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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: 804048-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth Suspected Maltreatment Reported: It was reported that a staff person (SP) was in a relationship with a vulnerable adult (VA1). Additionally, the SP took a picture of another vulnerable adult (VA2) and showed someone who did not work at the facility. Date of Incident(s): Ongoing prior to June 23, 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 July 14, 2022; from documentation at the facility; and through three interviews conducted with two facility supervisory staff persons (P1 and P2) and a staff person (the SP), who was a nurse at the facility. Attempts were made via phone and U.S. mail to contact and interview VA1 and VA2 but the attempts were not successful. Attempts were also made to contact and interview a community person (CP) but the attempts were not successful. The facility provided inpatient treatment for clients with substance abuse disorders. VA1 was diagnosed with severe opioid use disorder, severe alcohol use disorder, and moderate amphetamine-type substance use disorder. VA1 was at the facility from March 17 to April 14, 2022. VA2 was diagnosed with severe opioid use disorder, severe amphetamine-type substance use disorder, and mild cannabis use disorder. VA2 was at the facility from May 2 to 27, 2022. P1, P2, and a Memo dated June 22, 2022, provided the following information: · On June 22, 2022, the CP called the facility and left a voicemail stating that s/he had “concerns about a nurse” at the facility (later determined to be the SP) that was having a “relationship” with a client (who the CP did not identify) at the facility. · At 9:31 a.m., P2 returned the CP’s call. The CP said that s/he had a “profile picture” of a client at the facility and that s/he had “proof” on his/her phone. P2 asked the CP to send “anything” s/he had so that the facility could look into it. The CP also said that the SP “disappeared” during a shift to “sleep” with a client (who the CP did not identify) but no additional infomration was provided (Note: The facility did not have any infomration that this occurred and there were always two staff persons working at a time). · Additionally, the CP told P2 that the SP told him/her that s/he “manipulated drug court urinalysis’s [UA’s]” and “passed” clients “that [s/he] knew would fail.” The CP also said that the SP did this for clients that s/he “liked.” The CP did not provide additional information regarding this, including the names of those clients. (Note: The facility said that there was “no proof” that this had occurred). · At 1:12 p.m., P2 received photos from the CP (which the facility sent to this investigator) that the CP said s/he obtained from the SP’s phone. This included a photo of VA2 which P2 said was from VA2’s “profile” in the facility’s computer system. This “seemed to be a direct HIPPA violation.” · Additionally, the CP sent P2 another photo which was a screenshot of the SP’s Facebook messenger. The message did not have a date but said that it was sent on “Sunday.” The message showed that the SP sent VA1 his/her phone number along with a kissing emoji and said, “Be safe.” P2 said that it was the SP’s Facebook profile based on the SP’s profile picture. The facility also determined that it was VA1’s Facebook profile as VA1’s “full name” and picture were visible. · The CP also sent P2 a photo of an undated Facebook message from the SP to VA1 which said the following: o “I know you are and it’s okay I don’t expect anything from you and I am not mad at you for it or feel any type of way I get it it’s not easy and like I said I care about you and worry about you! I do want to continue the relationship we got and see where it goes and I totally understand you’re not in a place for all that right now and that’s ok no pressure to do anything. I will be here for you as a friend regardless if anything and if you need anything or need help I’ll help you anyway I can! And I want to see you and spend time with you!” o On “Sunday” at 12:22 p.m., VA1 responded and said, “I have to buy a new [sic] today and then we can then we can talk later that means so much to….[the message cut off here]” · On June 23, 2022, around 6:15 a.m., P2 received a message from the CP with a screenshot of a conversation between the SP and the CP. In that conversation, the CP stated, “You cheated on me and did it in such a fucked up way.” The CP also said, “So I figure you are already with [his/her] junkie ass.” The SP then said, “Thanks for giving me the summer off to collect unemployment and spend it with my new boo.” The CP then continued the conversation with the SP stating again that the SP cheated on him/her and that s/he was “very hurt.”
