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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: 1092294-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Marie Tierney Suspected Maltreatment Reported: It was reported that a staff person (SP) had a sexual relationship with a vulnerable adult (VA). During the investigation, information was received that on one occasion the SP choked the VA; and that on multiple occasions the SP purchased, possessed, used, and was under the influence of cocaine while driving and providing other services to the VA. Date of Incident(s): Multiple dates from November 2020 through January 23, 2021 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 (1); and subdivision 2, paragraph (c); 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. 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 November 17, 2021; from documentation at the facility and law enforcement records; and through ten interviews conducted with the VA (with law enforcement), the SP, the VA’s case manager (CM), the VA’s mental health professional (MHP), a former resident (R) of another facility operated by Bridges MN, and five facility staff persons, including supervisory and administrative staff persons (P1 – P5). The SP participated in a separate interview with law enforcement prior to his/her interview with the DHS investigator. The DHS investigator made multiple requests by phone and by mail to interview a former facility supervisor (P6), but P6 did not respond, and therefore was not interviewed. The facility’s file for the VA documented that the VA enjoyed fishing, exploring the community, and long car rides, including day trips to Duluth, Minnesota (an approximate two hour drive from the facility) with staff persons. The VA received 12 hours per day of one to one staffing, and 12 hours per day of two to one staffing, in large part because the VA displayed frequent and significant self-harm as well as physical and verbal aggression towards others. The VA had restricted access to sharps due to self-harm. The VA might make false reports about staff persons s/he did not prefer. The VA was vulnerable to physical and sexual abuse, and if staff witnessed or suspected abuse, they were to remove the VA from the situation and report suspected sexual abuse as required. When the VA was upset, walks or car rides helped him/her calm. The SP worked at the facility from November 1, 2020, through March 7, 2021. The VA lived at the facility throughout the time period that the SP worked there. The VA was hospitalized from January 23 through March 15, 2021, due to increased self-injurious behaviors including cutting him/herself. The VA discharged from the facility on August 14, 2021. The VA provided detailed and consistent information about the alleged incidents during his/her interview with law enforcement and the DHS investigator, and in text messages to the DHS investigator, including the following: · The VA and the SP went on frequent car rides together. The VA and the SP were attracted to one another and in November of 2020 they began “being touchy” including hugging one another and playfully poking one another. The touching escalated and the SP began “grabbing” the VA’s thighs and other parts of the VA’s body during car rides. The touching escalated further to the VA and the SP touching one another’s buttocks over the clothing. · During one car ride in November 2020, the SP parked the vehicle in a secluded area then the SP and the VA stood next to the vehicle and the SP “groped” and “fondled” the VA, including putting his/her hand down the VA’s pants and penetrating the VA with the SP’s finger. · After that, the VA and the SP frequently went on car rides and parked in secluded areas, including church parking lots and state parks. During these outings, the SP fondled and penetrated the VA with the SP’s finger. · On an unspecified date in December 2020, the VA and the SP went to the SP’s apartment, and while they were there the SP asked the VA if s/he was “in the mood” to perform oral sex on the SP. The VA said, “Yes,” and performed oral sex on the SP in his/her apartment. After that, during most outings, the VA performed oral sex on the SP and the SP fondled and penetrated the VA with the SP’s finger. (Note: The VA provided the correct address and unit number of the SP’s apartment.) · Once the sexual contact with the SP began, it occurred nearly every time the SP worked at the facility. The VA said, “It was just kinda like we were in a relationship.” · Sometimes the SP’s and VA’s car rides were in a facility vehicle, and sometimes they were in the SP’s vehicle. When the VA and the SP were using a facility vehicle for the car rides, they had sexual contact outside of the vehicle because they were “paranoid” there were cameras or audio recording devices in the facility vehicle. · On one occasion, the VA told the SP s/he was going to tell other facility staff persons about the VA and the SP’s relationship. The SP became upset and choked the VA’s neck with the SP’s hands. The VA said while the SP choked him/her, the SP looked at him/her “like [s/he] wanted me dead,” and, “All I can really remember is the fear in my eyes, how big they were when [s/he] was choking me.” The SP eventually stopped choking the VA and the VA “broke down” and began cutting his/her neck, chest, and arms, and the SP did not try to stop him/her. The VA got out of the vehicle and began to walk away, but the SP convinced him/her to get back in the vehicle. The SP apologized and the two drove around for some time then parked in a secluded area and the VA performed oral sex on