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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: 1072258-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that the SP kissed the VA at the SP’s home. Date of Incident(s): Prior to October 10, 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 (b), clause (2); and subdivision 2, paragraph (c): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 October 21, 2022, from documentation at the facility and through eight interviews conducted with the VA, the SP, the SP’s significant other (SO), a facility client (C), a management staff person (P1), the VA’s guardian (G), and two facility staff persons (P2 and P3). This investigator contacted another staff person (P4); however, P4 did not respond to requests to be interviewed. The VA lived at the facility with the C and one other client, who was unable to provide information due to his/her disability. The facility had two living areas. The VA lived on one side and had his/her own living room, bedroom, bathroom and a small kitchen/dining area. The C and the other client lived on the other side, but there were no walls separating the two areas. The VA’s CSSP Addendum showed that s/he enjoyed participating in karaoke, riding his/her bicycle, and reading. The plan further stated that the VA had one hour of alone time in the community and “longer” when visiting a family member. The plan also stated that it was expected that the VA tell staff his/her return time when the VA accessed the community. The VA’s Intensive Support Services Assessment showed that some of his/her diagnoses included a traumatic brain injury, bi-polar disorder, and depression. In addition, the VA had a “suicide attempt” in 2020 and a “possible suicide attempt” in 2021. The plan further stated that the VA had suicidal ideations, isolation, and “disturbances of reality.” A review of the VA’s file did not identify any concerns that the VA had a history of being sexually inappropriate with others. P1 provided the following information: · At about 4 p.m. on October 7, 2022, the VA told P1, who was working at the facility, that s/he was going to help a friend work on his/her car. At about 7 p.m., the SO knocked on the door and asked P1 if s/he had a supervisory role at the facility. When P1 told the SO that s/he had a supervisory role, the SO asked P1 where the VA was. When P1 responded that the VA was not at the facility, the SO stated that the VA was at the SP’s home. The SO then left. · P1 then called P3. P3 called the VA, but the call went to voice mail. A short time later, the VA came to the facility and his/her hands, face and clothing were “covered in grease.” When P1 asked the VA if s/he had been at the SP’s home, the VA denied it. P1 called the SP and asked him/her if the VA had been at his/her home and the SP denied that. · A couple days later, P1 talked to another staff person who received a picture from the SO, that showed the VA’s car parked in front of the SP’s home. When P1 saw the picture, P1 “verified” that it was the VA’s car based on the license plate number. · Based on work schedules, P1 did not observe much interaction between the VA and the SP, but P1 was aware of a time that the SP told P1 that the VA had been reaching out to the SP on Facebook and that P1 told the SP that s/he should not be interacting with the VA on Facebook. · P1 also remembered an earlier interaction s/he had with the SP in which s/he told P1 that while working a sleep overnight shift in the past, the VA “kissed” him/her on the forehead and told the SP that s/he needed to wake up. The VA provided the following information: · In late August 2022, the VA and the SP began “hanging out” at the facility. The VA and the SP held hands, kissed on the lips and began “cuddling” in the VA’s living room a “couple” times a week. Although the SP “wanted” to “have sex” with the VA, the VA “turned [him/her] down a few times.” · At about 5 p.m. on October 7, 2022, the SP called the VA and invited the VA over to the SP’s home. After the SP provided his/her address to the VA, the VA went to the SP’s home. When the VA was at the SP’s home, they “kissed” and had pizza. The VA did not remember how long s/he stayed at the SP’s home, but stated that they “didn’t have sex.” The SO provided the following information: · Although the SO did not know the date, the SP asked the SO to come to the facility because the SP wanted his/her phone charger. When the SO got to the facility, the door was partially open so the SO walked in and saw the VA and the SP, who were both standing at the time, and it “basically looked like they were kissing.” The SO did not say anything at the time, but left the facility. After the SO left, s/he called the SP and asked him/her what s/he was doing. The SP told the SO that the VA was “trying to kiss me” and the SP “was pulling away.” · The SO did not remember the date, but when s/he drove by the SP’s home, the SO saw the VA’s car parked on the street. The SO did not stop at the time, but came back a short time later and while walking toward the SP’s door, the SO saw the VA sitting in the living room, but the SO did not see the SP. After that, the SO went to the facility to ask staff where the VA was and to tell them that the VA was at the SP’s home. P3 said that after P1 called him/her, P3 called the VA and stated that s/he “heard a rumor” that the VA was at the SP’s home. The VA told P1 that