· On June 24, 2022, P1 and P2 met with the SP. The SP said that at some point, the CP “broke” into his/her home through a “dog door” and took screen shots from his/her phone. The SP said that the CP had been “blasting [the screen shots] out on social media” and that the CP was “trying to ruin [his/her] career.” · The SP told P1 and P2 that s/he and VA1 were “acquaintances” prior to VA1 being a client at the facility but not “good friends.” The SP and VA1 were also Facebook friends prior to VA1 being a client. P1 said that staff persons needed to tell supervisory staff persons if they had a pre-existing relationship with a client. The SP “did not think” that s/he needed to tell the facility that they were friends prior and was “upset” that s/he could not be “friends” with “past clients.” The SP asked P1 to show him/her where it was in the “code of conduct” and P1 had to “point it out.” · The SP said that the messages s/he sent to VA1 were to “support” VA1 as a “friend” because VA1 was using drugs again. The SP said that they were “nothing more” than friends and that s/he was not in a “romantic” or “sexual” relationship with VA1. The SP was asked by P1 and P2 why s/he gave VA1 his/her phone number if they were friends prior but the SP “did not respond and shut down.” When P1 and P2 asked the SP why s/he told the CP that s/he was going to spend time with his/her “new boo,” the SP said that s/he said those things “out of anger.” · P1 said that VA1 “may not have been able to refuse propositions” due to being a “vulnerable adult.” At a “minimum,” the SP “took advantage of [his/her] title or disregarded [his/her] need to protect all clients.” If VA1 reached out to the SP, the SP should have notified P1 or another supervisor to figure out how to “handle it.” P1 said that s/he would have told the SP not to respond VA1. · Additionally, the SP said that the CP was in a “gang” and was in prison for five years. The SP took the photo of VA2 to show the CP to see if s/he was “safe” with VA2 and to see if VA2 was in a “rival gang.” The SP also did so to ensure there was no “conflict” with the SP working with VA2. P1 and P2 said that this was a “serious breach of HIPPA” and that the SP had received HIPPA training on two occasions prior to the incident. Staff persons were to not disclose” who was receiving care at the facility and showing someone their photo was a “very big deal.” P1 said that the SP showing VA2’s photo to a “rival gang” could put VA2 in “danger.” If the SP was “scared” for his/her safety, s/he should have notified supervisory staff persons. The SP was “very frustrated” that s/he had been “confronted.” There was no infomration that VA2 was aware that the SP had done this. · There were also prior concerns regarding the SP’s boundaries with clients. This included that the SP talked about other staff persons with the clients. The SP also gave “certain treatment” to some clients but not others which made the “rules very hard to follow [Note: There was no additional information provided regarding this].” There was also a prior concern that another staff person was in a “romantic and sexual relationship” with a client, which the SP knew about but did not “disclose” to a supervisor. At that time, the SP received a “warning” and was retrained on boundaries. Additionally, the SP should have known about “boundaries” due to his/her training as a nurse. · The facility did not have a policy regarding being friends with a client on social media. However, clients and staff person could not have a “relationship” for two years after the client left the facility, which the SP was trained on. If would not be appropriate for a staff person to give a client their phone number. P1 said it would “not be appropriate” for a staff person to contact a client in any way other than via a work phone about the clients “services.” The SP provided the following information: · The CP made a “bunch of false allegations” regarding the SP because the SP was “in the process” of breaking up with the CP. · The SP had a photo on his/her phone of VA2. The SP did not recall when s/he took the photo but said it was when VA2 was a client at the facility. The SP got the photo from VA2’s “chart” at the facility. The photo did not have VA2’s name or other “identifying” information and was “only” a photo of VA2’s face. · The SP took the photo of VA2 because the CP was in prison for five years and had been “gang affiliated.” The SP and the CP had been receiving a “lot of threats” from “gang members” who the CP owed money. The SP “noticed right away” that VA2 had “gang affiliated tattoos” so the SP made a “bad decision” to take a picture of VA2’s photo to show the CP to see if VA2 was “related to the gang that was threatening [the SP, the CP, and their family].” If the CP would identified VA2 as a rival “gang member,” the SP would have told his/her supervisor that s/he could not be in “contact” with VA2 as it was a “threat” to the SP’s and the CP’s “family.” However, the SP did not get a chance to show the CP the photo as the CP and the SP separated. The picture remained on the SP’s phone and at some point, the CP broke into the SP’s home during the “middle of the night” and went through the SP’s phone. The CP sent screenshots to his/her phone and then sent them to the facility. · Prior to taking the photo, the SP told VA2 that s/he was going to “show someone” his/her photo to see if they knew VA2 and VA2 said that was “okay.” However, the SP did not tell VA2 