the SP while the SP penetrated the VA with the SP’s finger. The VA said, “For some reason, I felt like I was obligated to like fix kind of the situation by doing that.” · Sometimes the SP fondled the VA’s breasts over and under the clothing to calm the VA when s/he displayed self-harm. The VA said, “I don’t know why but for some reason it calmed me down.” · Sometimes the SP slept in his/her vehicle while the VA was with him/her. The VA got bored and looked through the SP’s vehicle and found sharps such as knives, tools, glass, and razor blades that had been previously removed from the facility. The VA kept some of these items and later used them to self-harm. · On several occasions the SP brought the VA to the SP’s family member’s home (FM), where the SP slept and/or did laundry and the VA met the FM and other family members. (Note: The VA supplied the FM’s first and last name and address of the FM’s home and described landmarks around the FM’s home that were accurate for that address. The SP confirmed that the FM lived at that address.) · The SP often purchased, used, and/or was under the influence of cocaine during outings with the VA. The VA tried to convince the SP to stop using cocaine, due to concerns about the SP’s health and safety. The VA said on one occasion, the VA, the SP, and the SP’s friend (F) rode in the F’s vehicle to a “drug dealer” from whom the SP and the F purchased cocaine. The VA supplied a photo from social media showing the SP with the F. (Note: Internet news articles showed that on February 5, 2021, the F was taken into custody by law enforcement, and a bag containing 2.9 grams of cocaine was found in the F’s residence.) · In July or August of 2021, the VA called P4 from the hospital and told him/her s/he wanted to “make a report.” P4 asked him/her if it was about the SP. When the VA said, “Yes,” P4 told the VA that s/he did not have time to discuss the VA’s concerns about the SP. The VA later told the MHP about his/her relationship with the SP. · The VA said s/he felt conflicted about disclosing the incidents to law enforcement and the DHS investigator because s/he was a willing participant in the sexual contact with the SP at first. However, over time the VA developed awareness of the exploitive nature of the SP’s conduct and s/he did not want the SP to have the opportunity to exploit other vulnerable persons. The following is a summary of additional information from law enforcement records, facility records, and interviews: · The MHP said the VA told him/her s/he had a sexual relationship with the SP. The VA did not provide much detail to the MHP, but did state that no sexual intercourse occurred. The VA told the MHP that s/he told P4 about the relationship. · P2 said s/he got “weird vibes” when the SP and the VA were together, but did not observe anything overtly abusive. P2 was aware that the SP took the VA to his/her home and introduced the VA to his/her friends and family, which P2 described as “weird.” On one occasion, P2 arrived at the facility at 11 p.m. and the VA and the SP were out on a car ride and did not return to the facility until approximately 1 a.m., at which time P2 saw blankets and pillows in the vehicle. The VA and the SP told P2 they had been at a beach. P2 told P6 about this concern, and P6 told P2, “It seems like [the VA] does better with [his/her] behaviors when [s/he] can lay on the beach and talk about [his/her] problems.” P2 also talked with P4 about his/her concerns, but s/he did not know what P4 did with the information. · P1 said s/he got an “eerie feeling of discomfort” when the VA was around certain staff persons, because the VA’s behavior changed and, “it felt like mischief was going to happen.” Sometimes P1 felt uncomfortable leaving the facility due to this concern. P1 said P2 told him/her that the SP and the VA went on car rides together and displayed “teenager mischief attitude” such as being giggly, smiling a lot, hanging on one another, and teasing one another when they left for car rides. Sometimes the VA and the SP brought blankets with them on the car rides, and some of their car rides lasted more than five hours. P1 informed P4 of these concerns and P4 said s/he would “take care of it.” P1 also told another administrative staff person whose name s/he could not recall. · P3 said in February or March of 2021, while the VA was hospitalized, P2 told him/her that s/he suspected the SP and the VA were having an “inappropriate relationship.” P3 asked why and P2 told him/her that they were quiet when they were together at the facility, and that the SP and the VA were often “gone all day.” When the VA returned from the hospital, another staff person (P8) asked the VA if “anything happened” between him/her and the SP, and the VA said, “No.” The SP no longer worked at the facility at that time. · The CM said there were no specific limits to the time of day the VA went on outings. However, the CM said that taking the VA out late at night and returning after midnight “did not seem appropriate for [the VA’s] supports” unless the VA attended a specific event in the community that ended late. The CM said returning to the facility that late “should be very occasional.” · The CM said that the VA needed help to maintain boundaries with others. The VA told the CM that a staff person (a different gender from the SP) brought the VA to his/her home, which the CM said was “not an appropriate thing to do.” The CM shared this information with facility management. · P3 said it was against facility policies and procedures to bring persons served by the facility to a staff person’s homes and, “They