MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

1089816-SUD (Substance Use Disorder)

Investigator(s):

Thomas Nixon/ Deb Neubauer-Hoffman
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
thomas.c.nixon@state.mn.us

651-431-2155

Suspected Maltreatment Reported:

It was reported that a staff person (SP1) had a sexual relationship with a vulnerable adult (VA). During the investigation it was also noted that another staff person (SP2) pursued an inappropriate relationship with the VA.

Date of Incident(s): Ongoing prior to February 2, 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); and subdivision 17, paragraph (a):

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.

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 February 9, 2023; from documentation at the facility; and through nine interviews conducted with the vulnerable adult (VA), staff persons (SP1 and SP2), facility supervisory staff persons (P1 and P2), staff persons (P3 and P4), and the VA’s former roommates (R1 and R2) from the facility.

The VA was diagnosed with several types of alcohol and drug dependencies. The VA was motivated to make life changes for his/her child.

The VA attended the facility several times prior and most recently from December 30, 2022, to February 3, 2023. SP1 worked at the facility from February 11, 2019, through February 7, 2023. SP2 worked at the facility from June 5, 2018, to present.

According to the facility website the facility offered a “well-rounded balance of individual, group and family education sessions, peer support meetings, social activities, exercise, healthy meals and alumni support.” The facility was located at a rural, lakeside community with a main structure that consisted of two adjoined buildings that were connected by an extended hallway separated by a fire door. The facility served individuals 18 years old and over. Staff persons were onsite 24 hours per day and were to be awake for overnight hours. There were several hallways of resident rooms with two to three residents in each room and a staff persons station in one of the hallways that housed staff persons information and medications.

P3 provided the following information:

· On January 30, 2023, P3 and SP1 worked together. SP1 said how s/he “just want[ed] to kiss [the VA]” and something along the lines of there being “a lot of sexual tension” between SP1 and the VA. P3 was not certain of the exact words used by SP1. SP1 said to P3, “How about you do rounds and we’ll [SP1 and the VA] go in the bathroom,” and “You can keep watching the door.” P3 questioned what SP1 had said and SP1 said, “Just kidding,” that it was “a joke,” and that s/he “would never do that with patients.”

· Prior to this conversation, P3 saw the VA often attempt to be around SP1 and saw their interactions while in open common spaces. SP1’s and the VA’s interactions were “flirty” as shown by their “body language,” “demeanor,” and “tone of voice.” P3 did not witness any “inappropriate” interactions between the VA and SP1. P3 did not recall if when SP1 went into the VA’s bedroom s/he closed the door.

· P3 said SP1 attempted to have the VA stay longer at the facility due to a new loss of someone the VA was close to. (Note: SP2 decided the VA’s end of service date would not be extended.)

· On February 2, 2023, P3 worked a shift with SP1. At about 6 p.m., while in the staff station, SP1 told P3 that s/he kissed the VA, “made out” with the VA in “private spaces,” and allowed the VA to touch SP1’s unclothed genitals. SP1 also told P3 that the VA “was pursuing [SP1] heavily” and “they had gotten intimate.” P3 recalled that SP1 said something along the lines that s/he was “sad” the VA’s services were about to end and SP1 appeared “choked up” with “tears in [his/her] eyes” when s/he said this. P3’s shift ended shortly after. P3 did not tell anyone at that time about what SP1 said, and s/he went home to take care of a family matter.

· On February 3, 2023, at 7 a.m. P3 arrived at work and at 7:30 a.m., P3 texted P1 and asked to talk. Around 8 a.m. while in the staff station, P3 told another staff person about what SP1 told P3 the night before and the other staff person then reached out to management. Later, P3 met with P1 and then P2 about what SP1 told him/her regarding SP1’s interactions with the VA.

· Later in the day, SP1 called P3 and said s/he was concerned because management asked him/her to come in and talk about the allegations. P3 said s/he could not talk with SP1 about that, ended the call, and later blocked SP1’s number. P3 did not have any communication with SP1 afterwards. Prior to the incident, P3 was friendly with SP1 and exchanged text messages, but did not socialize outside of work. P3 denied receiving any text messages from SP1 regarding SP1’s relationship with the VA.

· P3 was not aware of any concerns regarding interactions between SP2 and the VA.