that it was to identify VA2 as a potential gang member. · The SP did not tell any supervisory staff persons that s/he was going to take a picture of VA2. The SP was trained to keep clients information “safe.” However, the photo of VA2 did not have VA2’s name or that VA2 was a client at the facility. When this investigator asked the SP if the CP would have known that the SP got the photo of VA2 from the facility, the SP said that the CP would not have known and that the SP could have gotten the photo from the internet or VA2’s department of corrections “profile.” When this investigator asked the SP if it would be appropriate to do similar with a client at a medical clinic (for example) if the SP was a nurse there, the SP said, “No” but that s/he was in “fight or flight mode” and “not thinking clearly.” The SP said it was “spur of the moment.” The SP later deleted the picture of VA2 from his/her phone. · The SP knew VA1 prior to VA1 being a client at the facility through “mutual friends.” VA1 and the SP had known each other “for years.” VA1 and the SP were also friends on Facebook prior. It was a “small town” and people came to the facility “every day” that the SP knew prior. The SP did not tell a supervisory staff person that s/he knew VA1 prior, as staff persons were “only instructed” to notify supervisory staff persons if it was a “significant relationship.” The SP considered VA1 an “acquaintance.” The SP did not think that his/her prior relationship with VA1 impacted VA1’s treatment at the facility. · Approximately two to three months after VA1 left the facility, VA1 reached out to the SP via Facebook Messenger and was “looking for support” from a “familiar face.” VA1 was “struggling with using” and wanted to talk to someone who knew about his/her “addiction” and “struggles.” VA1 did not have a “good support” system and his/her friends and family used drugs so VA1 thought that the SP would be a “good person to reach out to.” VA1 had not reached out to the SP prior for similar help. However, VA1 did not know that the SP was “in that position as a supportive person who worked at a treatment facility” until VA1 became a client there. When this investigator asked the SP how his/her interactions impacted VA1, the SP said that his/her relationship with VA1 was “definitely beneficial” to VA1. · The SP did not tell anyone at the facility that VA1 contacted him/her or that VA1 was “struggling.” When this investigator asked the SP what s/he meant when s/he told VA1 that s/he wanted to “continue the relationship,” the SP said that s/he meant it as s/he would “still be [VA1’s] friend” and be there for VA1 “regardless” if VA1 was “using or not.” · VA1 was “always getting a new phone” which was why the SP gave VA1 his/her number. The SP called VA1 a “few times” to talk about VA1 “struggling with using.” However, the SP had not seen VA1 in person since VA1 left treatment. · The CP thought that the SP was in a “relationship” with VA1 due to these messages. Additionally, the CP thought that the photo of VA2 was of VA1. The CP “blew it out of proration” and sent the messages to the facility because the CP thought that the SP was doing something “inappropriate.” The SP denied that s/he or VA1 had a sexual relationship and said that they were “friends.” When this investigator asked the SP why s/he sent VA1 a kissing emoji, the SP said that s/he “meant” to send a “smiling emoji.” The SP told the CP that s/he was spending time with his/her new “boo” out of “anger” and to “rile [the CP] up.” · Staff persons were trained not to have a sexual relationship with a client. The SP denied having a sexual relationship with any client, including VA1. The SP denied having sexual contact with a client while at the facility and said that there was always another staff person present. · The SP denied altering a client’s UA and said that would not be appropriate to do. According to the Program Policy and Procedure last revised November 2021, staff persons were not to have sexual contact with a client or any written or electronic communication that may be reasonably interpreted to be sexually seductive, demeaning, or harassing to the clients. Staff persons should not engage in any sexual behavior within two years following the date of the last counseling service to a former person served. If a staff person, including a nurse, had a “personal relationship” two years prior to a client’s admission to the facility, they were to notify their supervisor for “need for replacement as soon as possible.” The Range Mental Health Center Employee Handbook provided the following information: · Staff persons were to provide services in a professional and ethical manner. Staff persons were likely to encounter current and former clients in the community. Staff persons were to keep current and former client’s status as a client confidential. Staff persons should not initiate contact. If a client initiated contact, it was “appropriate” to speak to them in a friendly manner but not talk to them about “matters” related to client care including therapy. Staff persons were to instead advise clients to contact the facility. · Additionally, all