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AMENDED 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.” NOTICE: This Amended Maltreatment Investigation Memorandum supersedes a version dated July 13, 2022, which must be destroyed. The Department of Human Services received additional information, which was added to this report, and changed the disposition from “false as to sexual abuse,” to “substantiated as to sexual abuse.” The disposition of substantiated neglect was unchanged and not appealed and is therefore conclusive. The SP was regulated by a health-related licensing board. The health-related licensing board was notified upon issuance of the investigation that the SP was determined to be responsible for serious maltreatment and would be disqualified from direct contact if s/he were not regulated by the board.
1107137-SUD (Substance Use Disorder) Investigator(s): Toni Puente/Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) and a vulnerable adult (VA) exchanged inappropriate text messages and photos, kissed, and had possible sexual contact. Date of Incident(s): On-going prior to February 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); and subdivision 17, paragraph (a): 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 March 1, 2022; from documentation at the facility; and through six interviews conducted with a facility staff person (P1), two supervisory staff persons (P2 and the SP), an administrative staff person (P3), a consumer (C1) who resided at the facility, and the VA. Attempts were made via phone, text, and mail to contact and interview C2, but the attempts were not successful. The VA was diagnosed with a substance use disorder. The VA’s Service Discharge Summary showed that the VA began receiving services from the facility on December 15, 2021, and was successfully discharged on February 21, 2022. The VA’s Individual Abuse Prevention Plan (IAPP) dated December 15, 2021, stated that the VA was not susceptible to abuse in all areas, but the IAPP dated January 3, 2022, stated that the VA was susceptible to self-abuse following an incident related to substance use. The VA’s Comprehensive Assessment (CA) and Individual Treatment Plan (ITP) each stated that the VA had difficulty with impulse control and may have minimal awareness of the severity of his/her substance use and the negative consequences associated with it. The facility was a split level residential treatment facility. Upon entrance, there are two staircases one each to the upper and lower levels respectively. The upper level consisted of double occupancy bedrooms, a kitchen, common room, and a group room. At the bottom of the lower level staircase, towards the right, there was a locked entry that led to a hallway that consisted of individual office spaces for clinical and nursing personnel, including P2’s and the SP’s offices; and towards the left, there was a door that led to double occupancy bedrooms, including the VA’s. Information was consistent that the SP was scheduled to work at the facility on weekdays, between 7 a.m. and 4 p.m. The VA provided the following information: · The VA stated that s/he did not want to give “too many details” to this investigator and apologized for his/her “resistance” to provide information, adding that s/he wanted the “best possible outcome” for the SP. · While at the facility, the VA had two cell phones, his/her personal cell phone and a “Wi-Fi” cell phone that the VA hid in his/her pocket. · On an unknown date while the VA was at the facility, the VA found the SP’s profile on Facebook and saw that they had mutual friends from growing up, but they had not known each other prior to meeting at the facility. Then, sometime in January or early February 2022 while at the facility, the VA was in the SP’s office, grabbed the SP’s cell phone from the desk, and sent a text message to the VA’s Wi-Fi cell phone from the SP’s cell phone, which exchanged their phone numbers. For the next month, the VA and the SP exchanged text messages back and forth. The VA was reluctant to provide details regarding what the text messages said, but stated that they included some “sexual” or “fantasy” communication. The VA stated that s/he and the SP exchanged photos, including that the VA sent a photo of his/her genitalia to the SP, but the SP only sent photos that contained the SP’s face. · On an unknown date prior to the VA’s discharge in February 2022, P2 spoke to the VA told the VA that s/he received information that the VA and the SP were involved in an inappropriate relationship. At that time, the VA “lied” to P2 and told him/her that they were not. Then, about one week later, on February 20, 2022, P3 told the VA that s/he had access to some text messages that the VA exchanged with the SP. The VA then told P3 the “truth” about his/her exchanges of messages and photos with the SP. Following that day, the SP no longer worked at the facility and as the VA prepared to discharge from