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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: 801558-RMI (Residential Treatment and Services for Adults with Mental Illness) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) “pushed” a vulnerable adult (VA) by repeatedly asking who raped/sexually assaulted the VA when s/he was younger. When the VA responded, s/he said the name of the SP’s significant other (SO). Prior to the interaction with the VA, the SP told a health care professional (HCP1) that the SP wanted the information for his/her personal benefit because s/he wanted to divorce the SO. Date of Incident(s): June 3, 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 (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 22, 2023; from documentation at the facility; and through nine interviews conducted with facility staff persons (the SP, and P1-P4), facility health care professionals (HCP1-HCP3), and the VA’s guardian (G1) who was also a family member. At the time of the site visit, the VA was hospitalized and not interviewed by this investigator. The VA was admitted to the facility on February 28, 2022. The VA’s diagnoses included borderline personality disorder, oppositional defiant disorder, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. The VA’s history included ingestion of foreign bodies. The VA enjoyed writing, playing cards, coloring, doing crafts, and listening to music. At the time of the incident, the VA resided on Tamarack West. Facility documentation showed that the VA had a long-standing history of “disruptive and self-injurious behaviors.” Prior to his/her admission to the facility, the VA resided at Anoka Metro Regional Treatment Center (AMRTC) due to “unmanageable self-harm” primarily by means of swallowing inedible items, requiring medical intervention on multiple occasions. While at AMRTC, the VA had a 4:1 staff ratio at all times and was able to acquire items to ingest while staff persons were present at his/her side. It was determined that staffing ratio or proximity to the VA at all times was not determined to impact his/her ability to swallow inedible items. On the contrary, staff person proximity to the VA added exposure to items s/he could swallow (face masks, name badges, keys, eyeglasses, etc.). Information also showed that the VA’s history included a plethora of psychotropic medications and electro convulsive therapy, all of which were thought be ineffective in managing his/her self-harm behaviors. The VA’s Functional Behavior Assessment stated that s/he was molested when s/he was a young child and again by the same person when s/he was 12 or 13 years old. The facility’s Internal Review and/or an interview with HCP1 provided the following information: · On June 3, 2023, the VA returned from an emergency room visit. · At approximately 2:15 p.m., HCP1 observed the SP in a conference room looking at an unidentified patient’s chart. (The Internal Review stated it was the VA’s chart and that the SP asked HCP1 several questions about the VA that “did not need to be known” for the SP to complete his/her job.) The SP asked HCP1 where s/he would find old legal documents. When HCP1 asked why the SP was looking for those documents, the SP said s/he was “looking for reasons to divorce [the SP’s significant other (SO)].” · At approximately 4 p.m., the VA obtained toilet paper from another patient’s room and attempted to hide it in his/her “private area.” Several staff persons (HCP1, the SP, and other unidentified staff persons) walked with the VA to his/her room and successfully got the VA to surrender the toilet paper. The SP asked the VA why s/he was “doing this” (getting items s/he then generally tried to swallow/inhale) and the VA referenced being “assaulted as a child.” The SP, the VA, and P1 went to the dining room area on Tamarack West to talk. HCP1 went to Tamarack East. · The SP “questioned [the VA] about a reported rape, and [the SP] asked [the VA] directly and repeatedly who raped [the VA].” The VA identified the person by name and when the SP heard the name of the SO, the SP left the unit and entered the unit station visibly upset and crying loudly. · At approximately 4:30 p.m., when HCP1 heard a door slam and heard the SP crying in the hallway between Tamarack East and West units, the SP told HCP1 that the VA identified the SO as the person who raped the VA. The SP was removed from the unit “due to conflict.” The VA “seemed concerned” about the SP because s/he saw the SP “emotional” when leaving Tamarack West and asked if the SP was “okay.” · Later that same day, HCP1 heard the VA on the telephone asking G1 where the SO was, and G1 said s/he did not know but believed the SO lived in another state. G1 said that the SO’s family members and the VA’s family members recently vacationed together. P1-P4, HCP2, HCP3, the SP, and the G1 were interviewed by this investigator and provided the following information: · P1 was working on Tamarack West on June 3, 2023. After the VA obtained toilet paper, the VA made statements about wanting to die and was crying. After the incident, the SP and VA sat at a table on the unit to “process the events” and talked for approximately five to ten minutes. Although P1 was “trying to be close to assist” if necessary, s/he also tried to “give them space” so remained approximately five feet away. “At some point” the SP and VA got up from the table and P1 “attempted to follow them” but the SP “made a hand gesture” that indicated P1 should remain where s/he was and a 15-20 second conversation continued; however, P1 did not hear what was said. As soon as that conversation was over, the SP went to the unit station. P1 said that the VA remained in his/her room most of the evening and P1 did not remember any additional incidents. When P1 was asked about his/her training regarding what to do if a patient was admitted that s/he might know, P1 said that occurred with him/her and s/he was trained to have a conversation with his/her supervisor. · P2 said that June 3, 2023, was the first-time s/he worked with the SP on Tamarack West. The SP asked P2 if s/he knew anything about the VA or why the VA was at the facility and proceeded to tell P2 that the SP’s SO knew the VA and that the SO’s and VA’s families went