to two inches long. P3 documented the marks. P3 had not previously seen any similar marks on the VA. When P3 asked the VA how the marks occurred, the VA was unable to provide information about what occurred. · P4 stated that s/he always worked the asleep overnight shift. In the mornings, s/he assisted the awake overnight staff person with getting the residents out of bed and dressed. S/he also helped change the residents’ bedding and prepared breakfast. · P2 stated that prior to the incident, none of the staff persons documented that the VA had unexplained marks on his/her back. The VA did not talk to any of the other staff persons about the incident. P3 stated that the staff persons assisted the VA with dressing in the morning and evening, so someone would notice any marks on the VA at those times and document them. The VA sometimes had marks on his/her body because s/he fell. The VA typically fell when s/he slid out of a chair or his/her bed or when s/he squatted to pick something up. At those times, the VA usually fell on his/her side or back. P6 stated that the VA sometimes had marks on his/her body, but the staff persons documented when the marks occurred. It was “very rare” for marks to “just come out of nowhere” and not be documented. Consistent information was provided that it was unlikely that the VA would be able to cause the marks on his/her back. · P3 stated that s/he often began his/her work shift as the SP was ending his/her shift. The SP sometimes had finished all of his/her night chores when P3 arrived, but sometimes did not finish everything s/he was supposed to do. The SP became “defensive” if P3 asked about why things were not completed. The VA often did not like staff persons, such as the SP, who were of a different culture and it took time for the VA to accept them. Although the VA said “awful” things to the SP, P3 never heard the SP respond harshly. · Consistent information was provided that the VA often refused to talk to anyone or responded in short, one word answers. P2 stated that the VA sometimes did not sleep at night and used his/her walker to go between the living room and outside to smoke cigarettes. Consistent information was also provided that the VA did not tell any of the staff persons that the SP was mean to the VA or hurt him/her. · P2 stated that the VA sometimes “slid” out of his/her bed onto the floor, so the staff persons checked on the VA every 15 minutes. There was a button in the VA’s bedroom that the staff persons had to press every time they went into the VA’s bedroom to check on him/her. If the staff persons did not push the button every 15 minutes, P2 was notified. On the night of the incident, the SP failed to push the button as required several times. · P2 stated that prior to the incident, none of the staff persons brought concerns about the SP’s interactions with the residents to P2’s attention. P3 stated that s/he never saw the SP “be mean” to the VA and the VA never told P3 that the SP was mean to him/her. P4 believed that the SP checked on the VA every 15 minutes as required and P4 never saw the SP yell at any of the residents or treat them roughly. P5 never saw any staff person yell at the VA or handle him/her roughly. P6 felt that the VA and SP “kept their distance” from each other, but s/he never saw any “alarming things” stand out between them. P7 never heard the SP become upset or loud with the VA. The SP provided the following information: · The SP worked at the facility as an awake overnight staff. At one point, s/he asked P2 if s/he could move to an asleep overnight position because s/he was having trouble working all night and then also working during the day. P2 told him/her to look for openings in other facilities. When the SP worked at the facility, the VA was often awake during the night. Sometimes the VA slid out of his/her bed and the SP found him/her on the floor. The SP then helped the VA stand and either go back to bed or go to the living room. · On one occasion, P1 worked the overnight sleep shift with the SP. The SP had not worked with P1 before. P1 went to sleep and the SP did his/her usual checks of the residents. At approximately 6 a.m., the SP found the VA on the floor and asked the VA if s/he was hurt and could help him/her get up. The VA said s/he was fine and asked for help getting up, so the SP helped the VA get up by placing his/her arms under the VA’s arms and lifting the VA. The SP helped the VA get back into bed and then changed the VA’s adult disposable brief and asked the VA if s/he wanted to get up for the day. The VA told the SP s/he wanted to sleep. The VA asked the SP to turn up the volume on the radio. The SP told the VA that it was already loud and the VA said something to the SP that s/he could not understand, so s/he turned the volume down and the VA stood and walked to the radio. The SP stated that it was the first time s/he saw the VA walk without assistance. The VA also spoke clearly, unlike his/her usual one or two word comments. The SP backed away so that the VA could