should not be doing that at all.” P1 said the facility did not consistently enforce professional boundaries for staff and clients, and that s/he tried to advocate for stronger boundaries but s/he was not supported by facility management. · The CM said the VA “can be an inaccurate reporter, but. . . a lot of [other] allegations [s/he] made [about facility staff persons] were backed up.” The VA had made two previous allegations of sexual abuse by a caregiver and for each allegation it was not determined whether sexual abuse occurred. The MHP described the VA as “a very accurate historian” who remembered details and was “typically forthcoming” when questioned. The MHP was not aware of the VA making any prior allegations of sexual abuse or any known false allegations about a caregiver. P1 said the VA often took photos of staff persons who appeared to be sleeping or doing other things that they were not supposed to do, in order to try to get the staff persons fired or disciplined. · P3 said staff should not use their personal vehicle to drive the VA because there was a facility vehicle for that purpose. P3 was aware of one exception when the facility vehicle was not working, and a staff person had to use their personal vehicle. That staff person was encouraged to submit a request for reimbursement for their mileage. P1 said the facility had two vehicles, but sometimes both were non-operational, so P4 authorized the SP to use his/her personal vehicle to take the VA for rides. P4 said typically staff persons used the facility vehicle but when it was not available, staff persons could use their personal vehicle and request reimbursement by completing a mileage reimbursement form. · P4 said s/he was aware that the SP “struggled with boundaries” regarding the VA, but P4 said s/he was not aware of any allegation of sexual abuse. When asked how the facility handled the VA’s difficulties with boundaries, P4 said, “Staff training and making sure we’re all being consistent. The biggest thing we’ve run into is if someone would handle [the VA] differently, give [the VA] the attention [s/he] wants and someone else wouldn’t then [the VA] would have behaviors. . . we tried to address that with staff training, and lay down boundaries like after hours you can’t call and text, things like that.” P4 said this training was provided in staff meetings, but s/he did not know whether it was documented. · P4 said s/he was “pretty sure” all staff persons were told during orientation that they should not take residents to their homes. In addition, the facility talked about this specifically with regard to the VA, because “that was something [the VA] would try to do.” P4 said s/he was not aware of any staff person taking the VA to their home. · P4 said it was “generally frowned upon” for staff persons to use social media with facility residents, and, “I think we would say they shouldn’t.” P4 was not aware of any staff persons having contact with the VA on social media. · P5 said on an unspecified date, s/he trained the SP on professional boundaries with the VA, but the training was not documented. Specifically, P5 clarified for the SP that s/he should not answer phone calls or texts from the VA when s/he was not working, that it was “absolutely unacceptable” to go to a staff person’s home with the VA, and “what we should and shouldn’t talk about” with the VA. P5 was not sure whether staff persons received guidance or training specific to the use of social media with facility residents.
During the investigation of another DHS report (#202109897) regarding a separate facility operated by Bridges MN, the R spontaneously provided the following information: · The SP also worked at the facility the R lived at. The R did not know the VA. · The SP brought cocaine and marijuana to the facility the R lived at. · On one occasion, the SP drove to the FM’s home with the R in the vehicle. The R provided information about the approximate location and landmarks near the FM’s home that were accurate for the FM’s address. At the FM’s home, the SP went inside, leaving the R in the vehicle. When the SP returned to the vehicle, the SP smelled like marijuana. The R asked the SP, “Did you pick up some weed?” and the SP said, “Yeah, just a little bit,” and “played it off like [s/he] did nothing wrong.” The facility completed an internal review that stated: · The VA had a history of becoming “obsessed” with staff persons of the SP’s gender and “had been known to cross boundaries” with staff persons of the SP’s gender. (Note: These concerns were not documented or addressed in the VA’s individualized plans.) · P2 told facility investigators that s/he heard a “rumor” from multiple staff persons who worked with the VA that the SP no longer worked at the facility because s/he had sexual contact with the VA. P2 said the VA and the SP had a “weird relationship,” the VA met the SP’s family and friends, and the VA had been to the SP’s home. In addition, the SP drove the VA around in his/her personal vehicle instead of the facility vehicle; and the SP and VA were often out on drives until around 1 a.m. and carried blankets and pillows into the facility. P2 said s/he reported these concerns to P6. · P4 said s/he was aware that the SP “struggled with boundaries” regarding the VA, but P4 said s/he was not aware of any allegation of sexual abuse. · A facility administrator (P7) said the SP was transferred to a different site operated by the same parent company, due to the VA “pushing boundaries” with the SP. For example, when the SP was not working, the VA “constantly” called the SP and engaged in negative behaviors; when