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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: 1109338-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux Suspected Maltreatment Reported: It was reported that a staff person (SP) placed his/her hands “all over” a vulnerable adult’s (VA’s) body and “lingered” on the VA’s stomach, legs, and pubic area. Date of Incident(s): Prior to June 6, 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 June 30, 2022; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, and the SP). This investigator met the VA, but s/he declined to be interviewed and said that s/he “did not want to talk about it.” A law enforcement agency was notified of this report. Facility documentation showed that the VA was friendly and enjoyed reading books. No information showed whether the VA had a history of providing inaccurate information, but s/he might suddenly become upset or frustrated and could usually be easily re-directed. The VA had a history of unspecified hallucinations and an injury to his/her back that impacted his/her ability to care for him/herself. The VA’s diagnoses included schizoaffective disorder and cerebral palsy, which caused him/her to have limited range of motion, difficulty raising his/her arms, and spasticity. The VA used a wheelchair for mobility and was non weight bearing. The VA had a weak grip, and needed assistance with bathing and other activities of daily living. Two staff persons usually worked at the facility during the day and evening shifts, but the facility was single staffed overnight. The VA was a good self-advocate, could explain his/her needs to staff persons, and wanted to live as independently as possible. Facility documentation, information provided by P1, P2, and the SP, and information from the facility’s Internal Review, provided the following: · The VA did not complete an interview with this investigator, but s/he provided information in the Internal Review showing that the VA thought that the SP “took too long” to do his/her cares, “enjoy[ed]” touching the VA, and got “pleasure” from it. The VA had a similar experience with a staff person whose identity s/he did not provide, who worked at a facility in which the VA had previously resided. That staff person was fired; the VA also wanted the SP to be fired and did not understand why his/her employment was not immediately ended at the facility. · The SP told this investigator that s/he loved his/her job and took his/her work very seriously. When providing cares to the VA, the SP described his/her actions before beginning them, and was careful to explain each step by step to the VA as s/he assisted the VA. The SP might say, “Now I’m going to……”and then complete the action. The SP often referred to the VA as “dear” when s/he assisted the VA with cares, but did not mean to imply that his/her relationship with the VA was personal by referring to the VA as dear. The SP enjoyed helping those who could not help themselves and was dedicated to providing exceptional care. According to the SP, the allegations in this report must have been based on a “complete misunderstanding” because s/he did not do anything inappropriate while caring for the VA or other residents at the facility. The SP denied that s/he touched the VA inappropriately, did not place his/her hands “all over” the VA’s body, and did not linger on the VA’s stomach, legs, or pubic area when s/he provided cares to the VA. Information provided to this investigator was similar to information from the SP in the facility’s Internal Review. The SP gave this investigator a letter (which was very important to the SP) attesting to his/her good character. · P1 and P2 (a supervisory staff person) provided consistent information to this investigator and in the Internal Review that P1 often worked with the SP and the SP trained P1. There were no concerns regarding the SP’s actions and s/he was described as a staff person who was very thorough and detail oriented. Prior to this incident, the VA had not voiced concerns regarding his/her care at the facility. When P2 explained to the VA that the SP would not “just be fired” without an investigation into the incident, the VA reiterated his/her wish to have the SP fired, but did not provide additional information regarding the SP’s actions. P2 was previously unaware of the VA’s concerns about a staff person at a prior facility in which the VA resided and had no additional information regarding them. · A law enforcement agency was notified of this report, but took no further action. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: The VA did not complete an interview with this investigator, but in the facility’s Internal Review, s/he said that the SP “took too long” to do the VA’s cares, “enjoyed” touching the VA, and got “pleasure” from it. The VA stated that there was a similar situation with a staff person at a facility in which the VA previously resided. That staff person was fired and the VA though that the SP should be fired, too. The SP provided consistent information to this investigator and in the Internal Review, that s/he enjoyed working at the facility and took his/her job responsibilities very seriously. The SP often called the VA “dear” when s/he assisted him/her but did not mean that s/he had a personal relationship with the VA. The SP denied that s/he touched the VA inappropriately; said that s/he did not place his/her hands “all over” the VA’s body; and did not linger on the VA’s stomach, legs, or public area when s/he did the VA’s cares. P1 and P2 had no concerns regarding the SP’s work at the facility, and said the SP was detail oriented and thorough. Although the VA said that the SP touched him/her inappropriately while providing cares, given that there were no witnesses to the incident, that P1 and P2 had no concerns regarding the SP, and that the law enforcement agency was aware of the report, but took no further action, there was not a preponderance of the evidence whether the SP touched the VA in a manner that met the definition of sexual abuse. 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 which determined that its policies and procedures adequate and were followed. After the incident, the facility required that two staff persons be present when the VA was assisted with his/her cares when the facility was double staffed and it was possible for both staff persons be present. When the facility was single staffed, staff persons were to tell the VA clearly what cares they were providing and what they were doing at all times. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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