the facility on February 21, 2021, and the SP ceased contact with the VA. The VA stated that s/he had not spoken to the SP since. · The VA described his/her relationship with the SP as “friendly” and s/he expressed that s/he had “feelings” for the SP and “assumed” that the SP had “feelings” for him/her. The VA stated that on one occasion at the facility, the VA and the SP were in the hallway and the VA “tried” to kiss the SP, but the SP pushed the VA away. The VA denied that s/he and the SP hugged or kissed on any other occasion. · The VA said that there were “rumors going around” that s/he and the SP slept together, but the VA denied having sexual contact with the SP. On August 22, 2022, the VA emailed the investigator stating that the VA had been dishonest during his/her initial interview for this investigation. The VA was advised by his/her therapist to be honest about his/her interactions with the SP. The VA provided the following additional information to this investigator in a follow up interview and via written statement: · In December 2021, the VA moved into the facility seeking treatment for his/her substance use disorder. It was there where the VA first met the SP. The VA described the SP as “very attractive.” The SP was a supervisory staff person and a healthcare professional at the facility. · One day, when the SP saw the VA at the facility, the SP “blushed” and told the VA, “Oh my god. I had a dream about you last night and it’s so awkward seeing you now.” The VA said that this interaction made him/her aware that the SP “had interest in” him/her. · At some point after, prior to mid-January 2022, the VA attended a client’s “graduation party.” This client had successfully completed programming, and was set to discharge. It was customary for other clients to write “goodbye letters” to the graduate. The VA did so, along with other clients. The SP collected the letters and read them out loud at the client’s “graduation party.” The VA had included his/her cellphone number in the letter, with the intention that the client and the VA could stay in contact. However, the SP copied or “memorized” the VA’s cellphone number, and at some point after this, the SP text messaged the VA’s cellphone. This text message was the start of the VA’s and the SP’s personal relationship. · The VA said that they began exchanging text messages on a regular basis. (Note: At the time of this investigation, the VA no longer had his/her cellphone and so was unable to provide the text messages for this investigation.) · Around mid-January, the SP was alone with the VA when s/he threw something on the floor in front of the VA, and said, “Oops. I dropped something.” The VA was standing behind the SP, as s/he bent down to pick up the item “while keeping eye contact with [the VA] and having a seductive, flirtatious look on [his/her] face.” The SP then “thrust” his/her buttocks backward so that it was touching the VA’s crotch through the VA’s pants. The SP began moving his/her buttocks against the VA’s crotch in a “grinding motion.” The SP then stood up, turned to face the VA, and started kissing the VA. The VA said that following this incident, s/he and the SP would “kiss and make out multiple times on a daily basis.” · Other times, if the SP was walking in front of the VA, the SP would abruptly stop causing the VA to run into him/her. The SP would then simultaneously put his/her hands behind his/her back “grabbing and squeezing” the VA’s genitalia through the VA’s pants. · One time when the SP and the VA were alone in the facility’s van, they “made out” (kissed) in two parking lots and also “stimulated” each other’s genitalia. · The VA and the SP also engaged in oral sex in the SP’s office on more than one occasion, and one time had sexual intercourse with penetration in the SP’s office. · The VA and the SP also exchanged Facebook Messages, which the VA provided copies for this investigation. The Facebook Messages were exchanged from February 12 to July 25, 2022, between a Facebook account with the SP’s first and last name, and another account with the VA’s first and last name. · The Facebook Messages included the following: o The VA referred to the SP as “nurse [the SP’s first name],” and the SP referred to the VA as “client [the VA’s first name].” (Note: The SP was a licensed healthcare professional.) o The SP stated the names of his/her children and which sports they were involved in. (Note: This investigator checked the public information on a Facebook account with the SP’s first and last name as the account holder. The public information included the names of his/her children and the sports they were involved in, which matched the information exchanged in the Facebook messages.) o The SP stated the name of his/her spouse. (Note: This investigator checked the public information on a Facebook account with the SP’s first and last name as the account holder. The public information included the name of his/her spouse, which