the SP was working with an individual who lived on another floor of the VA’s home, the VA intruded on the other individual’s area to access the SP; and when the SP was leaving at the end of a shift, the VA engaged in negative behaviors to make the SP feel s/he needed to stay at the facility. · The facility interviewed the SP about the allegations. The SP denied any sexual contact with the VA and said, “That is definitely false.” The SP said that although the VA demonstrated poor boundaries with the SP (such as sending text messages to the SP and manipulating the SP and other staff), the VA never acted in any sexual way toward the SP. The SP denied going to the beach late at night. The SP said s/he did take the VA on drives, because taking drives in the community was one of the VA’s calming strategies. The facility’s policies and procedures included the following: · Staff persons were prohibited from “fraternizing” with facility clients, sharing personal information with clients, touching clients when it did not serve a “good purpose” to the client, “over-involvement” with clients such as spending inappropriate amounts of time with the client or visiting the client when off-duty, and “unprofessional demeanor.” Staff persons were expected to “teach our clients how to develop appropriate boundaries for themselves and with other clients and staff.” · Staff persons were prohibited from purchase, possession, use, or being under the influence of illegal drugs while on duty. · If a staff person knew or suspected that maltreatment of a vulnerable adult occurred, they were required to report the suspected maltreatment immediately (within 24 hours) either internally to the facility’s designated reporter, or externally to the Minnesota Adult Abuse Reporting Center. · The facility did not have any policies and procedures specific to staff persons bringing residents to their homes, staff persons bringing residents on social outings with friends of staff persons during work hours, or on staff persons’ use of social media with residents. The facility’s Program Abuse Prevention Plan stated that staff persons were to be trained on the following: “appropriate boundaries,” Vulnerable Adult reporting procedures, and each service recipient’s individualized plans. The following is a summary of information provided by the SP during his/her interviews with law enforcement and with the DHS investigator: · The SP denied sexual contact with the VA, denied choking the VA, and denied purchasing, using, or being under the influence of cocaine while providing services to the VA. · The VA and the SP went on frequent car rides because that was the VA’s preferred calming method. Although most of the drives occurred during daylight hours, some occurred at night time when needed by the VA. When asked whether they made stops during the drives, the SP initially said, “We wouldn’t really stop except for like gas. Even then [the VA] has run away multiple times so I wouldn’t want to stop.” However, later the SP said they stopped if the VA “acted up” or began harming him/herself, “Which actually that was a lot too, so yeah we definitely stopped multiple times . . . toward the end it got to be a pattern, [s/he’d] do it almost every time.” · The SP denied ever going to a beach with the VA. · The SP said sometimes the VA brought blankets along for car rides, but not pillows. · Typically the SP drove a facility vehicle for the VA’s car rides. On one occasion, the facility vehicle was not working, and P4 authorized the SP to use his/her own vehicle. The facility paid the SP mileage for this trip. When asked the process for getting mileage payment, the SP said s/he used a facility credit card to fill up his/her gas tank. · The SP acknowledged that s/he and the VA were “friends” on Facebook during the time the SP worked at the facility and provided services to the VA. Later, “I realized that was the worst idea ever because [the VA] liked every one of my pictures,” and the SP “unfriended” the VA. The SP said that s/he was not aware of any facility policy about staff persons interacting with service recipients on social media, and said that social media “never really came up” during his/her training. · The VA had been outside the SP’s apartment building on two occasions, but never inside the building. When asked to explain how the VA knew the SP’s unit number, the SP said that on the one occasion the SP drove the VA in his/her personal vehicle, the VA left his/her phone in the SP’s car. The SP looked through the VA’s photos on his/her phone and saw that s/he had a photo of a piece of the SP’s mail, which had the SP’s full address on it. · The VA had been to the FM’s house on rare occasions when the SP picked up cigarettes and other items from the FM’s house. · The SP said s/he was “sure” the facility had a policy about bringing service recipients to staff persons’ homes. However, due to staffing difficulties, the SP worked “crazy” and unpredictable hours at the facility, sometimes up to 48 consecutive hours. Therefore, the SP said s/he “had no choice” but to stop at his/her home one time, and the FM’s home multiple times, in order to accomplish important tasks in his/her own life. · The SP denied that the VA met any of his/her friends, and denied that the VA rode in any of his/her friends’ vehicles. When asked to explain how the VA was familiar with the F, the SP said s/he had talked about the F to the VA, “Which I’m not supposed to do.” The SP said s/he did not know whether the F used cocaine. · The SP stopped working at the facility because s/he told P4 that the VA “liked” the SP. P4 told