|
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: 1100198-AFC (Adult Foster Care) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that a staff person (SP) put his/her hands on a vulnerable adult (VA) to get the VA out of bed and that the SP pushed the VA while assisting the VA inside causing the VA to land on his/her neck and scream in pain. The SP also told the VA that if anyone cared about the VA the SP “would be arrested already.” Date of Incident(s): May 23 and 31, 2023 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 June 14, 2023; from documentation at the facility; and through four interviews conducted with one supervisory staff persons (SP), the VA, and two of the VA’s case managers (CM1 and CM2). The VA’s diagnoses included mood disorder and antisocial personality disorder. The VA liked playing video games, hunting, fishing, and watching movies. There was a sidewalk that led up to the facility and then two concrete steps to a landing outside of the front door. There was another step up into the doorway. The main level consisted of a living room, kitchen, and dining room. Along a hallway there were three bedrooms and a bathroom. The lower level consisted of a family room, two bedrooms, a bathroom, and laundry room. The VA provided the following information: · The VA said that s/he had a few interviews with the SP before moving in and the SP seemed “legit,” and the VA was “excited” to be moving in (May 3, 2023). The VA stated the day s/he moved in when his/her workers left the SP “flipped a switch” and the SP started “being short and passive aggressive.” The VA asked the SP if something was wrong and the SP replied, “I have to do what I have to do to get clients.” · The VA thought the SP would “change [his/her] tune” so the VA gave the SP the benefit of the doubt. The VA said 24 hours later the SP became “aggressive” so the VA tried to contact his/her workers to let them know and the SP retaliated and told the VA that s/he “cannot contact people about me, I am kicking you out, I am done.” · A couple of days later the VA called law enforcement to mediate and diffuse a situation between the VA and the SP. The VA said law enforcement believed the SP and when they left the SP grabbed the VA by his/her arms and “shoved” the VA into the wall and left bruises. The VA said s/he told the SP to “get your hands off me or I am going to fuck you up.” The VA pushed the SP off and said, “If you ever touch me again, I will hurt you.” The VA went to his/her bedroom and then called a cab to go to a coworker’s house. · The VA left and went into work and then went out with the coworker after they were done working. The VA stayed until 1 a.m. and did not remember anything but said s/he was “found dead in the parking lot and flatlined five times” on the way to the emergency room and “two more times in ICU.” The VA then stated that s/he had to have his/her spine “cemented” back together and that s/he needed a wheelchair. The VA said that the emergency room called the SP and the SP said, “I hope [s/he] fucking dies.” · The VA said when s/he went back to the facility, s/he had no feeling in his/her legs and the SP refused to help him/her. The VA said the SP kept coming into the VA’s bedroom and the VA could not defend him/herself. The VA said the SP “grabbed my legs and knocked me on the ground.” The VA said s/he was on pain killers, was “very fragile,” and the SP “yanked” the VA off the bed “countless times.” · The VA said one time s/he was having a hard time getting inside after smoking and the SP “shoved” the VA over the walker the VA was using onto concrete steps. The VA screamed “bloody murder.” The VA got back inside and called someone from a church, and they set the VA up in a hotel for a week and the VA refused to go back to the facility. · The VA did not wish to continue his/her interview with this investigator, so no further information or details were obtained. Medical Records showed that on May 7, 2023, at 2:36 a.m., the VA presented to the emergency department for an altered mental status. The VA presented with no obvious signs of trauma other than some abrasions to his/her leg. There was concern for aspiration, so the VA was intubated. A head CT showed no obvious signs of intercranial hemorrhage. The VA was admitted to the ICU. The VA was extubated at 2:29 p.m. and left about two hours later AMA (against medical advice). The VA left the hospital to wait for a cab in the hospital parking lot and s/he tried to have a cigarette, became dizzy, and fell to the ground. The VA was brought back into the emergency department at 4:05 p.m. stating numbness with light touch and refused a cervical collar. An ECG (electrocardiogram) was performed. The results of the ECG were “NSR [normal sinus rhythm] with rate of 79 bpm [beats per minute]; normal intervals, normal conduction; no ST-T wave changes.” The VA refused a CT scan and left AMA again at 4:58 p.m. The VA was discharged and walked a couple steps to a wheelchair and was then assisted to the waiting room. The VA returned to the facility. The VA returned to the emergency department on May 8, 2023, at 8:19 a.m. stating that once s/he went to the facility s/he could not walk and that s/he needed a wheelchair. The VA said s/he had staff persons that helped the VA. The VA said s/he “fell down the stairs and hit the concreate.” The VA stated s/he hit his/her head. The VA refused all medications and interventions and left AMA again. The VA stated that s/he lived in a “halfway house” and an emergency department staff person tried to “contact them without success.” There were “no discharge medications for [the VA].” The SP provided the following information: · The VA moved in on May 3, 2023, and did not need supervision while the VA was outside smoking. The SP said that a few days after moving in the VA wanted to go and pick up some of the VA’s items. The SP said the VA became “explosive” in the car, yelling and insulting the SP. The SP was “shocked” and tried to calm the VA down. The next day the VA told the SP, “I do not think you want me here.” The SP told the VA that the plan was that the VA was going to be at the facility and a “few months from now, get [his/her] own place.” The SP thought the VA misunderstood and that the SP did not want the VA at the facility. · On May 7, 2023, the VA “wanted to go to work, got drunk, and then [s/he] got in an accident.” The VA told the SP that s/he was brought to the hospital by the police and that s/he discharged him/herself and came back to the facility. The SP said the day after the VA came back, s/he seemed to be having a hard time walking, but the SP did not see any physical