matched the information exchanged in the Facebook messages.) o The SP also mentioned the city s/he lived in. (Note: This city matched the SP’s address, which the facility had provided for this investigation). o The SP and the VA each shared messages that they wanted to “fuck” each other; that the VA had seen the SP’s genitalia; that they “loved” each other; that the SP sent a photograph of him/herself in a bathtub to the VA; that the VA had performed oral sex while the SP sat on a desk; and that the VA “can’t wait to touch [the SP] again.” o The SP and the VA also exchanged messages that included the first names of P1, P2, and C1; and one other name which was also a staff person at the facility. o The SP also asked the VA, more than once in the messages, about his/her medication changes and if the changes were helping the VA’s symptoms. o The VA told the SP that s/he was glad they met; and the SP responded, “Would’ve been better if you were done with treatment though so I don’t lose my license.” o The VA asked the SP if s/he still had his/her lawyer, and the SP responded, “No I wanted to wait to see what the outcome of this was.” (Note: These messages were exchanged during the time of the initial Department of Human Services investigation.) · The VA also provided photographs that were sent to him/her by the SP. One photograph showed a person, whose face was not visible, sitting in a bathtub with exposed legs holding a beer can covering their genitalia. Another photograph showed a person, whose face was not visible, with their upper chest exposed to the camera. The VA stated that the photos were of the SP. · According to the VA, the SP repeatedly told him/her to not tell anyone about their relationship because the SP was regulated by a board and could lose his/her license if their relationship was discovered. The SP also promised to leave his/her spouse for the VA, and according to the VA, this “proposition … coerced” him/her into not telling anyone about their relationship and “lying” when asked about it during the initial Department of Human Services investigation. · The SP also reminded the VA of the VA’s requirement to complete substance use disorder treatment in order to remain on supervised release from jail. The VA “feared” that s/he would have his/her supervised release revoked and would have to return to jail if s/he was “kicked out” of the facility for his/her relationship with the SP. · The VA said that the SP was aware that a Department of Human Services investigation was occurring regarding their relationship. After the VA discharged from the facility, the two maintained contact and continued their relationship. However, once the Department of Human Services investigation was completed, the SP abruptly ended his/her contact with the VA. · The VA said that his/her relationship with the SP had a negative impact on the VA’s life. Before their relationship began, the VA had disclosed to the SP that s/he struggled in relationships with partners as s/he would typically become “very vulnerable … attached quickly and … codependent.” “As I was now sober I voiced to [the SP] that my biggest relapse trigger that I identified to be a potential threat to my recovery would be any romantic or flirtatious involvement with a [partner].” The SP was aware of this information when s/he first text messaged the VA following the “graduation party.” · “I feel like [the SP] used me and manipulated me this entire time pending the completion of the [Department of Human Services] investigation. I’ve been put into a downward spiral over this and have been forced to seek treatments for mental health impairing my enjoyment of life.” P1, P2, P3, and C1, and facility documentation, an email between C1 and P2, and text messages between P1 and the SP, provided the following information: · C1 stated that when the VA arrived at the facility, the VA and the SP had a “background” so they became “pretty close.” Sometime prior to January 17, 2022, (the date that C1 completed the program) the VA told “everyone” that s/he obtained the SP’s phone number and they were exchanging inappropriate text messages to each other that included sexual content. On one occasion, during an outing, the SP and the VA left to go to a store and when the VA returned, s/he whispered under his/her breath to a “bunch of us” that s/he “just got done making out with [the SP] in the work van.” P1 said that the VA told him/her that s/he was “making out” with the SP while out in the community, and another unknown consumer told P1 that s/he observed the VA and the SP kissing in the hallway on the lower level. · P1 stated that sometime in the beginning of February 2022, when s/he worked, the VA talked about the SP and showed P1 texts messages between the SP and the VA which included a photo of the SP’s leg in a bathtub and text messages about a piece of jewelry that went missing in the facility vehicle. The VA told P1 that the SP’s jewelry fell out when the