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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: 1085945-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) had sexual contact with a vulnerable adult (VA). Date of Incident(s): February 11, 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 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 two sites visit conducted on February 24 and 28, 2023, from documentation at the facility, law enforcement records, the VA’s medical records and through nine interviews conducted with the VA, the SP, two management staff persons (P1 and P2), three facility staff persons (P3-P5), the VA’s guardian (G) and a community health care professional (CHCP). The facility’s main floor had a living room, garage, kitchen, bathroom, and three bedrooms. The VA’s ISSA Assessment Detail showed that s/he enjoyed swimming and “playing with dogs.” The VA’s Risk Assessment Detail showed that s/he “may not have the necessary cognitive, physical, verbal, or social skills to appropriately defend [his/herself] against sexual abuse.” The facility’s Incident Report provided the following information: · At about 1 p.m. on February 11, 2023, P1 notified P2 that P3 had “suspicion of sexual contact” between the SP and the VA because P3 observed the SP and the VA “exiting the bathroom with red faces and sweating.” P2 told P1 to go to the facility and talk to the VA. · When P1 talked to the VA, the VA stated that s/he and the SP “were brushing their teeth.” When P3 talked to the VA (after P1 talked to the VA), “the story gradually morphed into an allegation of sexual abuse.” The facility contacted law enforcement and the VA was taken to a hospital for a medical evaluation. The VA’s hospital medical records, dated February 11, 2023, and an interview with the CHCP provided the following information: · When the CHCP, who was a sexual assault nurse examiner (SANE) talked to the VA, who was brought to the hospital by P1 and P3, the VA had a “hard” time telling the CHCP “anything on [his/her] own.” When the CHCP talked to P1, P1 said that s/he thought that P3 put the “idea” in the VA’s head that the SP had sexual contact with the VA. · The VA told the CHCP that when P3 arrived at the facility around 10 a.m., P3 said “we both,” referring to the SP and the VA, “came out of the bathroom panting so [P3] asked me about what happened.” The VA told the CHCP that the VA and the SP did not kiss but the SP used both of his/her hands and “touched” the VA’s breasts while the VA was clothed. The VA stated that the SP exposed his/her genitals and then touched the SP’s genitals to the VA’s genital area. The VA initially stated that s/he was “not sure” if his/her clothes were on but later stated that his/her clothes were on and there was no “skin to skin” contact. · The VA was prescribed various medications, for preventative purposes. The HCHP did not see “obvious” signs that a sexual assault occurred. · When the CHCP talked to the G, the G stated that the VA was “very impressionable” and “can be overly agreeable or influenced.” The VA provided the following information to this investigator and a law enforcement officer (LEO2): · When the VA and the SP were in the bathroom, the SP used his/her hands and touched the VA’s breasts and “private part” while the VA was clothed. · When P3 came to work, P3 told the VA that s/he wanted to talk to the VA. When that happened, the VA began to cry because s/he thought s/he was “in trouble.” · The VA did not tell the G because the VA “didn’t feel comfortable” telling the G. P3 told this investigator and LEO2 that when s/he got to the facility the door was locked. P3 unlocked the door and went into the facility. The VA came out of the main floor bathroom and was brushing his/her teeth. Although the VA told P3 that the SP was downstairs, the SP came out of the same bathroom shortly after the VA and P3 did not understand why the SP would need to be in the bathroom with the VA. When P3 asked the SP why the front door was locked, the SP did not answer P3 and then the SP left the facility. Because of that, P3 thought “something was kind of going on” and that the SP might have done something to the VA so P3 called P4. P3 acknowledged that when P5 arrived at the facility later that day, P3 and P5 video and audio recorded an interview the conducted with the VA. P3 believed that his/her questioning of the VA was not leading, but more an attempt on P3’s part to have the VA tell the VA’s story of what happened. (Note: Information regarding the recording was included below from the law enforcement Incident Report.) P1 provided the following information to this investigator and LEO2: · On the morning of the incident, P1 received a call from P4. P4, who had talked to P3, told P1 to go to the facility and talk to the VA because some concerns had been reported. · When P1 got inside the house, P3 told P1 that when s/he talked to the VA, P1 needed to tell the VA, “You’re not going to give [the VA] any lunch” or “any dinner unless [s/he] tells you the truth about everything.” P1 told P3, “We cannot do that.” P3 told P1 that s/he thought that the VA had been sexually assaulted by the SP. · When P1 first saw the VA, the VA was “happy” and “upbeat.” P1 talked with the VA in the VA’s bedroom with the door closed. When P1 began talking to the VA, s/he asked the VA how s/he was doing and about various staff persons, including the SP. The VA said that s/he “really liked” the SP and the VA’s “body language” did not change when they talked about the SP. · The VA told P1 that while the SP helped another client (non-verbal) in the bathroom, the VA put his/her hand on the SP’s back, but the SP turned around, put his/her hand out, and said, “I got it from here” and “accidentally kind of touched” the VA’s chest “a little bit.” Later, the VA told P1 that the SP had caught the VA “stealing” food that morning and the VA thought that s/he was going to get into trouble for that.
