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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: 1066570-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that a staff person (SP) forced a vulnerable adult (VA) to perform oral sex. Date of Incident(s): Approximately March 27, 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 21, 2022; from documentation at the facility and law enforcement records; and through six interviews conducted with a community person (CP) who worked at an unrelated program, a supervisory staff person (P1), two facility staff persons (P2 and P3), a facility registered nurse (RN), and the VA’s case manager (CM). Attempts were made to contact and interview the SP, but the SP did not respond. The VA and the SP were interviewed by a law enforcement officer (LEO) and that information was included below. The VA was not under court appointed guardianship. The facility was a building with multiple levels. The upstairs (main level) of the facility included community space, the clients’ bedrooms, and a staff office. The downstairs of the facility included P1’s staff office and a laundry room. The VA resided at the facility from March 23 to 29, 2022. According to the VA’s Immediate Needs Assessment, the VA exhibited “risky sexual behaviors and engaged in oral sex with a peer.” Staff persons ensured the VA was “safe” at the facility, engaged in safe sex practices while at the facility, and addressed the VA’s mania and sleeplessness. According to the VA’s Abuse Assessment and Plan, the VA had a “very long” history of post-traumatic stress disorder and trauma. The VA had “trouble” refusing sexual advances from persons. The facility ensured the VA worked on a safety plan and ways to assert him/herself if s/he was asked for sex. The RN coached the VA on keeping him/herself safe, preventing sexually transmitted diseases, scheduling medical appointments, and physical and mental health. Staff persons coached the VA on proper hygiene, especially during hypersexual times. The VA provided the following information to law enforcement: · During the VA’s first night at the facility, while staff persons were in the medication room or staff office, the VA and another client (C) went outside a door on the lower level and smoked cigarettes. During that time, the C wanted oral sex and the VA refused and left. A short time later, the VA went back outside for another cigarette and the C was outside. In order to “shut [the C] up,” the VA and the C engaged in oral sex for approximately 25 seconds. · The VA stayed awake that night and in the morning, s/he went to the RN’s office and told the RN about the oral sex with the C. · The following night, the SP apologized to the VA for the incident with the C and told the VA it “should have never happened to you.” The SP offered the VA his/her personal cell phone number and the VA gave the SP his/her snapchat information. · On approximately March 27, 2022, the SP came to the facility and worked the overnight shift. Another staff person (the VA could not recall who) worked in the upstairs staff office. The VA lay in bed awake when the SP shined a flashlight into the VA’s bedroom. The SP left the room and then texted the VA to come downstairs. The SP and the VA walked downstairs together and into P1’s office. The VA could not recall if the SP sat or stood but the SP pulled down his/her pants and the VA performed oral sex on the SP. The VA did not recall what happened afterwards and did not tell any staff persons about the incident. · The following day, the VA left the facility and did not return. After leaving the facility, the VA lost his/her cell phone so s/he was not able to show law enforcement the text messages from the SP. The CP stated that on approximately May 1, 2022, the VA entered the program where the CP worked. During that time, the VA was “manic” and “reckless.” On May 11, 2022, the VA told the CP that s/he performed oral sex on the C. The SP then “saved” the VA so s/he later performed oral sex on the SP. The VA spoke “so fast” and the words “tumbled out.” The VA’s mania was “very elevated” and s/he left that program on May 12, 2022. P2 stated on May 11, 2022, at approximately 4 a.m., the VA called the facility. During the conversation, P2 took notes. P2 wrote down that the VA “accused” the SP of oral sex in the basement of the facility. P2 did not recall any information about that part of the conversation. Later that morning, P2 told P1 about the conversation. P1 provided the following information: · On May 11, 2022, at 8 a.m., when s/he arrived at the facility, P2 told P1 that the VA called earlier that morning. P2 wrote down notes and told P1 that the VA told P2 that the VA performed oral sex on the SP. The VA also requested that a supervisory staff person contact the VA. · Later that day, P1 called the phone number the VA provided but P1 was not able to speak to the VA. P1 then notified his/her supervisor (P4). Later on, P1 called the SP and told the SP that s/he was suspended from work. The SP was “upset” and did not understand why s/he was suspended. On May 13, 2022, the