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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: 801491-SUD (Substance Use Disorder) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a staff person (SP) called a vulnerable adult (VA), “babe;” sent the VA a “provocative” picture; and touched the VA in a “provocative manner”; and that the VA was “kicked out” of the facility. Date of Incident(s): Ongoing between August 2 and 10, 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 for this investigation was obtained remotely, including documentation from the facility; and through interviews conducted with facility staff persons (the SP, P1, and P2). The VA and another staff person (P3) initially responded to this investigator about scheduling a respective interview but then did not respond further or by the completion of this investigation. The VA provided some information at the outset, which was included in this report. In early August 2023, the VA moved into the facility seeking supports and services relating to his/her substance use disorder. The VA did not have a history of being a victim of, or susceptible to, abuse from others. The facility provided residential substance use disorder treatment, which included group and individual counseling, relapse prevention, sober living skills, health services, and recreation. The VA provided the following information at the outset of this investigation: · “A few days after” the VA moved into the facility, the SP started calling him/her, “babe,” and “rubbing against [him/her] in a provocative manner,” including poking the VA’s stomach. The VA did not want this contact from the SP. · The SP told the VA about the SP’s life and how it compared to the VA’s situation. The VA did not provide information regarding what information was shared by the SP. · One time, the SP invited the VA to “an orgy in the woods,” which the VA declined. · One time, the VA saw the SP “flirting” with an unidentified client. The VA did not provide information regarding what “flirting” entailed. · The VA’s family members visited him/her at the facility and during the visit, the SP “videotaped” them. · One evening, the VA entered his/her bedroom and discovered the SP waiting inside the room. The SP walked up to the VA, grabbed his/her shirt, and “began touching [the VA’s] chest provocatively.” The SP then said, “Have a good night sweetheart. Sleep tight,” and walked out of the room. · “About an hour to an hour and a half later,” P1 entered the VA’s bedroom “swearing at [the VA] about having a cellphone,” which the VA was not supposed to have. The VA told P1 that s/he did not have a cellphone but that s/he had a laptop, which was lent to him/her by the facility. · “The following morning,” an unidentified client told the VA that s/he overheard the SP and P1 talking about “making up a story that [the VA] had stolen [the SP’s] phone and was looking at pictures of [the SP’s intimate areas] from the pictures on the phone.” · “Later in the morning,” P2 and P3 met with the VA to discuss allegations that the VA had a cellphone and/or a laptop in his/her bedroom. The VA denied having a cellphone and said that s/he did not know s/he could not have the laptop in his/her room. P2 and P3 began asking the VA where s/he wanted to go for substance use disorder treatment. “[The VA] took this to mean [s/he] was being kicked out … [The VA] ended up being told that [s/he] had a few minutes to gather [his/her] belongings or [P2 and P3] would be calling the police.” The VA left the facility shortly after this and did not return. P1 and P2 provided the following information: · P1 provided information about an incident that happened on August 10, 2023. Around 2 or 3 AM, the SP completed a walk-through, or “round,” of the facility. During this time, there were no staff present at the staff desk; the desk was unoccupied. When the SP returned to the desk, s/he noticed that his/her cellphone had been used. The SP showed P1 that the VA’s cellphone number was listed as being recently dialed in the SP’s outgoing call log. The VA had used the SP’s cellphone to call the VA’s cellphone so that the VA now had the SP’s phone number. P1 saw this outgoing call in the SP’s call log. P1 reviewed camera footage, which showed the desk area and the VA accessing the SP’s cellphone. [Note: This camera footage was no longer available.] · P1 said that s/he and the SP went to the VA’s bedroom believing that s/he had a cellphone, which was not allowed. P1 used a flashlight to look through the room. The VA repeatedly said, “I’m naked,” and called P1, “police bitch.” The VA denied having a cellphone but stated that s/he had a laptop. P1 seized the laptop and later found a cellphone, which the VA had given to another client to hold. · P2 said that around 7 or 7:15 AM, on August 10, 2023, the SP and a supervisory staff person came to P2’s office with concerns about the VA. The SP told P2 that the night prior, the VA had accessed the SP’s cellphone, viewed the SP’s saved pictures, and texted the VA’s cellphone number so that s/he now had the SP’s number. P2 had not previously met the SP and was not familiar with him/her. · P2 met with the VA to discuss the allegations. “[The VA] became pretty defensive and started talking in circles.” The VA also brought up unrelated topics and it was difficult to refocus him/her. P2 asked the VA if the facility was the “correct placement for [him/her]” and/or if the VA needed to go to a detoxification facility. “[The VA] got upset and left our office.” The VA then yelled out from the hallway