to the same church. The SP then said s/he was going to “read up” on the VA and left the unit to find the VA’s chart. The SP returned and went on the unit with P1 to talk to the VA. P2 did not know why the SP went to talk to the VA because the VA was “not asking” to talk to the SP. P2 did not hear the conversation but after the SP’s conversation with the VA, the SP left the unit and went to the unit hallway where P2 heard sobbing and cursing. · P3 was interviewed by this investigator and said that s/he worked with the VA about 90% of his/her shifts and read about the VA’s history when the VA first arrived and heard updates about the VA in weekly clinical review meetings but did not recall hearing about a history of sexual assault. P3 did not have any information regarding the allegations in this report. When P3 was asked what s/he would do if a patient was admitted who was a friend of a family member, P3 said that s/he was trained to contact a management staff person and request to move to a different unit due to the “possible conflict.” · P4 was interviewed by this investigator and said the s/he was called to the unit when the VA obtained the toilet paper but that s/he left “almost immediately” after the incident. When P4 was asked about a staff person questioning the VA about who sexually assaulted him/her, P4 did not have any information about that and said the s/he “never would” ask a patient such a question because it was “not my job.” · HCP2 said that several months prior to the incident the SP found out that his/her SO “molested” a teenager several years ago. On June 3, 2023, HCP2 overheard the SP crying and talking to unidentified staff persons saying that the SO raped the VA. The SP then asked HCP2 if s/he heard about the SO. HCP2 asked the SP how s/he came to find out that information and the SP said s/he was trying to find out why the VA exhibited his/her behaviors and the SP said that s/he “pushed” the VA to talk. The VA agreed to sit at a table with the SP and “somehow it came up that some of the behaviors [the VA] engaged in [s/he] does due to sexual trauma history.” The SP “pushed” the VA to provide a name and the VA identified the SO. The SP asked the VA why s/he didn’t report the sexual assault and the VA said that s/he did but that no one believed the VA because the SO came from “a Christian family.” The VA could tell the SP was getting upset and asked the SP if s/he was okay and the SP left the unit. The SP repeated that the SO raped the VA and said s/he was” looking for a reason to divorce [the SO] anyway.” Shortly after the SP’s discussion with HCP2, HCP2 went to Tamarack West and heard the VA on the telephone with G1 asking questions about the SO. G1 said that s/he believed the SO lived out of state. The VA appeared “calm” but “confused and frustrated;” however, there were no notable behaviors that night. · HCP3 said that until June 3, 2023, the facility had no information that the SP’s family members and/or the SP knew the VA. HCP3 said that “as soon as [the SP] was aware of a family connection,” the SP should have notified a supervisor and discussed if there was a conflict. Although the VA’s unit was not the SP’s primary unit, when the SP was assigned to work on the VA’s unit, “The notification should have occurred as soon as [the SP] knew there was a connection.” HCP3 said the VA was sexually abused prior to his/her admission and the abuser’s first name was reflected in the VA’s chart. Although the VA’s history of abuse was well known, the name of the abuser was “not something referenced often.” HCP3 conducted a search of the VA’s Progress Notes to see if the name of the person who molested the VA was mentioned. Two entries were found: On August 16, 2022, the VA talked about “feelings of distress” caused by his/her sexual abuser (identified by his/her first name) and that a family member told the VA that s/he should “forgive and forget.” The VA was encouraged to bring forth these uncomfortable and traumatic events in order to break the cycle of guilt and self-harm. The VA was reminded of the mortality risk of continuing to swallow items. On June 8, 2023, (five days after the incident) the VA talked to a family member (G2) on the phone and said that when s/he thought of “bad stuff like [first name of sexual abuser]” . . . the VA also talked about having “flashbacks” about previous sexual trauma. HCP3 said that s/he could not think of a scenario where a person with the SP’s job title would need to review old legal documents. HCP3 was not aware of any negative consequences to the VA as a result of the incident. · G1 said that the VA called him/her on the evening of June 3, 2023, and they talked for approximately 12 minutes. That evening the VA asked G1 about the individual who sexually assaulted him/her on two occasions. G1 told this investigator the name of that person (confirmed to be the SO) and that the SO was someone that “our family knows.” The incident was reported to law enforcement but due to the VA’s mental status, no criminal action took place. G1 was aware that the SO was on probation for statutory rape of a different person. G1 told the VA that s/he did not know where the SO was currently living and believed that the SO lived out of state. · The SP said that s/he worked on Tamarack East or West about once or twice a month. Since the VA’s admission (February 2022), the SP worked with the VA two to three times a month providing “hospital coverage.” (The VA was frequently hospitalized for medical procedures related to swallowing and/or inhaling items and facility staff persons provided supervision at the hospital.) When asked about reviewing the VA’s file on June 3, 2023, to look for past legal information, the SP said, “I don’t recall that.” The SP also denied reviewing the VA’s file for a reason to divorce the SO. The SP said s/he “looked up some stuff” after the VA returned from the hospital because s/he was working with a new employee and wanted to see what was going on since the last time the SP worked with the VA. The SP said they were “encouraged” to review patient information. When asked if the SP suspected the SO sexually assaulted the VA, the SP said, “I suspected it was highly possible,” because the SP knew of a sexual situation that occurred