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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: 801101-SUD (Substance Use Disorder) Investigator(s): Anna Parkin/ Kyle Youker 651-431-6225 Suspected Maltreatment Reported: It was reported that a staff person had a sexual relationship with two vulnerable adults (VA1 and VA2). Date of Incident(s): unknown 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 a site visit conducted on May 17, 2023; from documentation at the facility; and through seven interviews conducted with two supervisory staff persons (P1 and P2), a facility staff person (P3), two registered nurses (RN1 and RN2) who worked at the facility, VA1, and a community person (CP) who worked at another licensed program that VA1 and VA2 attended after the facility. Attempts were made via telephone and mail to contact and interview VA2, but VA2 did not respond to the requests. VA1 was diagnosed with stimulant and opioid dependency and resided that the facility from September 19 to December 8, 2022. According to VA1’s Vulnerable Adult Individual Abuse Prevention Plan, VA1 was not concerned with sexual abuse. VA2 was diagnosed with alcohol and stimulant dependency and resided at the facility from January 17 to February 3, 2023. According to VA2’s Vulnerable Adult Individual Abuse Prevention Plan, VA2 was not concerned with sexual abuse. The CP provided the following information: · In early December of 2022, when VA1 began receiving services at the program that the CP worked, VA1 made comments about having a relationship with a staff person at the facility. The CP told VA1 that was not appropriate and VA1 “laugh[ed]” and said s/he was “kidding.” VA1 made other comments over the next few weeks about a nurse from the facility visiting VA1 where VA1 worked and “promised” VA1 employment at the facility. VA1 did not provide the CP with the name of the nurse. · On May 8 or 9, 2023, VA1 told the CP that the previous day, VA1 went to the facility to visit the nurse and VA2 was at the facility. VA1 was “upset” because s/he found out VA2 and the nurse were in a relationship. VA1 told the CP that when VA1 resided at the facility, the nurse came for medication counts and medication management, but s/he did not work on site. At one point, the nurse told VA1 that if VA1 did not have sexual intercourse with anyone else for 30 days then the nurse would have sexual intercourse with VA1. VA1 did not provide information to the CP if VA1 and the nurse had sexual intercourse while VA1 resided at the facility. · VA1 also told the CP that after VA1 left the facility, the nurse visited VA1 at his/her job and they “hooked up” in the parking lot. VA1 refused to provide the CP with any other information about the nurse, including the nurse’s name. The CP reminded VA1 that the nurse had “terrible boundaries” and should not have been in a relationship with any clients. · Later that day or the following day, the CP asked VA2 about residing at the facility and if s/he was in a relationship with a nurse. VA2 said s/he was friends with a nurse and that VA1 was “upset” with him/her visiting the nurse. VA2 spoke to the nurse and tried getting employment at the facility. VA2 “shrugged off” the conversation and would not provide the CP with any other additional information. · After VA1’s interview with this investigator on May 16, 2023, VA1 went to the CP and told the CP s/he was “very upset” about the allegations and would not tell this investigator who the nurse was. VA1 said s/he did not want to get staff persons in trouble and that VA1 “could not trust” the CP. VA1 stated that after s/he left the facility, a staff person who was a nurse came to a restaurant where VA1’s worked but VA1 could not remember the name of the nurse. VA1 denied having sexual intercourse with any staff persons including a nurse while at the facility and/or after s/he left the facility. VA1 stated that s/he “knew” P3 prior to residing at the facility. VA1 knew that P3 had a previous relationship with another client and that P3 was “flirtatious” with all the clients. P3 previously visited VA1 at his/her work “once in awhile.” VA1 no longer had contact with P3 and denied having sexual intercourse with P3. P1 provided information that during the time that VA1 and VA2 resided at the facility, RN1 and RN2 were the only nurses who had contact with VA1 and VA2. RN2 provided the following information: · After VA1 left the facility, RN2 saw VA1 while VA1 worked at a restaurant. Approximately two weeks prior to the interview with this investigator, VA2 visited the facility. During the visit, VA2 took out his/her cell phone and showed RN2 pictures of a family member. RN2 heard that VA1 and VA2 were at a program at the same time and that VA1 wanted to say “hi” to RN2. RN2 also “ran into” VA2 at a grocery store around that same time. RN2 denied having sexual contact with VA1 and VA2. · The clients often confused P3’s role with a nurse since P3’s role also administered medications. RN2 heard P3 had inappropriate relationships with clients, including VA1. On a previous occasion after P3 no longer worked at the facility, VA1 told RN2 that P3 was “interacting” with VA1 on social media including P3 sending “sexually explicit” photos. VA1 showed RN2 his/her cell phone but RN2 did not look at the photos that VA1 showed him/her. RN2 then told P2 about it. RN2 stated that VA1 would not admit to investigators who the staff person was if interviewed. RN1 stated s/he came to the facility approximately once per week for one hour to do health education classes with groups of 10 to 12 clients. RN1 stated on one occasion, s/he checked a client’s blood pressure but other than that did not have direct contact with clients, including administering medications. RN1 did not remember VA1 and VA2. RN1 did not have concerns with staff persons’ interactions with clients. P3 provided the following information: · P3 worked at the facility for approximately three months. P3 did not talk to VA1 often but recalled one occasion, when VA1 told P3 s/he remembered him/her through mutual friends prior to residing at the facility. P3 stated s/he “did not remember” if s/he knew VA1 prior to the facility. P3 denied texting or having contact with VA1 on social media. P3 did not know VA2. · On one previous occasion, P3’s vehicle broke down and VA1 and “all the other clients” who resided at the facility helped P3 with his/her vehicle. P3 did not have any other contact with VA1 outside of the facility. P3 heard a rumor that s/he was “messing around” with VA1 but P3 “shut that down really quick.” · P3 said s/he left working at the facility for a different job that paid “a lot better” and was better for personal reasons. When this investigator brought up P3 getting fired, P3 stated that s/he was fired for violating facility’s policy and private information but s/he was “going to leave anyways” for another job. After P3 stopped working at the facility, s/he did not have contact with any clients, including VA1 and VA2. P2 provided the following information: · P2 was not aware of the allegations prior to this investigation. P2 did not have concerns with RN1’s and RN2’s interactions with clients. P2 provided information that the registered nurses and clinical assistants (P3’s role) were able to administer medications to the vulnerable adults. · P2 had previous concerns with P3 and his/her interactions with a client that P3 had a previous relationship with and P3’s boundaries of talking to the client. P3 also violated a policy on private information so P3 was fired from the facility. P2 also heard that P3 allowed vulnerable adults to go to P3’s personal residence. P2 was not aware of P3 sharing sexually explicit texts with any clients, including VA1. · After talking to this investigator, P2 spoke to multiple staff persons who confirmed both VA1 and VA2 were visiting the facility the same around the time of May 8 or 9, 2023. P2 was aware that a case manager spoke to VA1 during that time but P2 did not know if VA1 spoke to other staff persons or nurses. According to P3’s Termination of Employment, P3’s last day of employment was October 3, 2022, for violating a facility private information policy. According to the facility’s Staff Client/Patient Relationships, staff persons were prohibited from socializing with clients during off-duty hours. This included no communication through online social networks, cell phones, text messaging, etc. Staff persons were prohibited from initiating or participating in a sexual relationship with a former client for a period of two years following the client’s last contact with the facility but such conduct was “always” discouraged, even after the two year period. The facility’s personnel files and training records documented that staff persons interviewed for this investigation were each trained on the VA1’s and VA2’s plans, the facility’s Staff Client/Patient Relationships policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The CP provided information that VA1 told the CP that VA1 said after s/he left the facility, a nurse visited VA1 at his/her employment and they “hooked up” in the parking lot. VA1 was upset because s/he found out VA2 was in a relationship with the nurse. Although it was concerning that VA1 told the CP that s/he and a nurse “hooked up” after VA1 left the facility, given that VA1 denied any sexual contact with a staff person while s/he resided at the facility; that when the CP asked VA2 about being in a relationship with a nurse staff person at the facility the VA2 responded they were only “friends”; that all staff persons interviewed denied any sexual contact with VA1 and VA2; and there was no information provided that VA1 or VA2 had sexual contact with a staff person while they resided at the facility, there was not a preponderance of the evidence whether a staff person had sexual contact with VA1 or VA2. 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 completed an internal review and determined that policies and procedures were adequate and followed. Staff persons received training on vulnerable adult and staff person/client relationships during hire and annually. Supervisory staff persons provided ongoing “continuous supervision,” “coaching,” and training on appropriate boundaries. No additional training was provided. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
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