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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: 1071674-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) and a vulnerable adult (VA) exchanged text messages that indicated that the SP “raped” the VA, that the SP was using/did not love the VA, that the VA sat on the SP’s lap, and that the SP had the VA call him/her “[daddy/mommy].” Date of Incident(s): Prior to April 13, 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 April 19, 2023; from documentation at the facility, from law enforcement records and through six interviews conducted with the VA, the SP, two facility management staff persons (P1 and P2), a facility staff person (P3) and the VA’s social worker (SW). The VA was not subject to guardianship. The VA’s Coordinated Services and Supports Plan showed that s/he enjoyed spending time with family and friends, watching sports, swimming, and listening to music. The plan also showed that some of the VA’s diagnoses included fetal alcohol spectrum disorder, attention deficit hyperactivity disorder, and “chronic depression.” The VA was deaf and used American Sign Language (ASL) to communicate. The VA’s Risk Assessment Detail showed that the VA was vulnerable to sexual abuse and “may not be able to communicate sexual abuse if it occurred.” Some of the clients who lived at the facility, including the VA, were deaf or hearing impaired. In a common area of the facility was a list of staff persons and their person cell phone numbers in the event that a client needed to get ahold of a particular staff person via text message. The facility’s Report Form for Internal Investigation, completed by a facility management staff person (P4) and interviews with the VA, P1, P2, P3, and the SP, provided the following information: · Although P3 did not remember specific dates, there were times when P3 arrived at the facility and saw the VA sitting on the SP’s lap watching a movie. There were also times that P3 saw the SP go into the bathroom when the VA was showering. When P3 asked the SP why s/he did that, the SP told P3 that s/he needed to say goodbye to the VA because the SP was leaving the facility. P3 also saw the SP go into the VA’s bedroom when the VA was changing clothes. On one occasion when P3 arrived at the facility for his/her shift, P1 showed P3 text messages, from the VA’s iPad, between the VA and the SP in which the VA told the SP, “You raped me, I think I might be pregnant.” In addition, the text message from the SP to the VA said something to the effect that the VA said, “You don’t love me, you just use me,” to the SP. When P3 asked P1 if s/he was going to “report” the information to P2, P1 said, “No, I actually don’t want to dig a deeper hole,” for the SP. P1 told P3 that s/he was going to “delete” the text messages. Because P1 told P3 that s/he was not going to tell P2, P3 contacted P2 and P2 told P3 that s/he was aware of the text messages, but that s/he could not provide information to P3 about the content of the text messages. On an unspecified date, P2 then brought his/her concerns to P3 that the “relationship” between the VA and the SP was “not professional” and the text messages that were sexual in nature occurred “a few months ago.” · When the VA was interviewed, the VA stated that the SP was a “good staff [person],” that the SP helped the VA with various tasks, and that the SP and the VA “respect each other’s boundaries.” The VA also stated that the SP had not entered the VA’s bedroom or the bathroom when the VA was not dressed. When the VA was asked about text messages between the VA and the SP, the VA “initially denied” any text messages suggesting “rape,” but later, the VA stated that s/he “made it up” and that it was “false information.” The VA also stated that the text message was “two years ago or something” and on the VA’s “old phone,” so the VA did not “have it anymore” because the VA “deleted” the messages. P1 did not “ask” the VA to delete the messages. After the VA sent the text message about “rape” to the SP, the SP “Face timed” the VA and told the VA to “stop sending those messages” and then the SP “blocked” communication with the VA. The VA also said that P3 “lied” about the concerns that s/he brought forward to management. The VA denied that the VA sat on the SP’s lap. · When P1 was interviewed, s/he stated that aside from the VA at the facility, there were three other clients and P3 “felt” that the SP was “protecting” the VA. P1 also stated that there were some “boundary crossing” between the VA and the SP about four or five months ago and that P1 talked to the SP and the VA about those concerns. P1 gave an example in which the VA called the SP “[daddy/mommy],” using ASL. When P1 addressed the communication between the VA and the SP, it “stopped.” P1 also stated that s/he saw the SP “carry [the VA] down the stairs once” after the VA kicked the SP’s shin and the VA “hurt” his/her foot, but that P1 did not have knowledge that the VA sat on the SP’s lap. P1 also stated that on one occasion, s/he saw the SP enter the bathroom