|
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: 1094352-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady Suspected Maltreatment Reported: It was reported that while being supervised by a staff person (SP), a vulnerable adult (VA) was able to access his/her cellphone, which was a violation of the VA’s support plan, and the VA was able to send text messages with sexual content to minors. Date of Incident(s): Ongoing, prior to July 16, 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 17, paragraph (a): 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 August 3, 2022; from documentation at the facility and law enforcement records; and through interviews conducted with the VA, three facility staff persons, and the VA’s guardian. The facility was a four level home. The main level included a living room, dining room, and a kitchen. Up half a flight of stairs from the living room was the upper level which included two bedrooms and a staff office. The staff office was immediately at the top of the stairs (in the staff office, there was a locked file cabinet for the VA). Half of flight of stairs down from the living room were three bedrooms including the VA’s bedroom. Off of that level there was half a flight of stairs that led to a common area. The VA’s support plans stated: · The VA’s diagnoses included anxiety and autism. · The VA was to be within six feet of a staff person at all times except when s/he was in his/her bedroom or bathroom. · Due to the VA attempting to contact persons who did not want to have contact with the VA and attempting to contact minors, the VA had a rights restriction regarding the use of his/her cellphone. The VA was able to have internet access on his/her cellphone, but the cellphone was to be flat on the kitchen table in a way that staff persons were able to observe what s/he was doing at all times. Each day between 8 a.m. and 2 p.m., the VA had up to two hours on his/her cellphone and another two hours between 2 and 10 p.m. When the VA was not using his/her cellphone, it was to be kept in the locked cabinet in the staff office. A police report contained the following information: · On July 17, 2022, a supervisory staff person (P1) reported that the VA called P1 and told him/her that the prior night s/he gained access to his/her cellphone and used an app to send a nude video of him/herself to two different minors. P1 was told that earlier in the day a family member of one of the minors called the VA, and after talking with the VA, said that s/he would not press criminal charges. No contact information for the family member was obtained. The VA deleted his/her call logs, apps, and text messages on his/her cellphone and locked it with a password. · On July 20, 2022, police responded to a community person who stated that a friend of the community person who attempted to catch sexual perpetrators (the person said like a television show) had posed as two different minors on a dating website and got the VA’s name. · Law enforcement took no further action. P1 provided the following information: · P1 found out about the incident on July 17, 2022, when the VA gave his/her cellphone to a staff person and then called and told P1 what s/he did. P1 said that the VA told him/her that s/he sent the messages the prior night. At that time, P1 asked the VA how s/he was able to access the cellphone and the VA did not want to tell P1. · Five staff persons were working the night of the incident (the overnight starting on July 16 and ending on July 17, 2022). During that shift, the SP was assigned as the staff person responsible for the supervision of the VA and was to be within six feet of the VA unless the VA was in his/her bedroom. · The VA’s cellphone was kept in a locked cabinet in the office. If staff persons were not in the office, the office door was also to be locked. · P1 believed that a staff person would have seen the VA going into the office to access his/her cellphone. P1 believed that at some point, a staff person gave the VA his/her cellphone. If staff persons were providing the VA with the required supervision, the VA would not have been able to access his/her cellphone. The VA provided the following information to this investigator and in a facility internal review report: · The VA had a cellphone, but the VA was not to use it unless a staff person was watching the VA. The staff person had to watch the screen when the VA used the phone. · During the overnight ending the morning of July 17, 2022, the VA obtained the cellphone by walking into the staff office and taking it out of a cabinet that was supposed to be locked. The VA took the cellphone to his/her bedroom. The VA took the cell phone two nights in a row and each morning returned it to the office. Five staff persons worked during the overnight with one staff person assigned to work with the VA. That staff person was to be within six feet of the VA. When the VA accessed his/her cellphone, the VA did not know the name of any staff persons working. When asked where the staff persons were when s/he went into the office, the VA said that s/he did not “pay attention” and “did not care.” The SP provided the following information and in the facility internal review report: · On the night of the incident, the SP arrived at 11 p.m. Nothing unusual occurred during the shift. The SP saw the VA for about 20 minutes. During that time, the VA was warming up food in the kitchen. The VA then went to his/her bedroom and the SP never saw the VA again before the end of his/her shift. Staff persons were not allowed to go into the VA’s bedroom without permission. During overnights staff persons were generally in the living room or the office. Staff persons were assigned to work with specific consumers. · The VA never asked the SP to access his/her cell phone. For the VA to access the cellphone, the VA would have to