knowledge that a staff person had about a client was confidential. Staff persons were not allowed to “divulge” this infomration in “any form” without the written consent of a client. Staff persons must not access clinical records without a legitimate reason to access them. Additionally, because of the potential vulnerability of clients and the need for community support, contact between staff persons and clients must be professional and appropriate. Any behaviors between staff and clients which were seen as violating professional boundaries were harmful or detrimental to the client’s rehabilitation or recovery and were not acceptable. Any staff person who had a therapeutic client contact should not engage in behavior that could reasonably be interpreted as sexual or suggestive. Staff persons who were involved in direct care shall make every effort to avoid the types of dual relationships that could impair their professional judgement, increase the risk of exploitation of the client, or undermine the confidentiality of the client. Personnel files from the facility showed that the SP, P1, and P2 were trained on facility policies and procedures, including on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was also trained on boundaries, HIPPA, the Code of Conduct Policy, the social media policy, confidentiality in the treatment of substance use disorders, obtaining client releases of infomration, and to “maintain professionalism [and confidentiality] at all times.” Conclusion: Regarding sexual abuse: Although the CP had concerns that the SP “slept” with an unknown client or had a “relationship” with VA1, there was no information provided that sexual contact occurred, including while VA1 was receiving services at the facility. Given that the SP denied being in a “romantic” or “sexual” relationship with VA1 and that VA1 did not respond to this investigators attempts for an interview, there was a preponderance of the evidence that the SP did not have sexual contact with VA1, including while VA1 was receiving services from the facility. It was determined that sexual abuse did not occur (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 showed that the SP communicated with VA1 via Facebook messenger and sent VA1 his/her phone number and a kissing emoji that said, “Be safe.” Another undated message showed that the SP told VA1 that s/he “cared” about him/her and wanted to “continue the relationship.” The SP said that s/he wanted to “see” VA1 and spend time with him/her. The SP told P1, P2, and this investigator that s/he and VA1 were “acquaintances” or “friends” prior to VA1 being a client at the facility. Given the information provided, it was likely that the SP and VA1 interacted with each other in some capacity, including for the SP to provide support to VA1 when VA1 was struggling with using, after VA1 no longer received services from the facility. However, without additional information from VA1, it was not determined how or when the interactions began or what they entailed. Therefore, it was possible that the SP’s interactions with VA1 were not entirely therapeutic. However, without further information, there was not a preponderance of the evidence whether there was a failure to supply VA1 with reasonable and necessary care or services. Additionally, the SP provided infomration that s/he took a photo of VA2’s profile picture, from VA2’s client file. The SP said that s/he did so to show the CP, to determine if VA2 was in a rival gang. The SP said that s/he did not get a chance to show the CP but that the CP accessed his/her phone and took a photo of the photo the SP had of VA2. Although the photo did not have VA2’s name and did not show that VA2 received services from the facility, and there was no infomration that VA2 was aware or that there was any harm to VA2, the SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and was inconsistent with the facility’s plans. The SP was regulated by a health related licensing board and a copy of this report was forwarded to them for their review of possible board violations. However, without further information, there was not a preponderance of the evidence whether there was a failure to supply VA2 with reasonable and necessary care or services. It was not determined whether 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.) Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate regarding VA2 but not followed, as there was a policy prohibiting disclosure of protected health infomration. The SP admitted to disclosing a profile picture of VA2 to the CP at the time while VA2 was a client in inpatient treatment. Regarding VA1, policies and procedures were adequate but not followed, as the SP did not notify supervisory staff persons that s/he was “friends” with VA1 when VA1 began receiving services from the facility. The SP denied “any physical relationship” with VA1. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was regulated by a health related licensing board and a copy of this report was forwarded to them for their review of possible board violations.
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