while the VA bathed because the VA was in the bathroom “for a couple of hours” and another client needed to use the bathroom. The VA was not wearing his/her “cochlear implant,” so could not hear knocking on the bathroom door so the SP entered. P1, who was also deaf, stated that “people who are deaf often use text messaging or Facetime as a primary way to communicate with others, especially when they are not together at the time.” P1 also stated that the content of the text messages the VA sent to the SP were sexual in nature, which happened “over a year ago.” The SP’s response to the VA sending the messages was to tell the VA to “knock it off,” but the VA continued to send the text messages to the SP because the VA “thinks it’s funny.” The SP did not send the VA text messages sexual in nature. P1 talked to P3 and P3 denied asking the VA to delete the text messages. In addition, P3 “denied” that the VA “ever reported to [him/her] that [s/he] and [the SP] were having a sexual relationship or ever had sex.” · When P2 was interviewed, P2 described the relationship between the VA and the SP to be a “love/hate relationship” that began when the VA moved to the facility. P2 also stated that the VA had a “lot of attachment issues” and “whenever” s/he talked to the VA about “being inappropriate or crossing boundaries with staff [persons], it didn’t matter to [the VA] what [s/he] said, [s/he] would keep up the inappropriate boundaries.” P2 also stated that s/he had “several conversations” with the SP to “address” the SP’s “inaction on redirecting” the VA when s/he was “inappropriate.” P3 gave an example in which the VA called the SP “[daddy/mommy],” but the SP “wouldn’t do anything to correct it.” When P3 learned in December 2022 or January 2023, that the SP and the VA were communicating via text, P3 told all staff persons to “block” messages from the VA. P3 also denied telling anyone to delete the text messages. P3 was aware of a time that the SP gave the VA a “piggyback ride down the stairs” and that was addressed with the SP. · When the SP was interviewed, s/he stated that s/he was “not in a relationship” with the VA and that the VA “does devilish, mischievous things” because the VA “knows” that the SP “doesn’t like it and thinks it is funny.” The VA called the SP “[daddy/mommy]” because the VA “doesn’t have a [dad/mom]” and that the SP “was okay” with the VA using that language toward the SP. The SP “didn’t seem to understand that this was a boundary violation.” The SP stated that if s/he were to “ignore” or “redirect” the VA, the VA would be “set off” and have a behavioral incident. The SP acknowledged that there were times when the VA sat on the SP’s lap and when that happened, the SP “would push” the VA off and tell the VA it was not “appropriate.” The SP provided an example in which s/he had worked a long shift and “fell asleep” on a couch and the VA “jumped” on the couch and “startled” the SP. When that happened, the SP “put [the VA] across [his/her] lap and spanked [his/her] butt, like a [dad/mom] would do to a little kid,” but that it “wasn’t an aggressive spank meant to hurt [the VA], but was just little taps” and “not done in a sexual way.” The SP denied going into the VA’s bedroom with the door closed but acknowledged going into the bathroom when the VA was bathing. Prior to going in, the SP “flashed” the light “several times” so the VA would know that the SP was entering the bathroom. The SP explained that s/he needed to do that because water was “overflowing the tub and leaking through the floor into the kitchen.” Also, the SP acknowledged that there were times that the VA would move from the bathroom to his/her bedroom while the VA was “naked.” When that happened, the SP told the VA to put clothes on. The SP denied sexual contact with the VA and thought that the VA “was saying things about rape” because the VA liked to watch television shows that “talked about rape.” The SW said that the VA told him/her that the SP came into the VA’s bedroom when the VA was sleeping and took the VA’s personal item (blanket), but the blanket was found and the SW did not know if the SP took it. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s specific care plans prior to April 19, 2023. Relevant Minnesota Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), stated that clients have the right to be treated with dignity and respect. Conclusion: Regarding sexual abuse: P3 saw a message the VA sent to the SP on the VA’s iPad that the VA said to the SP that the SP “raped” him/her. When the VA was asked about the text message s/he sent to the SP, the VA said that s/he “made it up.” The VA stated that when s/he sent a message to the SP about “rape” the SP told the VA to stop sending him/her text messages and the SP “blocked” communication with the VA. The VA stated this occurred about two years prior and s/he did not have the messages anymore. The VA stated that the SP and the VA did not have sexual contact. P1 stated that text messages the VA sent to the SP were sexual in nature, happened “over a year ago,” and the SP’s response