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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: 1118740-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) did not maintain visual supervision of a vulnerable adult (VA) as required resulting in the VA engaging in sexual contact with a friend (F) at a playground. Date of Incident(s): June 4, 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 June 14, 2023; from documentation at the facility and/or medical records; and through seven interviews conducted with the VA, four facility staff persons (SP1, SP2, P1, and P2), a friend (F) of the VA, and a guardian (G). The VA enjoyed community outings, art/drawing/painting, and music. The VA was described as athletic and very social. The VA was the only person residing at the facility and her gender was identified because body parts specific to the VA’s gender were included in this report. The VA’s diagnoses included post-traumatic stress disorder, attention deficit hyperactivity disorder, other conduct disorders not specified, and disinhibited attachment disorder of childhood. The VA’s program plans provided the following information: · A Coordinated Services and Supports Plan (CSSP) stated that it was “extremely important for [the VA] that people supporting [the VA] are able to practice and maintain strong boundaries, and help [the VA] maintain her safety in the community.” The VA received 2:1 supervision and support 24 hours per day, except when accessing services through school. · An Individual Crisis Management Plan stated that she had a significant history of sexual abuse, neglect, and complex trauma and lacked understanding of social boundaries and self-preservation skills. · An Individual Abuse Prevention Plan (IAPP) stated that the VA was very social and may not be able to see where her behavior may inadvertently put him/her in harm’s way with others. The VA was susceptible to sexual abuse and staff persons were to intervene to protect the VA should abuse occur by “standing between” the VA and the aggressor and by verbally prompting the VA to leave and if necessary, taking the VA by the hand and leading him/her to safety. · A Self-Management Assessment (SMA) stated that the VA was “not able to be in the community without staff supervision.” Facility information showed that on June 4, 2023, the SP1 and SP2 were working at the time of the incident. The VA said that SP1 and SP2 drove her to a school that had a playground to meet her friend (F). The VA believed they were at the playground for one to one and a half hours. The VA said that SP1 and SP2 were able to “pretty much” see the VA because the VA and F walked around the playground area while they talked. However, at some point the VA and the F went into a “tunnel” (tube structure connected to the playground equipment) and were inside the tunnel for approximately 30-40 minutes. While in the tunnel, the VA and F watched Tik Toc videos on the F’s phone and the VA gave the F “consent” to put his/her fingers in the VA’s vagina. Throughout the entire stay at the playground, SP1 and SP2 remained in a facility vehicle and were not able to see into the tunnel. The VA came out of the tunnel because she wanted SP1 and SP2 to see her. After returning to the facility, the VA discovered s/he was “bleeding” from her vagina and told SP1 what occurred in the tunnel. The VA was taken to a local hospital and remained at the hospital for “two nights.” SP1 and SP2 were each interviewed by this investigator and provided the following information: · SP1 said that the VA required 2:1 staffing because s/he “often wanted to run away.” On June 4, 2023, SP1 drove SP2 and the VA to the playground where the VA planned to meet the F. SP1 parked the vehicle along the sidewalk, approximately 15 feet from the playground equipment and got out and walked to the front of the vehicle. When the F waved to the VA and the VA ran up to the F, SP1 went back inside the vehicle where s/he remained with SP2 for the remainder of the activity. SP1 said that the VA required eyes on supervision. When asked by this investigator if the VA went anywhere in the playground area where SP1 and SP2 were not able to see her, SP1 said the VA went into an “enclosed tunnel” and remained in there for approximately 10 minutes. Although SP1 was not able to see their faces, s/he saw the VA’s and the F’s legs hanging outside the end of tunnel. SP1 said that “neither of us (SP1 or SP2) did anything” to address the VA while she was in the tunnel. After approximately 20 minutes, the VA and F came to the vehicle and SP2 said they should return to the facility. Because it was “rather warm” that day, SP1 offered the F a ride to his/her home located a few blocks from the playground. (SP1 believed the temperature that day was in the 90’s.) Upon returning to the facility, the VA and SP2 entered the facility. While SP1 was still outside, the VA came back out and showed SP1 a piece of toilet paper and said she needed to go to the hospital because she was bleeding and did not feel good. SP1 said the toilet paper looked “yellowish.” The VA then told SP1 that while at the playground, the F “fingered” the VA. · SP2 said that s/he knew the VA’s “history very well” and the VA required “eyes on” supervision. On June 4, 2023, prior to going to the playground with SP1 and the VA, SP2 told the VA, “If you don’t listen or follow rules, next time we will not go.” Once at the playground, the VA and the F ran and chased each other while SP2 watched them while SP2 stood outside of the vehicle, by a tree. At one point the VA and the F went into the tunnel and SP2 told the VA, “You need to come out” and the VA did. SP2 said the VA