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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: 1111170-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) who had a history of incidents of inappropriate actions including brushing up against young children, was left unsupervised in a YMCA locker room of his/her same gender with children present. During the course of the investigation, it was also reported that the VA “bumped” into a child while in the pool at the YMCA. Date of Incident(s): March 21, 2023 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 April 06, 2023; from documentation at the facility; and through seven interviews conducted with a supervisory staff person (P), two facility staff persons (SP1 and SP2), the VA, the VA’s case manager (CM), the VA’s guardian (G), and a community person (CP). The YMCA was located inside a community building. To gain access, a keycard was scanned at the front desk and then entrance occurred through a metal detector. From there, there was a hallway “lobby” area. Standing with the front desk behind, the men’s and women’s locker rooms were to the right, in front was an event room that had glass walls looking into part of the pool area, and to the left were offices on both sides of the hallway. Down that hallway to the left (approximately 20 feet), to the front was the Kid Zone and another hallway to the right. This hallway led to the family locker commons (approximately 40 feet away). The family locker commons was a hallway with two individual toilet/changing stalls and four individual shower stalls on the left side and one individual toilet/changing stall and two individual shower stalls on the right side. There were also lockers on the right side to store belongings. At the end of the family locker commons hallway was a doorway to a pool area. Once in the pool area there was an activity pool, to the left of the activity pool was a lap pool, and behind the activity pool there was a “lazy river” resistance pool which had jets that kept the water moving so people could swim/walk against the moving water for resistance. There were no floatation devices used in the “lazy river.” There were a separate therapy pool and hot tub. From the hot tub there was a clear view of the “lazy river.” The VA’s diagnoses included attention deficit hyperactivity disorder, conduct disorder, exhibitionistic disorder, and borderline intellectual functioning. The VA enjoyed reading, swimming, and watching the Wild hockey team. The VA’s Self-Management Assessment stated that while in the community, staff persons “should always be within eyesight of [the VA], and in a crowded situation, staff persons should be no more than an arm’s length away. The VA’s Community Support Plan stated that the VA had a history of incidents of inappropriate actions including brushing up against young children. The VA “needs intensive supervision to assure [the VA’s] safety and the safety of those around [the VA]” and “[the VA] required 1:1 supervision while in the community.” The VA stated on March 21, 2023, s/he, SP1, SP2, and two of the VA’s housemates (HM1 and HM2) went to the YMCA. The VA stated that s/he was in the “lazy river” and the current was “fast” and “hard to control sometimes” when the VA and a child “bumped” into each other. SP1 was in the “lazy river” with the VA and told him/her it was not the VA’s fault. After they were done swimming, the VA changed in an individual stall in the family locker commons area and then the VA and SP2 went to wait for HM1 and HM2, who were in the locker room of their gender, in the lobby area. SP1 was still changing in one of individual stalls in the family locker commons area. The VA said s/he saw the CP when the VA was standing in the lobby with SP2, and the VA said, “Hi.” The VA said s/he opened the locker room door of his/her gender to yell at HM1 and HM2. The VA stated s/he did not go into the locker room and that SP1 was still changing, but SP2 was standing outside the locker rooms by the front desk with the VA. The CP used to work with the VA prior to the VA residing at the facility and knew of the VA’s vulnerabilities and that the VA was supposed to be supervised at all times. On March 21, 2023, around 7 p.m., the CP went into the locker room of his/her gender to grab his/her shoes, saw the VA standing there without supervision, and the VA waved at the CP and might have said, “Hi.” The VA was fully dressed, but there were children in the locker room running around in their underwear. The CP thought the VA was about 15 feet away from the children and the VA did not say anything to them. The CP stayed in the locker room until the VA walked out and walked up to three individuals who were in the lobby area. The CP did not see a staff person. The G stated that the VA’s supervision requirement was “eyes on at all times in the community.” The VA told the G that while at the YMCA, SP1 and SP2 made the VA dress in a bathroom, and the VA “bumped” into a child. The G stated that staff persons had a specialized training about the VA and were aware of his/her supervision requirements. The G said the VA had done “very well” at the facility and the VA liked it there. The CM stated that s/he was “very happy” with the facility and that the VA was getting out to do things. The CM stated that the protocol for the VA to use a bathroom was that the VA needed to use a single stall bathroom. The CM stated that s/he had a psychologist train staff persons about the VA’s history. The P said that when s/he spoke with the VA, SP1, and SP2 they all stated that the VA was “never” left unattended in the locker room. The VA was in the lobby area and yelled into the door for HM1 and HM2 to come out. The VA used the family area, single person bathroom. The P stated that the VA’s plans stated that the VA should be in “eye shot” and if crowded staff persons should be in arms-length of the VA. The P stated that before the VA moved in, the facility had training through the county on what to watch for, staff persons read through the VA’s files, and staff persons trained on three shifts before working alone with the VA. The P had not heard about the VA “bumping” into a child. The P had no previous concerns with SP1 and SP2. SP1 provided the following information: · On March 21, 2023, the VA, HM1, HM2, SP1, and SP2 went to the YMCA around 6-6:30 p.m. HM2 went to the gym to play basketball, HM1 went into the locker room of his/her gender, SP1 and the VA went into the individual stalls in the family area, and SP2 waited in the