· P1 had not observed previous interactions between the VA and the SP. The facility’s Report Form for Internal Investigation provided information that was mostly consistent with the information provided, and provided the following additional information: · When P1 got to the facility, P3 “rushed” toward P1 and stated that s/he “knows” that the SP “did something” to the VA even though the VA “had not told” P3 that “anything specifically had happened.” · When P3 was interviewed, s/he stated that after the VA talked to P1, P3 did not think the VA told “the whole truth.” P3 said that while s/he and P5 (who was not working at the time, but came to the facility) recorded the VA, they asked “direct questions” because “that’s the best way to get answers” from the VA, but that after the recording device was turned off, they asked “open ended questions” and it was during that questioning that the VA stated that the SP touched the VA “up there” and “down there,” but the VA did not identify what that meant. P4 said that when P3 called him/her the morning of the incident, P3 “presumed” that something had happened between the SP and the VA because the SP was “breathing heavily” when s/he came out of the bathroom. Because P4 was unable to go to the facility at the time, s/he contacted P1 and asked him/her to go interview the VA. P3 providedP4 with a video recording of when P3 asked the VA about what happened with the SP. P4 listened to the video recording and believed that P3 was “persuading the individual to say something that all this” happened. When P5 was interviewed by this investigator and LEO2, P5 said that s/he was not working at the time of the alleged incident, but came to the facility to pick up his/her medication. When P5 was at the facility, the VA told P5 that s/he had just talked to P1 and that P1 was “rude” to the VA. P3 and P5 decided to video record the VA when they questioned him/her, but P5 did not remember what the VA said.
The Oakdale, Minnesota Police Department Incident Report provided the following information: · When P2 was interviewed by the initial law enforcement officer (LEO1) assigned to the case, P2 stated that P3 told P2 that P3 was “suspicious of what happened” when the VA and the SP left the bathroom because the SP “quickly left without saying anything” once P3 got to the facility. P3 also told P2 that s/he “immediately began questioning” the VA about what happened, but P2 “believes the questions were leading and that [P3] may have coerced [the VA] into claiming sexual assault.” · P2 also noted that P3 made a video (the video did not show the VA’s face, but recorded the conversation) recording of his/her discussion with the VA. P2 “said that the summary of [the VA’s] conversation with [P3] is that [the VA] told [P3] in the recording that [the SP] went out to [his/her] car, grabbed a condom, and then came back into the house, brought [the VA] into the bathroom and then forced [him/her] to have sexual intercourse.” · When P2 talked to the SP, the SP said that s/he was not in the bathroom with the VA right before the SP “clocked out,” but had been earlier when P3 was not at the facility. The SP told P2 that s/he “left in a hurry” because P3 was 30 minutes late. · When P2 talked to the VA, the VA’s “story was all over and changed several times and was not even close to what [P3] stated” and that P2 “was not able to get a reliable consistent idea of what occurred” from the VA. · P2 evaluated the “clock in logs” and determined that P3 “clocked in” at 8:52 a.m. from his/her cell phone, but was not at the facility at that time which was “against company policy.” · When LEO2 was assigned to look into the report, LEO2 reviewed the video made by P3 and determined that the “questions asked by [P3] were very leading in nature and [the VA] did not give a full version of events in [his/her] own words.” · When LEO2 talked to the G, the G stated that the VA had a history of “making accusations of inappropriate contact with [his/her] breasts” in which the VA “accused” a classmate of touching his/her breasts, but the VA later “recanted” the story because the VA did not want to go to work because the “accused classmate” also worked at the same place. The G stated that the VA “had never accused staff [persons] at the group home of sexual contact until now.” The G also told LEO2 that s/he and the VA had daily phone contact and that s/he when s/he talked to the VA on the day of the alleged incident, the VA “gave no indication that anything was wrong.” The G also stated that the VA was “very impressionable” and that s/he had not talked to the VA about the alleged incident. · The G told LEO2 that when s/he talked to the VA on the day of the alleged events at 9:30 a.m., after 10:30 a.m., and later that day, the VA “did not disclose” that “anything had happened that morning.” The G said that the first time s/he heard anything about the allegations was when the hospital called the G. When the G talked to the VA at the hospital, the G asked limited questions of the VA, but the VA told the G that the SP touched the VA, but the VA did not give specific information and the G did not ask further questions. When the G talked to P3 at the hospital, P3 said that the SP had a “guilty look” when s/he came out of the bathroom. The facility’s payroll records showed that on the day of the incident, P3 clocked in at 8:54 a.m. and the SP, who was scheduled to be off work at 10 a.m. on February 11, 2023, clocked out at 10:42 a.m. The SP provided the following information to this investigator: · The SP did not remember the date and said that s/he did not remember what the VA was doing at the time, but when the SP was working, the SP was assisting another client in the bathroom. At some point, the VA came into the bathroom and offered to help the SP with the other client. The SP denied that the VA put his/her hand on the SP’s back or that the SP touched the VA’s chest area. · On the day of the incident, the SP called P3 at about 10:20 a.m. because P3 was supposed to work at 10 a.m. and was not at the facility yet. P3 told the SP that s/he was on his/her way.