and the F were in the tunnel “some seconds,” “less than a minute.” SP2 did not know if SP1 got out of the car at the playground that day. They left the playground after 20-30 minutes. Upon returning to the facility, SP2 and the VA entered the facility and went to different bathrooms. SP2 heard the VA telling SP1 that s/he was bleeding. P1 said that on June 4, 2023, s/he received a phone call from SP1 who stated earlier that day the VA was at the playground in a tunnel structure with the F and there were no concerns at that time. However, upon returning to the facility, the VA went to the bathroom and said s/he was bleeding from her vagina. The VA told SP1 that s/he and the F engaged in sexual contact while at the playground and the F may have “scratched” the VA’s vagina. The VA’s supervision required staff person to have “eyes on” the VA and although P1 said that the staff persons had “eyes on from a distance” they “should have been much closer” to the tunnel to “redirect” the VA. P2 stated that the VA had 2:1 staffing and her plans stated that staff persons needed to keep the VA within their “line of sight.” On the day of the incident, P1 called P2 and said that it sounded like the VA engaged in sexual activity at the playground and was bleeding. Medical attention was provided at an emergency room. After the incident, P2 spoke to SP1 who provided information consistent with the information SP1 provided to this investigator. When P2 spoke to SP2, SP2 said that it was hot outside so SP1 and SP2 remained in the vehicle while the VA and the F were at the playground. SP2 said that the VA was in the tunnel less than five minutes and did not provide a response when P2 asked SP2 why s/he did not go get the VA out of the tunnel. P2 said that the VA was “not very accurate” and did not have a good concept of time when reporting details. The F said that s/he met the VA at the playground “at least three times.” The VA remembered that one of those times the VA told the F to “touch” the VA “inside her vagina” and the VA touched the F’s “crotch area” over his/her clothing. At first the F believed that two staff persons of the same ethnic group were at the playground that day and were sitting in the grass near the tunnel. Those two staff persons asked if the F and VA were able to see the staff persons while they were in the tunnel and they replied, “Yes.” The F did not know if the staff persons were able to see into the tunnel. However, when the F realized the incident occurred on the same day that the facility staff persons gave him/her a ride home from the playground, the F said it had to be two different staff persons than s/he originally stated. (The information provided by the F did not match the identity of the two staff persons working on June 4, 2023.) The G stated that the VA was “high needs” and believed that the VA’s plan stated that staff persons were supposed to have “eyes on” or be within “earshot” of the VA. An After Visit Summary for the VA on June 4, 2023, showed that s/he was seen in a local emergency room for “vaginal pain,” “dizziness,” and “suicidal.” The VA’s diagnoses included an “abrasion of the vagina,” “depression,” and a “bug bite.” A pelvic exam was completed and the VA was tested for sexually transmitted diseases. An over-the-counter medication was administered to her bug bite. The VA was discharged that same day. According to the facility’s Internal Review, SP1 and SP2 each provided information that they remained inside the vehicle while maintaining visual contact of the VA. Facility information showed that SP1 and SP2 were trained regarding the VA’s program and plans and the Reporting of Maltreatment of Vulnerable Adults. Conclusion: Information from the VA, SP1, and SP2 was consistent that the VA went to a playground on June 4, 2023, where she went into a tunnel and sexual contact between the VA and the F occurred. The VA required 24 hour staff person supervision. Although the VA’s CSSP, SMA, and IAPP did not specify staff persons had to have constant visual supervision when in the community, SP1, SP2, P1, P2, and the G each provided consistent information that they believed the VA’s supervision required staff persons to have their “eyes on” her. The VA said that while at the park on June 4, 2023, SP1 and SP2 did not get out of the vehicle to supervise her and were not aware the incident occurred until returning to the facility when the VA told SP1 that the F touched the VA’s vagina. SP1 stated that s/he and SP2 remained inside the vehicle despite seeing the VA in the tunnel with the F. However, although SP1 said s/he did not see the VA’s face, s/he knew the VA’s whereabouts because s/he had eyes on the VA’s and the F’s legs that were hanging out of the tunnel. SP2 provided information that was contrary to what the VA and SP1 said when SP2 said that s/he supervised the VA from outside of the vehicle and told the VA to come out of the tunnel and the VA complied within a few seconds or less than a minute. Although the VA, who required staff person supervision at all times, engaged in sexual contact at the playground, given the inconsistent information regarding the location of SP1 and SP2 while at the playground, that the F was not able to accurately identify what staff persons were working that day or their location, and that it was reasonable for SP1 and SP2 to supervise the VA by seeing the VA’s whereabouts and knowing she was inside the tunnel, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 policies and procedures were adequate but were not followed. SP1 and SP2 no longer work at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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