the SP s/he was already aware of this and that s/he was already working on transferring the SP to a different site operated by Bridges MN. · The SP said s/he though the VA was “upset” with him/her because the SP did not respond to recent Facebook messages and “friend requests” from the VA. · The SP said P2 did not like him/her due to previous interpersonal conflict not related to the VA. The facility’s personnel files and training records documented the following: · The facility supplied documentation that P1 – P4 and P6 were each trained specifically on the facility’s policies and procedures for reporting suspected vulnerable adult maltreatment. P2, P3, P4, and P6 also completed multiple additional training modules about vulnerable adult maltreatment prevention and response. · The SP’s job duties included “understand and adhere to the Vulnerable Adult and abuse policy.” · The SP received no corrective action from the facility. · The SP did not request reimbursement for mileage expenses related to use of his/her personal vehicle to complete job duties. · The facility did not supply evidence that the SP was trained specifically on the following: - the facility’s policies and procedures for reporting suspected vulnerable adult maltreatment, - any other module related to vulnerable adult maltreatment, - professional boundaries, nor - the VA’s individualized needs However, the facility documented that the SP was trained on the facility’s policies and procedures in general in January 2020, and again in October 2020, as well as training on a variety of other topics amounting to over 60 hours of training. The facility’s failure to train the SP on the aforementioned were violations of: o Minnesota Statutes, section 245D.09, subdivision 4, clause (5), states in relevant part that within 72 hours of first providing direct contact services, the license holder must provide and ensure completion of orientation to the Reporting of Maltreatment of Vulnerable Adults Act, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; and o Minnesota Statutes, section 245D.09, subdivision 4a, paragraphs (a) and (c) state in relevant part that before having unsupervised direct contact with a person served by the program, a staff person must review and receive instruction on the person’s coordinated service and support plan or coordinated service and support plan addendum, and the person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Conclusion: A. Maltreatment: The VA told law enforcement and the DHS investigator that from November 2020 through the VA’s hospitalization on January 23, 2021, the VA and the SP had sexual contact on multiple occasions; the SP choked the VA on one occasion; and the SP purchased, used, and was under the influence of cocaine on multiple occasions while driving and providing other services to the VA. The SP denied any sexual contact with the VA, denied choking the VA, and denied purchasing, using, or being under the influence of cocaine while providing services to the VA. However, the SP admitted to “friending” the VA on Facebook and bringing the VA to the FM’s home on multiple occasions. The VA and the SP each had diminished credibility: · The VA had a documented history of making allegations of abuse including sexual abuse by caregivers, some of which were unfounded; and according to P3, in March 2021, the VA denied that “anything happened” between him/her and the SP. However, the MHP and the CM also each stated that sometimes the VA was truthful and reliable and some of his/her prior allegations were supported by other evidence. The VA provided detailed and consistent information in his/her account to law enforcement and the DHS investigator, and the VA provided consistent (though less detailed) information to the MHP. · The SP had reason to minimize his/her actions due to fear of repercussions; and the SP provided conflicting information to P2 and to facility investigators regarding whether s/he went to the beach late at night with the VA, and whether they stopped during the car rides, which diminished the SP’s credibility. However, several details of the VA’s account of the incidents were corroborated by other evidence: · The VA provided the SP’s accurate address and unit number. · The VA provided the FM’s accurate address, and P2 also said s/he was aware that the VA visited the FM’s home and met the SP’s friends and family. In addition, the R provided information that the SP also brought the R to the FM’s home on one occasion. · The VA provided information that the F purchased cocaine with the SP, and supplied a photo of the F and the SP together; and news articles showed that the F had cocaine in his/her possession on February 5, 2021. In addition the R also provided information that the SP used cocaine and marijuana while providing services to the R. Regarding sexual and physical abuse: Given that the VA and the SP each had diminished credibility, and there was no clear corroborating evidence regarding the alleged sexual abuse and physical abuse, there was not a preponderance of the evidence as to whether the SP choked the VA nor whether the VA and the SP had sexual contact. It was not determined whether physical or sexual 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; any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast.) Regarding neglect: P4 said s/he was aware that the SP “struggled with boundaries” regarding the VA. This information in combination with the details of the VA’s accounts that were corroborated by other evidence as mentioned above, was a preponderance of the evidence that the SP purchased, used, and was