injury. The VA had a wheelchair, and the SP told the VA that the facility was not set up for that, so the SP provided the VA with a walker, and then assisted the VA with the stairs to go outside when the VA wanted to smoke. · The SP said the VA yelled at staff persons and called the SP a “criminal.” The SP told the VA s/he could not act like that and that the SP had other clients, s/he was responsible for. The VA called the police on multiple occasions, and they came out and talked with both the VA and the SP. · The SP said the VA had a bag in his/her bedroom that s/he asked staff persons to carry for him/her, otherwise the VA was able to get in and out of bed by him/herself and used the walker to get around. · On May 31, 2023, around 11:00 p.m., the VA went outside to smoke, and the SP accompanied the VA and assisted getting the VA out the door. About 30 minutes later the VA wanted to come back inside, so the VA used the walker to pull him/herself up and the SP helped get the VA’s leg on the step. The walker was stable on the second step when the VA leaned forward, tumbled, and was about to fall when s/he caught him/herself. The VA did not fall but the VA said s/he felt some pain, so s/he waited there for a few minutes, then went up the smaller step into the facility and to his/her bedroom on the main level. The SP stated that s/he had no knowledge of the VA falling and being injured. · The SP did not say anything about being arrested to the VA. The SP said that if the VA needed assistance, the SP could call for help. The SP said from the moment the VA moved in the VA stated that the SP, “should not have this job, that [the VA] can report me, and get the licensed revoked.” The SP did not know why the VA said these things. · The SP stated that the VA was able to get out of bed by him/herself and the SP stated s/he did not provide assistance to the VA when the VA got out of bed and denied pushing the VA. CM1 and CM2 provided the following information: · CM2 said it was a pattern with the VA that things would be “okay a couple days” then it was “up and done,” but with the SP, CM2 felt it was always “aggressive” like the SP was “frustrated and overwhelmed.” CM2 was not sure if the SP was “reacting the best way.” CM2 said the SP was terminating the VA’s services due to the VA needing a walker and not being able to provide that level of care for the VA. CM2 thought it was more about the VA’s behaviors though. CM2 said the VA was not an accurate reporter, that s/he would say things like s/he “flatlined five times” at the hospital when that did not happen. · The VA told CM1 that the SP “physically put hands on [the VA] and yanked [the VA] out of bed.” · The VA told CM1 that the VA went outside to smoke early in the morning and the SP was with the VA and that the SP “pushed” the VA. The VA said s/he hurt his/her back. The SP told CM1 s/he tried to help the VA, but the VA fell and refused help from the SP. CM1 spoke with the SP once a day, mainly because the VA was threatening staff persons, and to check on the VA’s behavior. CM1 said s/he did not have concerns about the SP and did not get “a vibe” between the SP and the VA when CM1 visited the facility regarding whether the SP or the VA was more accurate with the information they provided. Law enforcement stated that there were several reports made by the VA and at this time law enforcement was not investigating further due to insufficient evidence to prove a criminal assault occurred. The SP was trained on the VA’s plans and the Reporting of Vulnerable Adults Act. Conclusion: Consistent information was provided that on May 7, 2023, the VA left the facility and ended up in the emergency department. After this the VA used a walker that was provided by the SP to move about. On May 31, 2023, the VA went outside to smoke a cigarette and when s/he was returning into the facility the VA stated that the SP “pushed” the VA to the ground. The SP stated that the VA leaned forward and almost fell but caught him/herself. The VA expressed that s/he was in pain, but after a few minutes, went into the facility and into his/her bedroom. The SP did not see any physical injury to the VA. The VA stated that after his/her injury the SP “grabbed my legs and knocked me on the ground.” The VA said s/he was on pain killers, was “very fragile,” and the SP “yanked” the VA off the bed “countless times.” The SP stated that the VA did not need assistance getting out of his/her bed so the SP did not assist the VA with that. The SP denied pushing the VA. The VA told CM1 about the SP putting his/her hands on the VA and pushing the VA when the VA went outside to smoke. CM1 did not have concerns about the SP. CM2 stated that there was a pattern with the VA that things would be good and then it was “up and done,” but with the SP, CM2 felt it was always “aggressive.” CM2 stated that the VA was not an accurate reporter. Although the VA stated that the SP put his/her hands on the VA to get the VA out of bed, and that the SP “pushed” the VA on the stairs after the VA smoked a cigarette, given that the CM2 stated that the VA was not an accurate reporter, that CM1 had no concerns with the SP, and that the SP denied assisting getting the VA out of bed and pushing the VA, there was not a preponderance of the evidence whether there the SP’s actions and conduct produced or could reasonably be expected to produce physical pain or injury. The VA did not provide any information to this investigator about the SP’s comments about people not caring about the VA. The SP denied saying anything about being arrested to the VA. The SP said that if the VA needed assistance, the SP could call for help. The SP said from the moment the VA moved in the VA stated that the SP, “should not have this job, that [the VA] can report me, and get licensed revoked.” The SP did not know why the VA said these things. Although it was reported that the SP told the VA that if anyone cared about the VA the SP would be arrested already, and that the VA said (although the VA did not hear it) the nurses said the SP said s/he “hopes [the VA] fucking dies,” given that the VA did not want to continue his/her interview with this investigator so did not provide further information or details, that the SP denied saying that, and without further evidence to support or refute this allegation, there was not a preponderance of the evidence whether the SP’s actions caused the VA emotional distress. It was not determined whether physical and 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 found their policies and procedures adequate and followed by the SP. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
