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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: 1070988-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman Suspected Maltreatment Reported: It was reported that on April 19, 2022, a vulnerable adult (VA) showed a staff person (SP) where the VA’s new bedroom would be located downstairs. Once in the lower level the SP pulled the VA’s breasts out of her garment, touched her breasts and did not stop when asked to do so. The SP also showed his penis to the VA and touched the VA’s genitalia with his hand. Date of Incident(s): April 19, 2022 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 (c): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on April 28, 2022; from documentation at the facility, law enforcement records, and a forensic interview; and through six interviews conducted with three facility staff persons (the SP, P1, and P2), a family member (FM) and two case managers (CM1 and CM2). The VA participated in a forensic interview with local law enforcement. The VA enjoyed knitting, sewing, crocheting, and playing on her tablet. The VA’s diagnoses included bipolar disorder and diabetes. The VA was not subject to guardianship. The VA’s Individual Abuse Prevention Plan stated that she was not at an increased risk of physical, sexual or emotional abuse. The VA was able to be in the community unsupervised for an unlimited amount of time. The upper level of the facility included three bedrooms, a living room, a kitchen/dining room, a bathroom, and a porch. At the time of the incident, the VA’s bedroom was located upstairs; however, she was in the process of moving to a bedroom on the lower level. The lower level include one bedroom, an office, and a bathroom that attached to a storage area. After entering the storage area from the bathroom, around the corner to the right was an unfinished wall where a bookshelf was stored at the time of the incident. The VA participated in a forensic interview and provided the following information: · On the morning of April 19, 2022, the VA was wearing a strapless top with a strapless bra. The VA was talking to the SP and the SP asked to see where the VA was going to be living. The VA and the SP went downstairs into the bedroom, bathroom and storage area. Once in the storage are the SP saw a bookcase in the storage area and stopped to look at it. The SP mentioned he liked the bookcase. While standing near the bookcase the SP told the VA that her “boobs are so big” and that the SP wanted to touch them. The SP used his hands and “took my boobs out of my bra and shirt and started touching them inappropriately, licking them, kissing them.” The SP pulled down his pants “a little bit” and showed the VA his “dick.” The VA put her boobs back into her clothing. The SP “asked to have sex” but the VA told the SP, “no.” The VA estimated they were in the storage room for “a good 20 minutes.” · The VA went into the downstairs bathroom and was combing her hair and the SP told the VA she was “sexy.” The SP pressed his body against the VA and touched the VA “between the legs from behind” over the VA’s clothing when the VA was trying to fix her hair. The VA estimated they were in the bathroom for 15-20 minutes. · When the VA was going back upstairs, the SP was behind the VA and again touched the VA’s genitalia.
· Once upstairs, the SP continued to press his penis against the VA’s backside and touched the VA’s genitals by reaching around the front of the VA while the VA was standing and looking out a living room window. The VA walked away and told the SP that she was going to make breakfast. The VA said she started cooking breakfast “close to 8 a.m.” While the VA was making breakfast the SP followed the VA around the kitchen and tried to touch the VA. · When P1 arrived later that morning and the VA told P1 about the incident. Facility information, interviews, and shift notes for April 19, 2022, showed the following information: P1 documented that at 8:30 a.m. the VA asked to talk to P1 “privately.” The VA said that the SP sexually touched the VA on her breasts and between her legs. Multiple individuals were informed, paperwork was completed including a police report, and the VA “went about her day normally.” P2 provided the following information: · P2 arrived at the facility at 8 a.m. on April 19, 2022. Upon arriving, P2 said the VA was in the kitchen making a breakfast casserole and the SP was sitting on a couch in the living room. One client (R1) was also in the living room. The VA and the SP each greeted P2 “normally” and gave “no indication of anything odd.” The VA was wearing a “strapless romper.” When P2 entered the kitchen to “clock in” s/he saw a casserole dish prepared with eggs, sausage, and cheese in a baking pan. · At one point