s/he was “helping a friend,” but the VA was back at the facility “within 5 minutes.” P3 also stated that the VA, who did not have a history of being sexually inappropriate, was able to provide “accurate information.” When the VA was interviewed, s/he initially denied that anything of a sexual nature happened between the VA and the SP, but was “adamant” that s/he and the SP kissed, cuddled, and held hands beginning around the end of August 2022. P2 said that while s/he and the VA were driving on October 14, 2022, the VA told P2 that s/he had a “crush” on the SP and that “it kind of turned into a mutual thing.” When P2 asked the VA for more information, the VA told P2 that s/he and the SP held hands, kissed, and engaged in “cuddling” at the facility. The VA also stated that s/he had gone to the SP’s home the week prior, but that sexual contact did not occur. P2 had not seen much interaction between the VA and the SP, but stated that the VA was a “very honest person” and “very credible.” The C stated that s/he had not observed any inappropriate interactions between the VA and the SP. The G stated that the VA told him/her that the VA and the SP kissed, cuddled, and held hands at the facility and at the SP’s home and that they had “crushes on one another.” The G described the VA as being an “accurate reporter” of information. The facility’s job description for the SP, not signed by the SP, stated that staff were expected to “relate and interact with each person served in a mature and appropriate manner.” The SP provided the following information: · On an unspecified date, the VA kissed the SP’s forehead while the SP slept. When that happened, the SP told the VA to return to his/her bedroom and the VA did that. About three to seven days later, the SP told P4 what happened and P4 told P3 (Investigator’s note: P3 told this investigator that s/he talked to the VA about the concerns and told him/her not to do that again and another former supervisor talked to the SP and told him/her that the incident should have been reported sooner). · After that incident happened, the VA kept “bugging” the SP that they should be “hanging out.” When the VA made those requests, the SP said, “No.” · The SP denied kissing the VA, sexual contact, and that the VA was inside the SP’s home. P3 also said that the day after the SP’s employment ended, the SP sent the following text message to the VA, “Thanks to you, I am done. You’re not sad about jack shit so sober pretend you are. If you would have been sorry, you wouldn’t have pulled your crap in the first place and I’m sorry but what you’re 58 years old and moving to a group home? Seriously, grow the fuck up, get a job and get your own apartment. I know you probably don’t know what being an adult is considering that your own kid has a restraining order against you but honestly you need to grow up.” The SP admitted that s/he sent the text message to the VA. When P3 was asked how the VA responded to the text message, P3 stated that the VA was “distraught” and wondered why the SP “was being so mean.” In addition, the VA wondered if the SO would “cause any problems” for the VA. P3 provided text messages, from the SP to various staff, after the SP’s employment ended that discussed racial slurs regarding the VA, called him/her “disgusting” and that the VA “needs to be put on a lot more medications.” However there was no information that the VA was provided access to those text messages. Relevant Statute Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) stated that a person’s protection related rights include the right to be treated with courtesy and respect. The facility’s training records showed that all staff, including the SP, were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans. Conclusion: Regarding sexual abuse: Although there were concerns reported that the VA and the SP kissed, held hands, and cuddled, each stated that they did not have sexual contact and the SP denied kissing the VA. Given that that kissing did not meet the definition of sexual abuse and there was no information that sexual contact occurred, there was a preponderance of the evidence that sexual abuse did not occur. It was determined that sexual abuse (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) did not occur. Regarding emotional abuse: Although kissing, cuddling, and holding hands did not meet the definition of sexual contact, the SP’s action of sending a derogatory text message to the VA after his/her employment ended was inconsistent with the standards of a professional caregiver in a program licensed by the Minnesota Department of Human Services and in violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6),which stated that a person’s protection related rights include the right to be treated with courtesy and respect. Although the SP’s actions were not therapeutic or repeated, there was not a preponderance of the evidence whether the harm to the VA rose to the level of emotional abuse. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: The facility completed an internal review and determined that although policies and procedures were adequate, the SP did not follow the “Vulnerable Adult/Maltreatment” policy and that no additional training was needed because the SP was no longer employed by the facility as of October 11, 2022. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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