that s/he wanted to rescind all of the releases of information that s/he had signed at intake. P2 did this and printed the information for the VA. The VA told P2 that s/he was leaving and had a ride scheduled to pick him/her up. “Last I saw [the VA], [s/he] was walking up the driveway and leaving.” · P2 added that while the VA was leaving, s/he made a comment about the SP “rubbing” the VA’s chest. The VA did not say anything else about the SP’s conduct. P2 said that because the VA was at the facility a “short time,” P2 did not have enough time to get to know the VA or have noteworthy information about the VA or the VA’s past. · P1 said that s/he once heard the SP call the VA “hot stuff,” which P1 believed was “inappropriate.” P1 added that the SP “had some boundary issues.” The VA told P1 that the SP had text messaged a picture of his/her unclothed chest to the VA’s cellphone. The VA did not show P1 this picture. P1 did not witness such conduct from the SP. The SP provided the following information: · One night, when the SP was working with P1, s/he left his/her cellphone on the staff desk unattended. There was no one present in the area, including staff or clients, and so the SP believed it was okay to leave his/her cellphone on the desk. · When the SP returned to the desk, his/her cellphone was turned on and the screen was showing a new contact had been added to the SP’s contact list. The contact included the VA’s name and cellphone number. The VA had also used the SP’s cellphone to call the VA’s cellphone number and text messaged a “provocative pic” that the SP had saved in his/her pictures. The VA now had the SP’s cellphone number and a “provocative pic” of the SP. [Note: At the time of this investigator’s interview with the SP, the SP had changed his/her cellphone number.] · The SP did not give the VA his/her cellphone number or picture. · The SP did not call the VA “babe.” The SP called the VA by his/her first name or “[sir/madam].” · The SP did not poke the VA in the stomach or rub against him/her in a “provocative” manner. One time, the VA was standing and blocking the doorway to the kitchen. The SP asked the VA to move but s/he did not. The SP then touched the VA’s shoulders and moved him/her out of the way. The SP’s “outside leg” might have touched the VA’s leg as s/he walked past into the kitchen. The SP did not rub against the VA or walk past in a “proactive” manner. Another time, the VA would not wake up for an early morning appointment. The SP touched the VA’s shoulder to wake him/her. The SP did not touch the VA during any other encounters. · The SP did not invite the VA to an “orgy in the woods.” This was a “hilarious” thought and “One of the last things [the SP] would ever say to [the clients].” · The SP did not share information about his/her private life. The SP did attempt to “encourage” clients, like the VA, by providing information about substance use disorders and recovery and sobriety. · One time, the SP was in the VA’s bedroom when the VA returned to his/her room, but this was for a search of the roommate’s property, not for the VA. P1 was also present in the room at the time. · The VA told the SP about concerns that s/he had for other staff persons’ conduct. The VA never said anything about having concerns with the SP’s conduct.
The facility’s ethics and boundaries policies and procedures provided the following information: · Employees were expected to maintain appropriate boundaries with clients. · Employees were not allowed to socialize with clients when off duty, including text messaging or phone calls. · Employees were not allowed to initiate or participate in a sexual relationship with a client. Facility documentation stated that the SP and P1-P3 received training on the facility’s ethics and boundaries policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: It was reported that the SP’s conduct, included calling the VA “babe,” touching the VA in a “provocative” manner, text messaging the VA, and sharing personal information with the VA. The SP denied the allegations and although there was some concern regarding the SP’s boundaries, there was a lack of witnesses or information to state exactly what occurred between the SP and the VA. P1 witnessed the SP call the VA, “hot stuff” but did not witness other inappropriate conduct, and the same was said by P2. The SP’s account of what happened with his/her cellphone was consistent with P1’s account and with what was told to P2 the following day. Given the lack of additional information or witnesses to support the VA’s account, the SP’s account was deemed more credible. The SP denied touching or rubbing the VA in a “provocative” manner and said that his/her only physical contact was to the VA’s shoulders and possibly touching the VA’s leg as s/he walked past. Without additional witnesses or information, there was not a preponderance of the evidence whether the SP was responsible for sexual abuse. 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). Given the lack of additional information or witnesses to support the VA’s account and that the SP denied the allegations, there was not a preponderance of the evidence whether the SP’s conduct included a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA's physical or mental health or safety. 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 not followed. This was mainly based on incidents, which occurred after the VA left, and were unrelated to the VA. The SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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