that morning the VA sat down next to the SP and shared her licorice with the SP and offered the SP the whole bag. · P2 assisted two clients with showers, medication administration, and breakfast. The SP told P2 that he could not find a ride home and asked P2 to give him a ride. Typically the SP found a ride or walked but the morning was “chilly” and R1 said s/he wanted to go for a ride so P2 and R1 drove the VA home, leaving the facility around 8:45 a.m. · After returning to the facility, around 9:10 a.m., the VA told P2 that the SP took off the VA’s clothing and rubbed his penis on the VA’s leg, rubbed and licked the VA’s nipples in the storage room and continued to do so on the way up the stairs and in the upstairs living room. The VA demonstrated that the SP used “both hands and went over [the VA’s] breasts.” The SP told the VA that she was “sexy.” The VA said that the SP was “coming on to her a lot recently.” The SP continued to touch the VA in front of the window “until I got here” and the SP told the VA to cook breakfast. · According to P2, the SP “admitted” that he went downstairs with the VA, and the VA kept getting close to the SP and rubbed her breasts against the SP. When the VA asked the SP if he wanted to see her breasts the SP said yes, and the SP “touched and caressed them.” The SP said, “What was I supposed to do? She wanted it.” P2 did not “want to speculate” and believed the VA wanted the SP “to touch her and do stuff with her. I gathered from that he believed that was what was okay.” · When asked if P2 had difficulty understanding the SP’s speech, P2 said “I have difficulty following the way he talks” and “I understand the words but not how he got from one topic to another.” · Following the incident the VA kept talking about how she “gets to talk to all these people and has all these important meetings.” The VA “speaks as if it is an honor to have so much attention on her.” P2 described the VA as “very dramatic and loves to be the center of attention.” The FM said that the VA told him/her that the SP touched the VA “inappropriately” by coming up behind the VA and touching the VA’s neck with his lips, breathing behind the VA’s ear, and touching the VA’s “crotch” from behind, between the VA’s legs. The VA said that the SP also “took one of her boobs out of her bra.” The SP also told the VA that he was “in love” with the VA and “wanted to have sex” with her. The FM believed what the VA told him/her about the incident and described the VA as “honest;” however, “sometimes (the VA) will embellish a little bit.” CM1 knew the VA for a number of years. For a period of time the VA resided in Iowa and upon returning to Minnesota the VA had “severe mental health issues.” Within the past “two to three months” the VA was “hypersexual” and talked in “graphic detail” about sexual interactions with her “boyfriend.” The VA also told “mistruths” about housemates. CM2 said that prior to the incident s/he was told about the VA talking to staff persons about her “sexual encounters or fantasies with her boyfriend” that made the staff persons “uncomfortable.” CM2 also said that the VA’s history included “not accurately reporting” or “over exaggerating.” However, CM2 was not aware of the VA making sexual allegations about anyone. Facility documentation and/or the internal review showed the following: · The facility schedule showed that the SP worked the overnight shift that began at 10 p.m. on April 18 and ended at 8 a.m. on April 19, 2022. · On an unknown date, P1 wrote an email regarding what the VA reported to P1 on April 19, 2022. The VA told P1 that the SP touched the VA over her clothing, on her breast, and between her legs at 7:11 a.m. Later in the morning on April 19, 2022, the VA told P1 that the SP pulled down the VA’s shirt, touched her breast and showed the VA his penis, asked to have sex, continued to touch the VA between the legs as the VA walked upstairs, and touched the VA again in the living room. The VA told an unidentified staff person who worked that morning that the SP had the VA recline on the basement floor in the storage room and rubbed his penis on the VA’s leg. Over time the VA’s “story has changed about what happened” and the VA added “new information.” · P2 stated that on April 21, 2022, (two days after the incident) the SP showed up for an overnight shift and P2 told the SP that he was not supposed to be at the facility and asked the SP to leave. The SP told P2 that s/he did not know why he would be in trouble because the VA “obviously wanted it” and “what was [the SP] supposed to do?” The SP told P2 that he touched the VA and “for a while” the VA was “coming out in a towel” and “showing” the SP the VA’s breasts. The SP said that on the morning of April 19, 2022, the VA was walking around the basement