P1 provided the following information:

· SP1 had a “bold controlling personality.” SP1 participated in facility gossip, displayed “some stir the pot issues,” and tended to “get involved with everything.”

· On February 3, 2023, at 7:32 a.m., P1 received a text message from P3 asking to talk with P1 when P1 got to the facility. P1 attended to a few items and then around 9:30 a.m. P1 spoke with P3. P3 told P1 that s/he heard from SP1, that SP1 kissed the VA and had sexual contact with the VA in the VA’s bedroom. P3 also said that SP1 texted P3 about how s/he made out with the VA, allowed the VA to touch SP1’s unclothed genitals, and SP1 asked P3 to “keep an eye out” for him/her. SP1 asked P3 to keep this information in confidence.

· P3 was aware of the situation for “about a week,” and s/he “broke down crying” when s/he told P1 this. The week prior P1 saw a change in P3’s behavior. P3 typically was a “bubbly outgoing personality” and the last week was quiet and did not make eye contact with others as much. P1 ended the conversation with P3 to have P2 talk with P3 per facility procedures.

· SP1 was not scheduled to work on February 3, 2023. P1 believed SP1 became aware that P3 informed management because SP1 texted other staff persons asking if they heard about what occurred, for any information they could share, and “to cover [his/her] tracks.”

· After P3 talked with P2 there was communication through the weekend with P1, P2, Human Resources, and upper management about how to follow up.

· On February 4, 2023, SP1 emailed P1, P2, and upper management about the situation.

· On February 6, 2023, SP1 texted s/he could not come into the facility and “I know I am fired, can’t we do it over the phone.” P2 then followed up with SP1.

P2 provided the following information:

· On February 3, 2023, P3 told P2 about the allegations involvingSP1 and the VA including that SP1 said s/he and the VA “[snuck] off” and spent a lot of time together, that SP1 asked P3 to be a “look out” for SP1 so “they could get some alone time,” and that SP1 said s/he and the VA kissed and the VA touched SP1’s unclothed genitals.

· Earlier that same morning, the VA’s service ended and the VA was discharged from the facility before P2 could speak with him/her in person about the situation. Later, P2 tried to contact the VA, but the VA did not respond to P2. P2 reached out to SP1 about the allegations but SP1 only wanted to communicate by text. P2 read the email SP1 sent on February 4, 2023.

· On February 6, 2023, P2 talked to SP1 by phone. SP1 did not want to talk about the email s/he sent earlier. SP1 no longer worked for the facility.

· The facility had cameras. P2 reviewed camera footage and there were no cameras in the facility pointed at the VA’s door that showed for how long SP1 was in the room with the VA, if the door was open or closed, or if they were alone in the room together.

· P2 was not aware of any concerns regarding interactions between SP2 and the VA.

On February 4, 2023, SP1 emailed P1, P2, and facility upper management and provided the following information:

· SP1 had an “emotional connection” with the VA, s/he “felt cared about” by the VA, and there was a “sexual attraction” between the two. SP1 acknowledged “lying to [P3]” about what occurred and denied having any physical contact with the VA.

· SP1 said it was difficult to “prove” this “due to the extent of the messages and nasty childish lies I said happened” and lies told to P3. (Note: P3 denied there were any messages from SP1 about the relationship with the VA.)

· SP1 said the VA talked to him/her about topics because the VA felt uncomfortable with SP2 because there was a “past between them” and SP2 continued to “try to make things happen” with the VA. SP1 felt the need to “protect” the VA from SP2 and that s/he could “fix” the VA. SP1 said s/he shared personal information with the VA and went “crazy” to hear about SP2’s continued attempts to pursue the VA. SP1 explained how s/he fell into the same pattern as when s/he lost a boyfriend/girlfriend to overdose in the past with the VA.

· SP1 talked with the VA “about a future and what things could be in 2 years if we ever crossed paths again and we were ever both single.” SP1 said “nothing physical ever happened,” s/he did not share his/her phone number with the VA, and the VA “never made a pass at me.” SP1 said “a lot of the time [the VA’s] roommates or peers were present for the interactions we had.”

R1 stated s/he was not aware of any inappropriate interactions between residents and staff persons.

R2 provided the following information:

· R2 said the VA “follow[ed] [opposite gender staff persons] around like a puppy dog” and “never really hung out with [same gender peers].” In the bedroom, the VA often talked about opposite gender persons.