VA and the SP were kissing in the facility vehicle. P1 reached out to the SP via Snapchat to “hint” that s/he was aware of the VA’s and the SP’s phone interactions, but the SP told P1 that the VA found the SP on Facebook and the SP further denied any inappropriate interactions with the VA. On P1’s “next shift,” P1 went to the SP’s office, and told the SP that s/he knew that the SP and the VA were “talking.” The SP “immediately lied” and denied the allegation. Then P1 told the SP that the VA showed P1 text messages exchanged between the two, and the SP said, “What the fuck?,” and “immediately broke down crying” and said that s/he “will never” talk to the VA again. (Note: The facility schedule showed that P1 worked on February 5, 10, 19, and 20, 2022.) · P1 stated that on one occasion, s/he walked into the SP’s office and saw the SP and the VA in there. P1 observed that the SP’s lips were red and when the VA stood up, s/he zipped up his/her pants. P1 “assumed” that the VA and the SP had engaged in sexual contact. · P1 and text messages between P1 and the SP stated that on February 10, 2022, at 5:33 p.m., a consumer (C2), who was preparing to leave the facility, gave P1 a letter that was sealed in an envelope and asked P1 to slide it under P2’s office door. C2 told P1 that the letter discussed “situations” at the facility. Because the SP was P1’s supervisor, P1 notified the SP about the letter and the SP told P1 to open the letter when C2 left the office. Later, P1 called the SP and read the letter to the SP which included concerns that the VA and the SP had a romantic relationship and communicated via a “secret phone.” The SP told P1 to have the VA come to the office and when the VA did, P1 read the letter aloud in front of the VA and the SP, who was on the phone. The VA and the SP wanted the letter destroyed, so the SP directed P1 to shred the letter. P1 did so because s/he feared retaliation or termination. The next morning, the SP sent a text message to P1 that said, “Maybe we should play the card where you say [C2] never gave you the letter,” in the event C2 also contacted P2 by phone. P1 replied, “Okay I can,” and did not tell P2 about the letter. Later that night, the SP sent a text message to P1, telling P1 to tell the VA to “lose my fucking number,” and further stating that P1 did not need to “be involved” with anything and that the SP was “totally done” with the VA. · C1 stated that s/he heard from other consumers, whom s/he remained contact with, that C2 wrote a letter about the VA’s and the SP’s interactions, but “somehow,” the SP intercepted it and gave it to the VA to “get rid of,” so C1 decided to reach out to P2 via email. On February 12, 2022, at 2:37 p.m., C1 emailed P2 that the VA and the SP were involved in a sexual relationship. On that same date at 8:08 p.m., P2 sent another email that stated there was a possibility that the allegation was “not true” but this was the information that the VA and others were “spreading” around the facility. P2 stated that on February 13, 2022, s/he read both emails and forwarded them to P3. On February 14, 2022, P2 spoke to the VA and the SP and they each denied the allegation and said it was “just a rumor.” · P1 and P3 stated that on February 19, 2022, in the evening, P1 contacted P3 and told P3 that over the past two weeks, the VA told P1 that the VA and the SP were sending text messages to each other and P1 was “in the middle of it.” On February 20, 2022, P3 spoke to the VA. The VA told P3 that s/he and the SP exchanged sexual text messages and photos, kissed on one occasion, and were “in love.” The VA denied that any sexual contact occurred. · P3 stated that on February 21, 2022, s/he contacted the SP and the SP provided information regarding his/her interactions with the VA that had “similar details” to what the VA told P3 including the text messages and photos, that they kissed on one occasion, and that they were “in love.” The SP also denied that any sexual contact occurred, adding that s/he did not want to “lose” his/her license. · P1 said that on February 21, 2022, sometime after P3 spoke to the SP, the SP called and spoke to P1. The SP told P1 that s/he told P3 that s/he “loved” the VA and wanted to pursue a relationship with him/her. P1 said that on February 22, 2022, s/he received a text message from the SP stating that since the VA and the SP did not have “sex,” and even if they had engaged in sexual contact, the allegation was “not career ending,” and s/he asked P1 to “spread that around” so P2 and P3 were aware that the SP was not going to “lose” his/her license. · P1-P3 stated that they were not aware of any similar allegations involving the SP. P2 said that as part of general clinical training, P2 previously spoke to the SP about maintaining boundaries with consumers, such as not sitting close to consumers when assessing their health care/nursing related needs. C1 stated that the SP was not “very ethical” and s/he was “pretty