ask one of the staff persons for a key and then go and get his/her cellphone. All the staff persons working that night would state that the VA did not go into the office that night and that s/he did not leave his/her bedroom after going to bed. The SP believed that the VA had his/her cellphone before the SP arrived. The SP did not give the VA the cellphone. The night of the incident, the SP provided the VA with the required supervision · The VA was not supposed to have access to his/her cellphone. The cellphone was kept in a locked cabinet in the office. The VA had to ask staff persons to get him/her the cellphone. Staff persons were to be with the VA when s/he used the phone. In addition to the SP, four other staff persons (P2-P5) worked the night of the incident. P2 provided the following information: · P2 regularly worked overnights. Four or five staff persons worked each overnight depending on how many consumers were living at the home. On each shift, each staff person was assigned to be responsible for one consumer. During overnights, staff persons were mainly in the living room and kitchen. Staff persons were not in the office unless they were doing training on the computer. The staff office was to be locked if staff person were not in office. · If the VA left his/her bedroom, the staff person responsible for supervising him/her would take care of everything with him/her. The VA typically was up late playing video games or getting food in the kitchen. Sometimes the VA did go to bed until 3 or 4 a.m. P2 never saw the VA use a cellphone during an overnight shift. P2 never saw the VA go into the staff office during an overnight shift. P2 did not think the VA could leave his/her bedroom, go into the office and get his/her cellphone, and then go back to his/her bedroom without a staff person noticing. P2 always provided the required supervision when s/he worked overnights. This investigators left two voicemails each for P3, P4, and P5 to contact this investigator and each of them did not respond. The G stated that s/he did not talk to the VA about the incident because the VA was not truthful when s/he told the G about events. The G stated that the VA did not like certain staff persons and would try to get staff persons fired. Facility documentation showed that the SP received training specific to the VA and on the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Statute Minnesota Statutes, section 245D.07, subdivision 1a states that the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and support plan addendum. Conclusion: The VA was able to access his/her cellphone two times each day, but the phone was to be flat on the kitchen table in a way that staff persons were able to observe what s/he was doing at all times. When the VA was not using his/her cellphone, it was to be kept in the locked cabinet in the staff office. On the morning of July 17, 2022, the VA told P1 that s/he contacted two minors during the prior overnight shift. The VA told P1 that s/he sent nude videos and then received a phone call from a family member of one the minors. The VA deleted all evidence of the contacts from his/her cellphone. An investigation by law enforcement showed that the VA actually contacted one adult who was posing as two different minors. Law enforcement did not take any additional action. When the VA initially told P1 about what happened, the VA did not say how s/he obtained his/her cellphone. The night s/he had his/her phone, five staff persons were working and the SP was responsible for the supervision of the VA. The VA told this investigator that s/he obtained the phone by walking into the staff office and taking it out of a cabinet that was supposed to be locked. The VA said that s/he took the cell phone on two different nights in a row and each morning returned it to the office. The VA did not know who was working and did not pay attention to where staff persons were when s/he was able to get his/her phone. The SP stated that on the overnight ending the morning of July 17, 2022, the VA never left his/her bedroom after going to bed about 11:30 p.m. The SP said that the VA did not go into the office. The SP denied giving the VA his/her cellphone. The SP believed that the VA already had his/her cellphone prior to the SP’s shift. Four other staff persons worked that night and P2, the only staff persons who contacted this investigator, stated that s/he did not think the VA would have been able to obtain the cellphone without staff persons knowing. Given that the VA did not provide more specific information about how s/he obtained the cell phone and that the VA deleted all the information that would have shown the times and dates that the VA used his/her cellphone, it was not determined when the VA actually obtained the cellphone. Although it was not determined when the VA obtained his/her cellphone, the only way the VA could have obtained it was because staff persons failed to follow the VA’s support plan which was a violation of Minnesota Statutes, section 245D.07, subdivision 1a. However, because the VA sent messages to an adult posing as a minor and law enforcement declined to charge the VA with a crime and there was no harm to the VA, there was not a preponderance of the evidence whether there was a failure to provide the VA with supervision which was reasonable and necessary to obtain or maintain his/her physical or mental health or safety. 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 their policies and procedures were adequate but not followed. The facility provided retraining to staff persons on the VA’s rights restrictions. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: Because the facility provided retraining to the staff persons and took corrective action with the SP, a Correction Order was not issued and no further action was taken by the Department of Human Services.
|