· On two occasions, R2 found SP1 in their bedroom talking with the VA. R2 thought “it seemed weird” that SP1 was in their bedroom with the door closed. While in the bedroom, R2 saw SP1 and the VA “always talking, always close to each other” with “very close contact, it just seemed like it was borderline.” R2 did not see “anything crazy inappropriate” and did not see SP1 and the VA touch.

P4 provided the following information:

· SP1 told P4 that s/he had an emotional connection with the VA, but “nothing physically had happened” and s/he lied to P3 about the relationship between him/her and the VA.

· SP1 told P4 that the VA found SP1 on Snapchat and messaged him/her. SP1 denied giving the VA his/her phone number. SP1 said SP2 gave the VA his/her personal number when the VA left the facility previously. The VA said SP2 texted him/her about the investigation of the relationship allegations between the VA and SP1.

· SP1 gave P4 a transcription of Snapchat messages between SP1 and the VA about the investigation. This included messages that SP2 sent the VA’s friend $100.00 through Cash App. (Note: P4 took screenshots of the message SP1 sent over of his/her transcribed Snapchat messages with the VA, they were not the Snapchat messages themselves.)

· SP1 said SP2 “fudged” the VA’s program attendance hours to avoid the VA’s services being ended early as the VA did not participate in sessions.

The VA provided the following information:

· The VA had no concerns regarding staff persons boundaries and denied having conversations of a personal nature with staff persons.

· The VA denied having physical contact with staff persons beyond a hug and that occurred when the VA learned s/he lost a friend and when the VA left the facility. The VA denied kissing staff persons, touching a staff person’s genitals, or that his/her genitals were touched by a staff person.

· The VA denied pursuing a relationship with SP1 and denied that s/he followed SP1 around. The VA denied having any communication with any staff persons after s/he left the facility.

· Prior to the completion of the interview, the VA stated s/he needed to end the interview and the call was ended. The VA did not respond to follow up attempts by phone or mail to continue/finish the interview.

SP1 provided the following information:

· SP1 worked with the VA when s/he attended the facility prior. SP1 denied there were any emotional or physical relationships with the VA at those times.

· During the VA’s most recent stay at the facility, the VA told SP1 that SP2 was “creepy” and made the VA feel “uncomfortable” so the VA withheld information. The VA said s/he would only talk to SP1 and would not talk to SP2. SP1 told P1 what the VA thought about SP2. SP1 often saw that when the VA was near the staff person workstation, SP2 would be there and “would make it apparent [s/he] was around.” SP1 said, “You could tell something was off, you could tell [the VA] was uncomfortable with it.” SP1 saw “how awkward” the interactions between SP2 and the VA were and they each told SP1 different things. SP1 asked SP2, “Why would [the VA] be avoiding you?” and SP2 would “make up something that I knew wasn’t true at all.”

· SP1 often found the VA in his/her bedroom and crying. Each time, SP1 processed with the VA and then SP1 began to get emotionally close to the VA. The VA and SP1 each talked about their respective children and SP1 told the VA about his/her personal home life and his/her mental health items “that I normally would not share.” The VA then started to seek out SP1 more often. SP1 thought s/he was “protecting” the VA and “completely emotionally let my guard down.”

· SP1 acknowledged that s/he struggled in his/her personal life at that time and felt “valued” by the VA. SP1 found similarities between the VA and SP1’s past significant other that struggled with addiction who passed away. SP1 “reverted back to [boyfriend/girlfriend] I was with my ex that was the addict.”

· SP1 said there was a “mutual understanding” that s/he and the VA both “clearly had feelings for one another.” SP1 and the VA talked about “what if in two years we were both single and ran into each other, maybe things could happen.” One time when SP1 was in the VA’s bedroom the VA “jokingly” told R2 to “go out [of the bedroom] for twenty minutes so I can shoot my shot” with SP1. SP1 told R2 not to leave the bedroom.

· SP1 said P3 was aware of the situation between him/her and the VA. SP1 lied to P3 about what occurred between him/her and the VA to “feel like [s/he] was mine.” P3 was “very supportive” of the way SP1 felt towards the VA. P3 “kept encouraging” SP1 as s/he could see SP1 was “so happy” around the VA and how unhappy SP1 was otherwise. SP1 lied to P3 about the sexual contact between him/her and the VA that never actually occurred. SP1 said at the time it “felt like a different life.”