· When P3 got to the facility at about 10:45 a.m., the SP was on the lower level putting clothes in the washing machine.
· The SP stated that s/he probably was panting and breathing heavily when s/he came upstairs because the SP was “out of shape.” · The SP denied any type of sexual contact with the VA but stated that it was possible that s/he went to his/her car during the overnight shift because the SP kept snacks out there, but the SP did not specifically remember doing that. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the VA’s care plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to February 11, 2023. Conclusion: On the morning of February 11, 2023, the SP worked the overnight shift. P3 stated that when s/he arrived at the facility, s/he saw the VA and the SP come out of the main floor bathroom with “red faces and sweating.” P3 thought that the SP might have done something to the VA in a sexual manner because the SP left in a hurry and was breathing heavily. P3 then called P4 who told P1 to go to the facility to talk to the VA. The VA told P1 that the SP inadvertently touched the upper part of the VA’s chest in the bathroom, but the SP denied that happened. At some point, P5 arrived at the facility to pick up a personal item. P3 and P5 talked to the VA and made a video recording of their discussion with the VA about the alleged incident. The law enforcement incident report stated that the summary of the VA’s conversation with P3 was that the VA told P3 in the recording that the SP went out to his/her car, grabbed a condom, and then came back into the house, brought the VA into the bathroom and then forced him/her to have sexual intercourse. LEO2 said that the “questions asked by [P3] were very leading in nature and [the VA] did not give a full version of events in [his/her] own words” and P4 believed that P3 was “persuading the individual to say something that all this” happened. When interviewed by LEO2 and this investigator, the VA stated that the SP touched his/her breasts over his/her clothes and touched his/her “private part” while the VA was clothed. When P3 came to work, P3 told the VA that s/he wanted to talk to the VA. When that happened, the VA began to cry because s/he thought s/he was “in trouble.” The VA did not tell the G because the VA “didn’t feel comfortable” telling the G. P1 and P3 took the VA to the hospital for a SANE evaluation. The CHCP stated that the VA told the CHCP that although the SP and the VA did not kiss, the SP used both of his/her hands and “touched” the VA’s breasts while the VA was clothed, but later said that the SP exposed his/her genitals and touched the SP’s genitals to the VA’s genital area. The VA initially stated that s/he was “not sure” if his/her clothes were on, but later stated that his/her clothes were on and there was no “skin to skin” contact. Facility documentation showed that P3 clocked in to work from his/her cell phone at 8:54 a.m. and the SP, who was scheduled to be off work at 10 a.m. on February 11, 2023, clocked out at 10:42 a.m. The SP stated that when P3 arrived, the SP was in the lower level doing laundry and as the SP came up the stairs, s/he might have been breathing heavily because s/he was out of shape. In addition, the SP stated that P3 was 30 minutes late so that was why the SP left the facility in a hurry. The G said that the first time s/he heard anything about the allegations was when the hospital called the G. When the G talked to the VA at the hospital, the G asked limited questions of the VA, but the VA told the G that the SP touched the VA, but the VA did not give specific information and the G did not ask further questions. When the G talked to P3 at the hospital, P3 said that the SP had a “guilty look” when s/he came out of the bathroom. The VA provided different information to different people regarding the incident including that the SP touched the VA’s breasts inadvertently, that the SP exposed his/her genitals and touched them to the VA’s genital area, that the SP brought in a condom and had sexual intercourse with the VA, and that the SP touched the VA’s breasts over his/her clothes. However, given that P3 asked the VA leading questions which hindered the LEO’s and DHS’s ability to obtain credible information; that when P1 arrived at the facility, the VA was not upset and told P1 that the SP inadvertently touched the VA’s breasts while in the bathroom helping another client; that when the G talked to the VA at 9:30 and 10:30 a.m. that day, the VA was fine and did not tell the G anything about the SP; that the SP denied having sexual contact with the VA; and that there was no further information to confirm or dispute the allegations, 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’s Report Form for Internal Investigation showed that although policies and procedures were adequate, they were not implemented, but specific information was not provided. The review also showed that additional training was provided to the SP related to “care plans.” Action Taken by Department of Human Services, Office of Inspector General: No action taken.
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