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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: 1107107-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth Suspected Maltreatment Reported: It was reported that a staff person (SP) had sexual contact with a vulnerable adult (VA) on two occasions. Date of Incident(s): Unknown prior to September 4, 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 for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through six interviews conducted with two facility staff persons (the SP and P1), three supervisory staff persons (P2, P3, and P4), and the VA’s case manager (CM). Attempts were made via phone and U.S. mail to contact and interview the VA’s guardian (G) but the attempts were not successful. Additionally, law enforcement interviewed the VA and that information is provided below. The VA was diagnosed with oppositional defiant disorder, attention deficit hyperactivity disorder, and unspecified focal traumatic brain injury. The VA enjoyed riding his/her bike, listening to music, being outdoors, and spending time with family members. The VA’s Individual Abuse Prevention Plan said that the VA had a lack of understanding of sexuality and was likely to seek or cooperate in an abusive situation. The VA “struggled” with boundaries with relationships and sexuality. The VA would often think a relationship was further along than what the other person felt it was. The VA would likely participate or seek out an abusive situation. The VA had a history of sending inappropriate messages to people via social media or text message. The VA had a history of “sexual encounters” with a co-worker at work. The VA said that in 2012, s/he was sexually assaulted by three “individuals” who then took his/her belongings “without permission.” There was no additional information provided regarding this. Staff persons were to assist the VA in creating and respecting boundaries with others. Staff persons were to redirect the VA if s/he was having inappropriate sexual conversations with them and report any suspected abuse. P1 and a progress note written by P1 provided the following information: · On September 4, 2022, at 9 a.m., the VA told P1 that at some point the prior week (the VA did not provide a date), the SP told the VA that s/he was a “vulnerable adult [him/herself].” This “raised some red flags” for P1 so P1 then began “questioning more things about [the SP and the VA].” P1 asked the VA, “What else [the SP] had done to [the VA]?” As P1 asked the VA “questions,” the VA became “very quiet” which caused P1 “great concern.” P1 then “began to question [the VA] more” and the VA continued to be quiet and did not respond to P1’s questions “at all.” · Later while P1 was asking the VA questions, the VA said that the SP “did something.” P1 asked the VA if the SP “tried to kiss [him/her] or make out” with him/her and the VA did not respond. P1 “finally” asked the VA if the SP had “made any advances towards [the VA] or [tried] to kiss [the VA] at any time or in any way” or “make out” with him/her. The VA then stated that the SP “did” [Note: The General Events Report said that the VA denied that the SP kissed him/her] and that the SP also “did way more than just kissing [the VA].” The VA told P1 that the SP performed oral sex on the VA on two separate occasions in the VA’s bedroom. The VA did not provide dates but said that it occurred “last week.” The VA said that s/he felt “relieved” to tell P1 what happened and that s/he felt “extremely taken advantage of.” P1 then notified P2. · The VA had a history of not being “very truthful” and would “manipulate” a situation so that it “went in [his/her] favor.” Regarding the incident, P1 was initially in “complete disbelief” and “believed” the VA but later, the details seemed a “little fuzzy” and were not “adding up much.” P1 then began “question[ing] a little bit more of what had happened.” · P1 thought that the VA may have said these things because P2 was getting a new position. Additionally, the VA had been trying to reach the G or the CM for about a week but was not able to, so P1 thought that the VA may have said these things to “spark a faster response.” · The VA was “kind of sexual” and would talk to staff persons about “sex stories” and “masturbating.” The VA also “boasted” about another time s/he had received “oral sex” from a co-worker. If the VA talked about these things, staff persons were to redirect the VA to talk about something else. · P1 had worked with the SP and thought that s/he and the VA “got along great.” However, they seemed a “little flirty” together. P1 provided an example that they would color together and were really “giggly.” The SP had also spoken