adjust the volume of the music and then assisted the VA back to his/her bed. The SP did not recall if s/he used the wheelchair or the walker to move the VA back to his/her bed. The SP told the VA to ask if s/he needed anything else. · While the SP was talking to the VA, P1 woke and entered the VA’s bedroom and asked the SP if s/he needed help. At that time, the SP had already helped the VA back into his/her bed. The SP told P1 that s/he did not need help and that the night had been “fine.” P1 did not say anything to the SP about not hurting the VA and did not have any further conversation with the SP. The SP took the VA’s bedding to the laundry room and when s/he returned to get the trash, the VA and P1 were “whispering and talking,” but the SP could not hear what they were saying. The SP stated that it was a normal night, with no issues, except for the whispering between the VA and P1. The SP did not yell at the VA, grab the VA’s arm, or pull the VA into his/her wheelchair. The SP did not tell the VA that s/he had to go back to bed. That morning, the VA was calm and did not swear at the SP and was agreeable to the SP assisting him/her. The SP stated that the marks might have occurred when s/he lifted the VA off the floor, but at the time, the VA did not say that the SP hurt him/her and the SP did not see any scrapes on the VA’s back. The SP was not “mean” to the VA, did not put his/her hands on the VA in anger, or hurt the VA. The SP did not know why the VA would say that s/he did those things. · The SP was scheduled to work that night, so s/he planned to complete his/her shift documentation at that time. The SP was doing laundry and taking out the trash when P1 told the SP that s/he was leaving. There was no further conversation between the SP and P1. The SP remained until the morning staff person arrived for their work shift. Later that day, P2 called the SP and told him/her that s/he was suspended. · The VA wore chains around his/her neck and several rings on his/her fingers. Sometimes the VA had red spots in the morning from the chains or rings rubbing against his/her skin. The SP did not see any marks on the VA and did not know how they occurred. The CM stated that the VA typically used a wheelchair for mobility and often attempted to transfer to and from his/her wheelchair without assistance, which sometimes resulted in falls. The VA needed the assistance of the staff persons to complete personal cares. The VA rarely spoke and the CM was uncertain how aware the VA was of what happened around him/her. The VA did not have a history of being an unreliable reporter of events. 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 VA’s plans prior to the incident. Conclusion: On July 10 – 11, 2026, the SP worked at the facility as an awake overnight staff person and P1 worked as an asleep overnight staff person. P1 stated that s/he woke early because s/he heard “blaring and screaming” so s/he got up and walked into the VA’s bedroom, where s/he saw the VA and the SP standing by the dresser. P1 noticed three scratch marks on the VA’s back. The SP “yelled” at the VA to “sit the fuck down, sit down right now, sit down” and pulled the VA into his/her wheelchair. The SP then assisted the VA partially into his/her bed, but left his/her legs hang over the side of the bed. The SP left the bedroom and P1 helped the VA into bed and calmed him/her. The VA told P1 that the SP always “hurt” him/her and was “mean” to him/her. The SP stated that s/he was not “mean” to the VA, did not put his/her hands on the VA in anger, or hurt the VA. The SP did not know why the VA would say that s/he did those things. The SP did not know how the marks on the VA’s back occurred. Consistent information was provided that the VA did not tell any of the other staff persons that the SP was mean to the VA or hurt him/her. None of the other staff persons had concerns about the SP’s interactions with the VA. The VA and the other residents did not express any concerns about the SP’s interactions with them. Although P1 stated that the SP yelled at the VA to “sit the fuck down, sit down right now, sit down” and that the VA told P1 that the SP was mean and hurt the VA, P1 stated that s/he saw the marks on the VA’s back prior to when the SP pushed the VA into the wheelchair, it was unclear when or how the marks occurred; P3-P7 had never seen/heard of any prior concerns regarding the SP’s interactions with the VA making it more likely a single incident of yelling/swearing; and the SP denied causing the marks unless it happened inadvertently as s/he lifted the VA from the floor. Therefore, there was not a preponderance of the evidence whether the SP’s actions produced physical pain or injury or emotional distress to the VA. It was not determined whether physical or 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. 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 were not followed by the staff persons. After the incident, the VA’s plans were updated. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