was to “knock it off.” The VA continued to send the text messages to the SP. The SP did not send text messages to the VA that were sexual in nature. The SP denied sexual contact with the VA and thought that the VA “was saying things about rape” because the VA liked to watch television shows that talked about rape. The SP stated that on one occasion, the VA “startled” the SP when the SP fell asleep on a couch. The SP stated s/he reacted and then “spanked” the VA by tapping the VA’s butt with his/her hand which was behavior inconsistent with the standard of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that the SP and the VA denied sexual contact with one another, that the SP stated when s/he “spanked” the VA it was not aggressive or with sexual intent, and that the VA stated that s/he “made up” the text message about “rape,” there was not a preponderance of the evidence whether the SP touched an intimate part of the VA’s with aggressive or sexual intent. 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). Regarding neglect: P3 did not remember specific dates but said that s/he saw the VA sitting on the SP’s lap, saw the SP go into the bathroom when the VA was showering, saw the SP go into the VA’s bedroom when the VA was changing clothes, and saw that the VA and the SP exchanged text messages. The VA described the SP as a “good staff[person]” and said that they “respect each other’s boundaries.” The VA denied that the SP entered the VA’s bedroom or the bathroom when the VA was not dressed. The VA stated that P3 “lied” about the concerns P3 had about the SP. The VA stated that s/he did not sit on the SP’s lap. P1 stated that there was some “boundary crossing” between the VA and the SP, such as the SP allowing the VA to call him/her “[daddy/mommy]” and when P1 addressed the issue with the VA and the SP, the SP and the VA stopped. P1 was aware of one time when the SP entered the bathroom when the VA was in there for an extended period of time and the SP went in to check on the VA. The SP flicked the lights to indicate to the VA that s/he was entering because the VA was deaf. P1 was aware of one time that the SP carried the VA down the stairs when the VA was hurt but not aware of a time that the SP sat on the VA’s lap. P2 described the relationship between the VA and the SP to be a “love/hate relationship” and said that the VA had a “lot of attachment issues” and “whenever” s/he talked to the VA about “being inappropriate or crossing boundaries with staff [persons], it didn’t matter to [the VA] what [s/he] said, [s/he] would keep up the inappropriate boundaries.” P2 also stated that s/he had “several conversations” with the SP to “address” the SP’s “inaction on redirecting” the VA when the VA was “inappropriate.” The SP said that the VA called him/her “[daddy/mommy]” using ASL and that s/he was “okay” with it because if the SP were to ignore or redirect the VA, the VA would be “set off” and have a behavioral incident. The SP acknowledged that there were times when the VA sat on the SP’s lap and when that happened, the SP “would push” the VA off and tell the VA it was not “appropriate.” The SP denied going into the VA’s bedroom with the door closed but acknowledged going into the bathroom when the VA was bathing, but that s/he “flashed” the light “several times” so the VA would know that the SP was entering the bathroom. The VA and other clients at the facility were deaf or hard of hearing so there was a list of staff persons’ cell phone numbers in a common area so the VA or other clients could contact staff persons via text message if they needed to. Although the VA did not have concerns related to how the SP interacted with him/her, the SP allowing the VA to call him/her “[mommy/daddy]” and not redirecting the VA when the VA was “inappropriate” was behavior that was inconsistent with the role of a professional caregiver in a program licensed by the Minnesota Department of Human Services. However, given that the SP stated that when the VA tried to sit on his/her lap, the SP did not allow it, that when the SP entered the bathroom when the VA was showering, it was to check on the VA and the SP flipped the light switch to indicate his/her presence, that the VA had the SP’s phone number and they communicated via text message because the VA was deaf, and that there was no information that the SP communicated inappropriately with the VA, 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’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 SP was no longer employed by the facility and P1 and P2 “received corrective action plans regarding following reporting guidelines and keeping information confidential.” In addition, the facility provided additional training to “all staff [persons]” related to “professional boundaries” and “VA/Maltreatment and reporting timelines.” Action Taken by Department of Human Services, Office of Inspector General: A Correction Order for the violation outlined in this report was not issued because the facility took immediate action.
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