to the VA about a relationship s/he was in and received “advice” from the VA. The SP would also “complain” about his/her personal life and “overstep [his/her] boundaries,” which staff persons were not supposed to do. On one occasion, prior to the SP taking the VA on an outing to a nearby gas station, the SP went into the bathroom and then took the VA on an outing. P1 then went into the bathroom and noticed that it smelled of perfume/cologne “really bad.” P1 thought this was “odd” that the SP may have sprayed a “bunch of [perfume/cologne]” on him/herself prior to taking the VA on an outing but did not think much of it at the time. However, the VA and the SP were back to the facility within a “normal” time and “everything seemed fine” once they returned. The VA also told P1 that the SP showed him/her a photo of a “penis” that s/he had received from someone but P1 never saw the photo. P1 never saw the SP touch the VA inappropriately. · The SP also recently had surgery and the VA told P1 that at some point, the SP “called” the VA into the bathroom to have the VA bring the SP something the SP needed from his/her bag for post-surgery care. When the VA walked into the bathroom, the SP had his/her pants pulled down and the SP showed the VA a scar which P1 said was “completely inappropriate.” · There were typically two staff persons at the facility and the SP typically only worked alone for “half hour tops” “every so often.” P1 was not aware of any other staff persons having concerns with the SP. The Department of Public Safety report provided the following information: · The LEO said that s/he spoke to the VA about the incident. The VA said that it “sucks” telling the LEO “details” about the incident as it was “like having to relive the incident.” The VA did not want to meet with the LEO in his/her bedroom because that was where the incident occurred. The VA said that the SP “gave [him/her] oral sex twice.” The incidents occurred when the SP was the only staff person working. When the LEO asked the VA if the SP “forced it on [the VA],” the VA said that s/he “did not agree to it.” When the LEO asked the VA if any “threats” were made by the SP, the VA said, “No,” but that the SP told him/her not to tell anyone about the incident. The VA said that the SP called it his/her “secret love affair.” · P2 told the LEO that the dates the incident could have happened were on August 21 and September 1, 2022, when the SP was the only staff person working. · P2 and P4 both told the LEO that P1 asked the VA “leading questions” when talking about the incident. · The SP told the LEO that the incidents did not occur. · The LEO sent the report to the county review for review of charges which was still pending at the time of this investigation. P2, P4, and the Internal Review provided the following information: · On September 4, 2022, P1 sent P2 a text message stating that s/he had just “learned something disturbing.” This included that the SP and the VA had oral sex on two different occasions. P2 said that there was no kissing or any other sexual contact. P2 was “kind of in shock.” P2 then went to the facility and spoke to the VA who said that s/he did not know the date of the incident but that it occurred twice within the past couple weeks and within 10 minute of another staff person leaving their shift. P2 “estimated” the dates based on when the SP was the only staff person within the past couple weeks and thought that the incidents may have occurred on August 21 and September 1, 2022. The VA also said that the incidents occurred in his/her bedroom. · The facility timesheets showed that the SP worked with the VA on August 21, 2022, from 1:16 to 10:08 p.m. Progress notes showed that the SP documented that on that day, s/he assisted the VA with cleaning his/her bedroom. The SP had also worked with the VA on September 1, 2022, from 3:39 to 5:59 p.m. There was nothing in the progress notes indicating that the SP had been in the VA’s bedroom. · On September 5, 2022, P4 spoke to the SP who denied the allegations and said that s/he did not have physical or sexual contact with the VA at “any point.” The SP said that s/he would “never do that.” The SP appeared “shocked.” The SP told P4 that the VA had talked about “inappropriate” things with him/her, including “pleasuring” him/herself and asked the SP about his/her significant other. The SP told P4 that when the VA did these things, the SP told the VA that s/he did not feel comfortable talking about those things. P4 said that the VA did this to other staff, including P2, which P2 confirmed. · On September 5, 2022, the LEO spoke to the VA. The LEO then told P2 that s/he “had concerns that the allegations” were “not accurate.”