· Two to three days prior to the planned end of services for the VA, the VA’s friend overdosed and died. The VA followed SP1 to the parking lot that night and continued to process with SP1 for 40 minutes. SP1 talked with the VA about his/her own loss of a significant person to overdose as well. SP1 later texted SP2 about the situation. SP1 asked if the VA’s stay should be extended due to the loss. SP1 and SP2 messaged if the VA’s stay was not extended how the VA might get to the next facility to ensure his/her admission.

· After the VA left the facility, s/he reached out to SP1 through Snapchat. SP1 denied s/he gave the VA his/her personal contact information and the VA found him/her on the platform on his/her own. SP1 knew it was against facility policy to have contact with the VA and still accepted the request from the VA. SP1 thought “just because everything was already going on. . . I did have those feelings, I care about [the VA]” caused him/her to respond.

· The VA told SP1 that s/he was contacted by SP2 via text about the investigation. The VA apologized that SP1 was involved in the situation when SP1 had done nothing wrong. The VA also told SP1, that SP2 put his/her personal number on his/her business card the last time the VA left the facility and again this time. After the previous stay at the facility, SP2 texted the VA and attempted to meet up with the VA multiple times. The VA reminded SP1 of when SP2 said that s/he was “ghosted” a few months back. The VA messaged that the ghosting was in reference to when the VA stopped communication with SP2 before the VA’s most recent admission to the facility.

· The VA said when s/he returned to the facility SP2 continued to attempt to have a relationship with him/her. SP2 asked the VA to put a necklace on him/her and “kept shutting [his/her] door when they would go in [to his/her office].”

· The VA messaged SP1 the number of a friend’s cellphone. SP1 called the number and talked with the VA. The VA told SP1 s/he had messages from SP2 and that SP2 sent money through Cash App to the VA’s friend. The VA also asked SP1 for money but SP1 said, “No.”

· SP1 asked the VA for screenshots of the messages between the VA and SP2, but the VA said it was not possible on his/her phone. The VA told SP1 what the messages stated and SP1 copied the content onto his/her phone. (Note: The messages were the same as shared by P4 above.) The VA said, “It’s bullshit that [s/he’s] the one texting me and sending me money, but you’re the one losing your job over this.”

· SP1 asked the VA for a screenshot of the transfer of funds from SP2 to the VA’s friend. The VA said to get it from the friend. SP1 asked the VA’s friend for a screenshot and was told “I don’t want to be brought into your guys’ mess.”

· SP1 denied any physical interaction with the VA apart from hugging the VA twice. SP1 denied kissing the VA, denied touching the VA’s genitals, and denied that the VA touched SP1’s genitals.

The VA sent SP1 the following Snapchat messages:

· The VA messaged about his/her plan to sue the facility.

· The VA messaged that s/he had “messages on my phone from [SP2],” that SP2 “sent [the money] to [my friend’s] cash app,” and that “[SP2] just sent me $100 and was trying to call me I have missed calls from [him/her].”

· The VA messaged, “I know [P3] handed out [his/her] number.”

· The VA messaged, “I wish I could do something to help. I feel so bad this is happening to you. I’m gonna tell them nothing happened if they do. That’s gotta count for something.”

The VA provided SP1 with Snapchat messages between the VA and SP2 to the VA. The messages provided the following information:

· SP2 messaged the VA:

o “just don’t do anything stupid” and “don’t respond to anything from [P2].”

o “keep your distance if you got anyone else’s number from here.”

o “but I am not telling you any of this… and you are going to move on from this shit” and to “just ignore everything.”

o “so it’s up to you if you want to continue to risk having me in your life.”

o “apparently [SP1] was texting [P3] 24/7 about you,” and “Apparently [SP1] is putting it on me saying [s/he] was trying to protect me from you.”

· The VA messaged SP2 that s/he “felt bad for [SP1] cause [SP1] did nothing wrong.”

SP1 was not able to provide any additional screenshots of text messages including those to P3 because they had been deleted from his/her phone.

SP2 provided the following information:

· SP2 worked with the VA during the VA’s prior admissions to the facility. SP2 denied having any interactions with the VA after those services ended.