under the influence of cocaine on multiple occasions while driving and providing other services to the VA; that the SP “friended” the VA on Facebook, and that the SP brought the VA to the FM’s home on multiple occasions. Given the VA’s mental health support needs, it was reasonable that the VA would continue to need supports to develop and maintain the necessary life and social skills to live in the community. Further, given the VA’s history of becoming “obsessed” with staff persons of the SP’s gender and of “crossing boundaries” with staff persons of the SP’s gender, it was both reasonable and necessary to reinforce appropriate professional boundaries with the VA. The SP’s actions including “friending” the VA on Facebook and bringing the VA to the FM’s home hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationships which could interfere with other individuals’ attempts to provide therapeutic services to the VA, both now and in the future. In addition, purchasing, using, and being under the influence of illegal drugs while driving and providing other services to the VA, both involved the VA in illegal activities and endangered the VA when the SP drove under the influence. The SP’s actions were not accidental or therapeutic conduct and represented a failure or omission to supply the VA with reasonable and necessary care and services to maintain the VA’s physical or mental health or safety. It was determined that 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.) 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. Although P5 stated s/he trained the SP on professional boundaries with the VA, the facility did not supply documentation of this training. The facility also lacked evidence that the SP was oriented specifically to: the facility’s policies and procedures for reporting suspected vulnerable adult maltreatment, any other modules related to vulnerable adult maltreatment, or professional boundaries; or the VA’s individualized needs, which were violations as outlined above. Although the SP may not have received training as mentioned, the SP was trained on the facility’s policies and procedures in general in January 2020, and again in October 2020, as well as training on a variety of other topics amounting to over 60 hours of training. In addition, it is generally understood that the purchase, use, and driving while under the influence of cocaine is illegal and presents a risk to others in the vehicle. Therefore, it was determined that the SP was responsible for the neglect of the VA. Further, information from P1 and P2 was consistent that they told P6 (a facility supervisor), P4 (a facility administrator), and other unspecified facility management and administrative staff persons about their concerns about the SP’s boundaries and interactions with the VA, but there was no evidence that the SP received any corrective action. In addition, information from staff persons that showed there was variation among staff persons in their understanding of the facility’s expectations surrounding professional boundaries. Considering this information, in combination with the facility’s related lack of compliance with regulatory standards and training, it was also determined that the facility was responsible for the neglect of the VA. C. 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;” and whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “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 neglect for which the SP was responsible in this report did not meet the definition of serious or recurring maltreatment because the SP’s pattern of behavior toward the VA was considered a single incident of neglect for which the VA did not sustain a serious injury that reasonably required the care of a physician. However, information maintained by the Department of Human Services, in combination with this report, resulted in the SP being disqualified for recurring maltreatment. The SP was disqualified from providing direct contact services. It was determined that the substantiated neglect for which the facility was responsible was not serious maltreatment. The neglect did not result in serious injury which reasonably requires the care of a physician, and it was not determined whether the neglect resulted in criminal sexual conduct against a vulnerable adult. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed because P6 did not report suspected maltreatment as required. The incident was similar to past events with the persons or services involved because the VA “has a history of inaccurate reporting and not respecting personal/professional boundaries with staff members [and] has a history of becoming attached to [staff persons of the SP’s gender].” The facility determined there was no need for additional staff training or any other corrective action to be taken by the license holder to protect the health and safety of vulnerable adults in care. The SP, P1, and P6 no longer worked at the facility; and the VA no longer received services 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. On June 27, 2022, the facility was issued a Determination of Maltreatment. Based on the determination of substantiated maltreatment and the nature, severity, and chronicity of licensing violations an Order of License Revocation was also issued. The maltreatment determinations, the SP’s disqualification, and the revocation are each subject to appeal. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was not fined $200 for failure to report maltreatment because a more serious licensing action was taken.
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