inappropriate” or made sexual comments about genitalia in front of consumers. The SP provided the following information: · When the VA admitted into the facility, the VA looked “familiar” to the SP, but they did not know each other prior to meeting at the facility. Then, as the SP got to know the VA, they realized that they were from the same town and had mutual friends. The VA often frequented the SP’s office, and on one occasion, the VA took the SP’s phone and sent him/herself a text message, which was how the VA obtained the SP’s phone number. The SP told the VA that s/he “should probably” delete the SP’s phone number, but shortly after, for about one month, the VA and the SP exchanged occasional text messages that began “slow” and then eventually included “very flirtatious” messages and photos. The SP added that s/he sent the VA “flirtatious selfies,” but no “full nudity,” and the VA sent the SP photos of his/her genitalia. The SP said that s/he “probably” told the VA that s/he “shouldn’t” say anything about their exchanges. · The SP stated that the VA had a “crush” on the SP and “hinted” towards a potential future relationship with the SP. The SP stated that s/he did not realize how strong his/her boundaries needed to be at the facility, because the work environment and clientele was “completely different” than the SP’s previous employment. The SP added that s/he “should have” handled the text messages differently and told the VA to “stop.” · On an unknown occasion, P2 received an email from C1, stating that the SP and the VA were in a relationship. P2 talked to the SP about the allegation which the SP denied, adding that s/he did not know what the VA told other consumers, but the allegation was “not truthful.” At that time, the SP did not tell P2 about the text messages with the VA, because “it wasn’t really anything.” · On another unknown occasion, C2 wrote a letter addressed to the P3 and gave it to P1. P1 called the SP and read the letter aloud. The SP stated that s/he was “really offended” by the letter, because it accused the SP of a having a sexual relationship with the VA. The SP provided information regarding P1’s knowledge of the text messages and C2’s letter that was consistent with the information that P1 provided to this investigator. The SP stated that at some point, s/he told P1 to shred the letter, but the SP was not certain whether P1 did so or gave it to the VA. The SP added that s/he “maybe” told P1, “You don’t have to say anything” about the VA’s and the SP’s interactions, but the SP denied that s/he threatened P1’s employment. · When the SP spoke to P3, P3 told the SP that s/he had “evidence of maltreatment” from text messages exchanged between the SP and the VA. P3 did not provide further details of the text messages or the allegation to the SP, but the SP “acknowledged” that they texted each other. The SP apologized to P3 and the SP no longer worked at the facility. · The SP denied that s/he made inappropriate sexual comments to or talked about genitalia in front of consumers. · The SP denied that s/he hugged or kissed the VA or had any physical or sexual contact with the VA, with the exception of one occasion when in the hallway at the facility, the VA approached the SP and “tried” to kiss him/her. The SP told the VA, “No,” adding, “I did stop [him/her].” The SP was not able to recall whether anyone else was around when that occurred. · The SP was not able to recall whether s/he reviewed the facilities policies and procedures, but then s/he stated that s/he likely reviewed them upon hire and electronically signed a document indicating that s/he reviewed them. The SP added that s/he also facilitated monthly staff meetings, and provided training to newly hired staff persons, which included: vulnerable adult reporting procedures, the facility’s policies and procedures, as well as maintaining professional boundaries with consumers. The SP was notified that the investigation was reopened. The SP declined the opportunity to provide additional information and stated that s/he would not participate in a second interview. The facility’s Personnel Policy stated that the facility prohibited “immoral conduct” on the premises and personal involvement, including sexual contact, with clients or former clients within two years of receiving services. The facility’s Sexual Harassment Policy stated that no employee may engage in making unwelcomed sexual advances or other verbal or physical conduct of a sexual nature, such as “suggestive” jokes, preferences and/or desires, towards another client or employee. Personnel files showed that P1, P2, and the SP each received training on the Reporting of Maltreatment of Vulnerable Adult Act, facility policies and procedures, and the VA’s program plans. Conclusion: A. Maltreatment: Information was consistent that while the VA resided at the facility, the VA obtained the SP’s cell phone number and they exchanged text messages and photos and engaged