· The VA was “very intelligent” but had a history of inaccurate reporting, including for “attention seeking.” However, P2 said it was nothing “quite to this level involving a staff.” · P2 said that the VA may have said this happened as the VA had been trying to call the G for about a week but the G was on vacation. Additionally, P2 was switching positions which the VA brought up to P2 “every day.” The VA may have felt that s/he “needed more attention.” · The SP had worked with the VA for approximately one month. The VA and the SP got along “well” and spent a “lot of time” coloring pictures at the dining room table together. The facility was typically double staffed with the exception of between 8 and 10 p.m., when the clients went to bed. · No other clients or staff persons had expressed concerns with the SP’s interactions with clients. The “only” concern P2 had regarding the SP was the SP sharing about his/her significant other and the SP’s health issues, including a recent surgery. · Following the incident, P4 spoke to P2 about telling staff persons not to ask “questions that are misleading,” which is what P1 did. P4 said that when staff persons asked the VA questions that were “very misleading,” the VA would “go in that direction.” This included P1 asking the VA if “something happened between you guys” and “did [the SP] try to kiss you?” P4 said that P1 was “leading [the VA] in that direction.” Additionally, P1 had concerns that the VA did not initiate the conversation but P1 did. The VA may have said these things because s/he was “getting attention” from P1. P3 provided the following information: · The VA needed a “lot” of support with boundaries, as the VA made “a lot of inappropriate” comments towards others. The VA also talked to persons of the opposite gender online and there were prior concerns with that. · The VA had a history of providing inaccurate information and may “elaborate” things. However, the VA had not said anything similar regarding staff persons prior. · P3 thought that the VA may say that the incident occurred if it were not true and it would “not necessarily shock [P2]” if the VA did so. The VA could “feed” into things and if the VA wanted to get “attention” or “get someone in trouble” the VA may say “different things.” · P3 was not aware of any other concerns with the SP. The SP provided the following information: · The SP denied engaging in oral sex with the VA. When the SP heard about these concerns, s/he was “literally sick to [his/her] stomach” and said that was not something that s/he would do. · At times, the VA had made “various comments” about person’s genital area, including the SP’s, which the SP “brushed off.” The VA also talked about his/her past sexual relationships. The SP told the VA that was not “okay” to talk about. · The SP denied telling the VA that s/he was also a vulnerable adult. The SP denied spraying perfume/cologne at the facility but said that s/he sprayed perfume/cologne prior to coming to work, but that it was not for the VA’s benefit. The SP denied showing the VA a photo of someone’s genital area. · The SP said that at some point, s/he had an “incision” due to a surgery and while at the facility, the SP was bleeding. The SP said that s/he asked the VA to bring him/her his/her backpack to get “medical supplies.” The SP later went to the emergency room to have the incision looked at. · Anytime the SP was in the VA’s bedroom, including to assist the VA with cleaning, the door was “always open.” The CM said that the VA could “stretch the truth a little” but the CM was not aware of any similar incidents. The VA called the CM “periodically” but did not tell the CM about the incident. The CM had a concern that the VA had a significant other sleep over without approval from the VA’s team. However, the facility put together a “plan” to address that going forward. The CM did not have any other concerns with the facility. Personnel files showed that the SP, P1, P2, P3, and P4 each received training on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adult Act. The SP, P1, and P2 were also trained on the VA’s plans. Conclusion: The VA provided consistent information to P1, P2, and the LEO that the SP and the VA had oral sex on two occasions in the VA’s bedroom. The VA did not know the date of when the incidents occurred but said that it occurred within the past couple weeks prior to September 4, 2022. The SP denied the allegations. Although the VA provided consistent information that the SP had sexual contact with the VA, given that the LEO, P2, and P4 each said that P1 asked the VA “leading” questions, including if the SP tried to “make out” with the VA or make any “advances;” that the VA had a history of providing inaccurate information; and that there was no information to support or refute either account, 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 procedures were adequate and followed. The VA had a history of “inaccurate reporting.” Following the incident, the SP no longer worked at the facility with the VA. The SP received retraining on professional boundaries. Action Taken by Department of Human Services, Office of Inspector General: No further action at this time.
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