SP resigned from the facility. · P1 met the VA on April 28, 2022, and did not have much contact with him/her while at the facility but said that the VA was mentally decompensating while s/he was at the facility. There was no reason why the SP and the VA would have been in P1’s office, especially during the night. P3 worked the overnight shift with the SP on March 27, 2022. P3 was possibly doing online training in the staff office upstairs and the SP did hourly checks on the clients including the VA. P3 and the SP were together “most of the time” except while they cleaned. P3 did not recall anything unusual that night and did not have concerns with the SP’s interactions with clients. The VA historically did not sleep and “was all over the place” during the night so staff persons often checked for the VA. The RN provided the following information: · On an unknown date, the VA came to the RN’s office and told the RN that s/he had oral sex with the C. The VA said s/he willing participated and it occurred in the basement laundry room. The C gave the VA $10 in “hush money” but the VA was not coerced. · In the next few days, the VA’s version of the incident changed when talking to peers and the RN, including saying the C forced the VA into oral sex and the number of times s/he performed oral sex on the C. After that, the RN told all overnight staff persons, including the SP, to complete additional checks since the VA was awake at night often and tried going to the basement with the C. The VA did not tell the RN about any concerns with the SP. The SP provided the following information to law enforcement: · The SP recalled on multiple previous occasions, the VA, who’s name the SP could not recall, told the SP about an incident between the VA and the C. On one of those occasions, when the SP gave the VA his/her medication, the VA again told the SP s/he had sexual intercourse with the C. The SP reminded the VA that s/he and other staff persons previously discussed the incident with the VA, that the SP “sympathize[d]” with the VA, and would “make sure that doesn’t happen again” because “this is what all staff [persons] do.” · The SP typically did rounds at 2 and 5 a.m. which always had two staff persons. The SP denied being alone with the VA including in the staff office, denied texting with the VA, and denied having sexual intercourse with the VA. The CM provided the following information: · The VA’s mental health declined while s/he resided at the facility. The CM was concerned because the facility had not contacted the CM when the VA’s mental health “very quickly decompensate[d]” which lead to a crisis. A few days after the VA left the facility, the facility contacted the CM to let him/her know the VA left. They also informed that CM that the VA had a sexual interaction with the C. · The CM had not heard from the VA for a few weeks after s/he left the facility until s/he “resurfaced at a hospital.” While at the hospital, the VA told a worker there that s/he had a sexual interaction that was not consensual. The CM had not been aware of the allegations and did not know who the sexual interaction with was. · The CM then spoke to the VA over the phone and the VA was manic and “all over the place.” The VA “blended” together a sexual incident that took place approximately eight months prior and also the allegations in this report. The CM was not sure if the VA was talking about performing oral sex on another client or a staff person and the VA was not able to provide a “clear” response. Later on, once the VA stabilized on his/her medications, s/he was “very coherent.” According to the law enforcement report, on August 3, 2022, a law enforcement officer (LEO) reviewed the VA’s and the SP’s phone records and did not find contact between them. The facility’s personnel files and training records documented that staff persons interviewed for this investigation, including the SP, were each trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: The VA provided information to the LEO that on approximately March 27, 2022, the SP texted the VA to come downstairs. The SP and the VA went into P1’s office and the VA performed oral sex on the SP. The SP denied being alone with the VA including in the staff office, denied texting with the VA, and denied having sexual intercourse with the VA. Given that P3 stated that P3 and the SP were together “most of the time” except while they cleaned and did not have concerns with the SP’s interactions with clients; that the SP denied the allegations; there was no phone records indicating contact between the VA and the SP; and that there was no additional information to support or refute the VA’s information about the incident; there was not a preponderance of the evidence whether the VA and the SP had sexual contact. 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 procedures were adequate and followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On October 26, 2022, the facility was issued a Correction Order for failing to report possible maltreatment as required.
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