· After the VA’s most recent admission, SP2 saw SP1 and the VA interact while s/he walked around the facility. SP2 did not see anything of note, concern, or flirtatious behaviors between SP1 and the VA.

· SP2 denied asking the VA to assist him/her with a necklace or attempting to kiss the VA. SP2 denied that s/he attempted to have attendance and session hours changed intentionally to stop the VA’s services from ending due to lack of participation.

· SP2 was told by P2 that SP1 asked if the VA’s stay could be extended after the death of the VA’s friend. P2 and SP2 discussed whether SP1 attempted to operate “outside of [his/her] scope.” SP2 talked with the VA about the situation and agreed to not extend the stay.

· SP2 denied giving the VA his/her personal contact information, denied s/he was in contact with the VA after the VA’s services ended, and denied sending money to the VA’s friend for the VA.

Facility documentation showed that the staff persons interviewed for this investigation were trained on professional boundaries and on the Reporting of Maltreatment of Vulnerable Adults Act.

Conclusion:

A. Maltreatment:

Regarding Neglect by SP1:

SP1 stated that during the VA’s most recent stay at the facility, s/he developed an emotional connection and sexual attraction to the VA. SP1 said s/he and the VA mutually understood how the other person felt, s/he shared personal information with the VA “that I normally would not share,” and they talked about a possible future together. SP1 was noted to spend time in the VA’s room without others present and with the door closed. The VA commented to R2 about “shooting [his/her] shot” with SP1. SP1 attempted to get the VA’s stay extended due to concerns about a recent loss and acknowledged that s/he sent messages and spoke on the phone with the VA after placement. SP1 also stated that s/he wanted the VA to “feel like [s/he] was mine” and at times it “felt like a different life.”

Given the VA’s history of chemical dependency, it was reasonable that the VA would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety. SP1’s interactions with the VA as described by SP1, likely hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the VA, both now and in the future. Although the VA denied having a relationship with SP1, given the interactions between the VA and SP1 as described by SP1, that the VA had previous admissions to the facility and likely would need supports to maintain necessary life and social skills, there was a preponderance of the evidence that SP1’s actions were not therapeutic and that there was a failure to supply the VA with care or services that were reasonable and necessary.

It was determined that 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.)

Regarding Neglect by SP2:

SP1 provided information that s/he and the VA had concerns regarding SP2’s interactions with the VA that included previous and ongoing boundary issues from SP2 to the VA; that SP2 provided his/her personal phone number on several occasions and contacted the VA after services ended; and that the VA told SP1 that SP2 acted “creepy” towards him/her, asked him/her to assist SP2 put on a necklace, and sent a friend of the VA’s money. Given that SP2 denied the allegations and that the VA said s/he had no concerns regarding staff persons boundaries, and that there was no additional information to support SP1’s account, there was not a preponderance of the evidence whether the VA and SP2 engaged in a nontherapeutic relationship.

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.)

Regarding sexual abuse by SP1:

SP1 provided conflicting information regarding sexual contact with the VA. SP1 and P3 each stated that SP1 told P3 that s/he had sexual contact with the VA at the facility. However, during SP1’s interview s/he said s/he lied to P3 about a physical relationship with the VA and denied having sexual contact with the VA. Although SP1 had reason to minimize his/her actions for fear of repercussions, given that the VA also denied having sexual contact with SP1, and there was no additional information to support that sexual contact occurred, there was not a preponderance of the evidence whether SP1 and the VA had sexual contact.

It is 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 resident 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.)

B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c):

When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

Facility documentation showed that SP1 trained on professional boundaries and on the Reporting of Maltreatment of Vulnerable Adults Act.

SP1 was responsible for maltreatment of the VA.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.”  Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. 

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury.  For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment.  For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke.  Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated neglect for which SP1 was responsible did not meet statutory criteria to be determined as recurring or serious, SP1’s actions were considered a singular incident which did not meet the definition of serious.

Action Taken by Facility:

The facility completed an internal review and determined that their policies and procedures were adequate and were followed. The facility determined that there was not a need for additional training or corrective action. SP1 no longer worked at the facility.

Action Taken by Department of Human Services, Office of Inspector General:

SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP1. The determination that SP1 was responsible for maltreatment is subject to appeal.

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