with the SO when s/he was younger that was not reported/charged. The SP provided information consistent with other staff persons regarding June 2, 2023, when the VA obtaining toilet paper and staff persons successfully intervened. The SP told the VA there was a “whole team” ready to help the VA and the VA could talk to anyone, and the VA “chose [the SP] to talk to [the VA].” The VA told the SP about his/her past and how s/he was assaulted when s/he was a “kid” and “mentioned a name.” The name the VA identified was the same name as the SP’s SO. The SP said that s/he was able to keep his/her composure in front of the SP and excused him/herself. When asked about “pushing” the VA to identify the person who sexually assaulted him/her, the SP said s/he did not know if s/he pushed the VA to disclose; however, the SP believed s/he “was in a therapeutic moment, trying to sympathize with [the VA].” The SP said there was “no malicious intent so when [the VA] said the name, I was shocked and had the reaction I did.” When asked if s/he was trained as a therapist, the SP said, “I am for this position,” and that s/he did one to one counseling for the patients. Regarding the policy to disclose knowing a patient, the SP said that s/he would need to “reread” the policy but “would guess” s/he was “supposed to report something to a supervisor.” The SP admitted that several months prior (January or February 2023) the SO’s family members talked to the SP and SO about a person (the VA) they knew from church, who was also friends of the family, and was having a hard time at a facility. (The SP said that the facility was not identified.) The SP asked who the person was and the VA was identified by name. The SP did not acknowledge to the SO’s family members that s/he worked with the VA. The SP said s/he was not aware the policy addressed “if it was a family member” who knew a patient and thought the policy was “only for employees who knew someone first-hand.” The SP said although s/he was aware that the SO and the SO’s family knew the VA, and that s/he “suspected it was highly possible” that the SO assaulted the VA, that information was not confirmed until June 3, 2023, when the VA stated the SO’s name to the SP. The facility’s Boundaries policy states that staff persons must notify their supervisor immediately if a patient is admitted that the staff member knows on a personal or professional level or that the staff member currently or formerly has had a personal, familial, or professional relationship with outside of the program; or if they are experiencing difficulty managing boundaries or emotions working with patients. A review of the SP’s job description stated that s/he was responsible to use person centered techniques, be aware of patient needs and vulnerabilities, to treat patients in a respectful and therapeutic manner, and to demonstrate professional composure and boundaries at all times. Facility information showed that staff persons were trained regarding person centered thinking, boundaries, and the Reporting of Maltreatment of Vulnerable Adults Act. However, there was no documentation that the SP was trained regarding person centered thinking. Conclusion: Information showed that around January or February 2023, the SP realized that the SO’s family members knew the VA and knew that the VA was having a difficult time at the facility. Although staff persons (P1, P3, and HCP3) stated that they were trained to tell a supervisor of any conflicts such as knowing clients prior to their admission, the facility’s Boundaries policy was vague regarding a family member having a personal, familial, or professional relationship with a client outside the program. The SP worked with the VA numerous times and did not disclose a possible conflict despite stating s/he probably should have reported the information to a supervisor. On June 3, 2023, HCP1 and P2 each said the SP talked about reviewing the VA’s chart and indicated the SP referenced looking for something related to “divorcing” the SO. The SP admitted to reviewing the VA’s chart but provided other reasons for the review. A short while after reviewing the VA’s chart, the SP was on the unit talking to the VA. P1 was closest in proximity when the conversation with the VA and SP took place; however, P1 did not hear what was said. In addition, at one point when P1 attempted to get closer, the SP gestured to P1 to stay back. During the conversation between the SP and the VA, the SP said that the VA disclosed the person who sexually assaulted him/her by name, and that name was the same as the SO. Although the SP admitted that prior to June 3, 2023, s/he “suspected it was highly possible” that the SO sexually assaulted the VA, the SP said there was “no malicious intent” regarding his/her discussion with the VA. Regardless, the SP did not provide professional boundaries as identified in his/her job description and most likely had a personal reason for discussing the name of the abuser with the VA. Although there were concerns regarding the SP’s motives and information showed that the SP’s actions were not consistent with a professional caregiver in program licensed by the Department of Human Services, given that the VA had no further incidents that were directly related to the conversation between the VA and SP, and that this was a single incident, there was not a preponderance of the evidence whether the SP engaged in conduct that caused or could reasonably be expected to cause emotional distress to the VA or whether there was a failure to provide the VA with care or services that was reasonable and necessary to obtain or maintain the VA’s health or safety. It was not determined whether emotional abuse or neglect occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening or 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 the policies and procedures were in place and were adequate but were not followed and there was an identified need for additional training. At the time of the completion of this report, the facility was still completing a personnel investigation regarding the SP’s conduct and will follow up with any necessary corrective action. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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