interactions that were concerning and that according to the VA, the SP, P1, and P3 involved the development of a personal relationship between the SP and the VA. Regarding sexual abuse: The VA initially denied engaging in a sexual relationship with the VA. However, after the investigation was complete, the VA provided information that s/he and the SP exchanged text messages, Facebook messages, kisses, and sexual contact while the VA was receiving facility services and the SP was employed at the facility. The SP said that s/he exchanged “flirtatious” text messages with the VA, but that s/he never kissed or had sexual contact with the VA. Although the VA initially denied the allegation and that the SP denied the allegations, the VA provided additional information that they did have sexual contact in the SP’s office, and the VA provided Facebook messages, which supported this account. Given this and that P1, P2, P3, and C1 also provided information, which supported the VA’s account, there was a preponderance of the evidence that the SP engaged in sexual contact with the VA while the VA was receiving services at the facility. It was determined that 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.) Regarding neglect: Information was consistent that the VA and the SP exchanged text messages and photos that contained sexual content. Despite inconsistent information regarding whether or not the VA and the SP kissed, the VA and the SP provided consistent information to this investigator and P3 about their interactions which included: text messages and photos that contained sexual and/or flirtatious content, and an occasion when the VA attempted to kiss the SP, but the SP stopped him/her. The SP’s conduct was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Given the VA’s vulnerabilities, it was reasonable that the VA would continue to need supports to develop and maintain necessary life and social skills. The SP’s interactions with the VA likely hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the VA, both now and in the future. Therefore, there was a preponderance of the evidence that the SP failed to maintain therapeutic boundaries and that the SP’s interactions with the VA were detrimental to the VA’s mental health and/or progress in his/her treatment. 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. The SP received training on the Reporting of Maltreatment of Vulnerable Adult Act, facility policies and procedures, and the VA’s program plans. The SP was responsible for maltreatment 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.” 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 sexual abuse and neglect for which the SP was responsible was “serious” maltreatment. Although the neglect allegation was considered a single finding of maltreatment based on the SP’s pattern of behavior, the SP was also responsible of sexual abuse, which was defined as “serious” maltreatment. D. Person Regulated by Health-Related Licensing Boards Pursuant to Minnesota Statutes, section 245C.31, subdivision 1, when individuals regulated by a health-related licensing board are determined to be responsible for substantiated maltreatment under Minnesota Statutes, section 626.556 or 626.557, instead of the Commissioner of the Department of Human Services making a decision regarding disqualification, the licensing board makes a determination whether to impose disciplinary or corrective action under Minnesota Statutes, chapter 214. The SP is regulated by a health related licensing board. The health related licensing board was notified upon issuance of the investigation that the SP was determined to be responsible for serious maltreatment and would be disqualified from direct contact if s/he were not regulated by the board. Action Taken by Facility: The facility completed an internal review and determined that its policies and procedures were adequate but not followed, and there was a need for additional staff training. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On September 30, 2022, the SP was notified of the amended maltreatment determination. The maltreatment determination regarding sexual abuse is subject to appeal. The SP did not appeal the finding made on July 13, 2022, that s/he was responsible for neglect and therefore, that determination is conclusive. The SP was regulated by a health related licensing board. The health related licensing board was notified upon issuance of the investigation that the SP was determined to be responsible for serious maltreatment and would be disqualified from direct contact if s/he were not regulated by the board. Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that one individual failed to report suspected maltreatment as required. A letter from DHS was sent to each of these individuals regarding his/her failure to report the suspected maltreatment and potential consequences for future such failures.
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