family common area hallway for the VA to get changed. SP1 described the family common area as a corridor with single use bathrooms on both sides, single use showers on both sides, and lockers on one side. The door at the end was closed to the pool area. · Then, SP1, SP2, the VA, and HM1 went into the pool area. They sat in the hot tub for awhile and when the “lazy river” opened, and the VA went into that. The “lazy river” had jets and you were supposed to walk opposite of the flow. The VA liked to swim in it if there were not too many people, but when there were too many people the VA walked around. From the hot tub, SP1 could see the “lazy river” and based on the amount of people in the “lazy river” s/he joined the VA in there. While in there, a child “hit” one of the jets and it “bumped” the child into the VA. The VA closed his/her arms over his/her chest and brought his/her legs together. SP1 stated it was an accident, and that the jets were strong. · After about 10-15 minutes, SP1 left the “lazy river” to go get changed first as it took him/her longer to shower and get changed. SP1 let SP2 know. SP1 went into the family common area and showered, and when s/he got out, the VA was standing in the doorway of the family common area, fully dressed, and the VA told SP1 s/he was looking for him/her. · SP1 went to grab his/her shoes and the VA started to walk back to SP2 and was maybe 10 feet in front of SP1. The VA went to open the door to the locker room where HM1 and HM2 were and SP1 told the VA that s/he should not do that. The VA let go of the handle and HM1 and HM2 walked out, and they left the YMCA around 7:45 p.m. · SP1 said when leaving the family common area, s/he needed to take a left and then another left to get back to the lobby. SP1 said SP2 would not have been able to see the VA when s/he was standing at the doorway of the family common area, but thought it was only for 30 seconds as the VA stated, s/he just came to find SP1. When SP1 turned the corner to the lobby area, SP2 was looking in their direction. SP1 believed the VA’s supervision plan in public was to keep eyes on the VA as best as possible and that the VA used the single stall bathrooms to protect him/herself. SP2 provided the following information: · On March 21, 2023, SP2, SP1, the VA, and HM1 went to the YMCA to go swimming. SP2 did not remember if HM2 was with them, but if s/he was HM2 went to play basketball. HM1 went into the locker room of his/her gender while SP2, SP1, and the VA went to the family rooms. SP1 and the VA got lockers and then went into separate shower rooms to change while SP2 waited on a bench for the VA. The VA changed “real quick” so SP2 and the VA went through the door out to the hot tub and then SP1 joined them in the hot tub. The VA went into the “lazy river” and SP1 joined him/her there. SP1 and the VA swam for quite a while and then SP1 went in to get changed. The VA came back to join SP2 in the hot tub. · The VA then said s/he wanted to get changed. SP2 told HM1 that s/he needed to go get changed, and the VA and SP2 went into the family changing room. The VA changed and then s/he and SP2 went to the lobby behind the reception desk to wait for everyone else. The VA went back to the family room to see where SP1 was and came back and said SP1 “was coming.” SP2 stated that s/he could see the VA the whole time as the VA did not go back into the family changing area but stood at the door. The VA walked back to SP2 and the SP1 came out after the VA. The VA started to walk towards the locker room to yell in for HM1 that the VA was ready to go, but SP1 told the VA to not do that so the VA stepped away from the locker room. · SP2 was not aware of the VA “bumping” into a child. SP2 stated that the VA’s supervision requirement in public was to “see [the VA] at all times.” Based on a drawing made by SP2, the VA and SP2 were standing in the lobby behind the reception desk and then it was a straight hallway down to the entrance of the family locker rooms. Facility records showed that SP1 and SP2 were trained on the Reporting of Vulnerable Adults Act and the VA’s plans. Conclusion: The VA had a history of incidents of inappropriate actions including brushing up against young children and required eyes on supervision by staff persons when in the community. On March 21, 2023, the VA, SP1, SP2, and HM1 went to the YMCA’s pool area. While the VA and SP1 were in the “lazy river,” a child got propelled along by the jets in the pool and “bumped” into the VA at which point the VA crossed his/her arms over his/her chest and brought his/her legs together. SP1 was in the “lazy river” with the VA and stated it was accidental. Then, the VA and SP1 joined SP2 and HM1 in the hot tub. When they were done in the pool area, first SP1 went to the family changing room to shower and then HM1 went into his/her changing room while the VA and SP2 went into the family changing area so the VA could change. Once changed, the VA and SP2 went to the lobby area to wait for the others. The VA walked back to the family locker commons to see if SP1 was ready. The VA then walked back to the lobby and SP1 followed. The VA went to open the locker room door to yell to his/her housemates, but SP1 told the VA that would not be a good idea. Although the CP stated that s/he saw the VA in the locker room of his/her gender unsupervised; the VA, SP1, and SP2 each stated that the VA did not go inside the locker room of his/her gender but used the family changing area while SP2 was present and then went to the lobby with SP2. However, while in the lobby the VA left SP2 to look for SP1 who was still in the family changing area. Although SP2 stated the VA was within eyesight the entire time, the layout of the YMCA and what SP1 said, showed that from where SP2 was standing, the area the VA went to that SP1 was in was not visible so the VA could have been out of SP2’s eyesight during this time. However, given that when the VA reached the family changing area, SP1 was there, that is was likely less than a minute that the VA was out of eyesight, and that there was no information that there was any harm to the VA or that the VA came into contact with any children, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services to keep the VA safe and to prevent the VA from engaging in inappropriate actions. 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 found their policies and procedures adequate and followed by staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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