and rubbing against the SP. The VA asked the SP if he wanted to see her breasts and the SP said “yes” so the VA pulled down her clothing and the SP touched her breasts. The SP provided the following information when interviewed by law enforcement and this investigator or later when interviewed by a management staff person (P3): · On the morning of April 19, 2022, the SP was sleeping on a couch when the VA woke up the SP between 6 and 6:30 a.m. by making noise in the kitchen and talking. The VA told the SP that she was moving downstairs and asked the SP if he wanted to see the VA’s new room downstairs. · The SP and VA went downstairs and the VA showed him the bedroom, the living area, the bathroom, and the storage room. While in the storage room, the SP was standing in the corner looking at a book shelf when the VA “showed me her boobs” and was “getting touchy.” The VA was standing close to the SP and there was no space for the SP to get out of the corner so he used the palm of his hand and placed it above the VA’s breast and pushed her aside. The SP went upstairs first and the VA followed him. · The SP said that he should have immediately told someone about the incident but he was “shocked” and “scared” and he also did not want the VA to get in trouble. · That morning the VA prepared something that required baking for breakfast. · When P2 arrived at the facility the SP asked him/her to give the SP a ride home. · The SP denied touching or kissing the VA’s breasts, showing the VA his penis, and telling the VA that she was beautiful, sexy, or had big breasts. Facility information showed that staff persons were trained regarding the client’s program plan and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The VA and the SP each provided consistent information that on April 19, 2022, they went downstairs together to see the living area where the VA planned to move. Once downstairs, the VA said that the SP commented on the VA’s breasts, took her breast out of her clothing and touched her breasts. The VA also said the SP showed his penis to the VA, said that he wanted to have sex with the VA, and touched the VA’s genitalia. P2 was the first staff person to arrive on the morning of April 19, 2022, and said that the VA and the SP each greeted him/her “normally” and gave “no indication of anything odd.” That same morning, the VA sat down next to the SP and shared her licorice with the SP. Later that morning the VA told P2 that when the SP and VA were downstairs, the SP took off the VA’s clothing, touched her genitalia, touched her breasts, and told the VA that she was “sexy.” The VA also told P2 that the SP continued to touch the VA in the front window until they saw P2 arrive and at that point the SP told the VA to cook breakfast. However, P2 said that when s/he entered the kitchen upon his/her arrival, s/he saw a casserole dish already started with eggs, sausage, and cheese in a baking pan. According to P2, a couple days later the SP “admitted” that when he went downstairs with the VA, the VA asked if the SP wanted to see her breasts and the SP “touched and caressed them.” The SP told P2, “What was I supposed to do? [The VA] wanted it.” However, P2 admitted s/he had difficulty understanding the SP’s speech. Therefore, it was possible that P2 misunderstood the SP’s statements. The SP said that the VA wanted to show him where she was moving and once they went downstairs, the VA showed her breasts and was “getting touchy” in the storage room. The SP was in the corner when this occurred and he used the palm of his hand to push the VA’s upper chest to move the VA aside so that the SP could go upstairs. The SP said he should have immediately told someone about the incident but he was “shocked” and “scared” and did not want the VA to get into trouble. The SP denied touching or kissing the VA’s breasts, showing the VA his penis, and/or telling the VA that she was beautiful, sexy, or had big breasts. The SP also denied admitting any of this occurred when he spoke to P2 two days later. Given that the SP denied touching the VA’s breasts or genitalia, showing the VA his penis, or making any inappropriate statements to the VA, that there were no other witnesses, that the FM, CM1 and CM2 each provided information that the VA had a history of telling mistruths or over exaggerating, and that the VA’s version of the incident continued to change over time, there was not a preponderance of the evidence whether the SP had sexual contact with the VA. It was not determined whether sexual abuse occurred (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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedure were adequate but were not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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