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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: 1104338-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that a staff person (SP) kissed and hugged a vulnerable adult (VA) while at the facility. Date of Incident(s): Ongoing prior to June 2, 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 July 21, 2023; from documentation at the facility; and through four interviews conducted with two facility supervisory staff persons (P1 and P3) and two staff persons (P2 and the SP). Attempts were made via phone, email, and text message (Note: There was no known mailing address for the VA) to contact and interview the VA but the attempts were unsuccessful. The facility was a high intensity residential treatment facility located in a two-story building that was formerly a hotel. The facility had video cameras in main areas, including the hallways. The facility had a large lobby that had a staircase leading to an open foyer at the top of the stairs. Within the foyer was a desk where staff persons often worked. This was referred to as the “Crow’s Nest.” According to the VA’s plans, the VA was diagnosed with moderate to severe alcohol use disorder. The VA received services from the facility between February 17 and March 28, 2023. The VA “successfully discharged” from the facility due to completing all his/her program recommendations and hours. The VA then went to an intensive outpatient program “with lodging.” While at the facility, the VA was educated on the difference between healthy and unhealthy relationships including with his/her family members (Note: There was nothing noted in the VA’s plans regarding the VA having a history of inappropriate relationships with staff persons). The VA had difficulty trusting others. The VA’s Individual Abuse Prevention Plan said that the VA was not susceptible to sexual abuse. The VA enjoyed listening to music and fishing. P1, screenshots from the VA’s Facebook page, and the Internal Investigation completed by P1 provided the following information: · On June 2, 2023, the SP was “terminated” from the facility. This was due to “poor boundaries” regarding the SP sharing his/her “personal life” with the clients such as what the SP did on the weekends. The SP tried to be the client’s “friends” instead of “professional.” The SP would also spend “a lot of time” with some of the clients in the “Crow’s Nest.” However, there were no concerns of the SP being in a relationship with any client or any “inappropriate” physical touch. · Additionally, on June 2, 2023, a staff person (P4) showed P1 screenshots from the VA’s Facebook page which showed two photos of the SP smiling wearing a shirt with the facility logo. Above one of the photos was a caption written by the VA stating, “These sort of people can’t be trusted at all. These are people that are suppose [sic] to be helping in treatment centers and they are misusing clients.” The VA also said, “This type of person in rehabs [sic] can’t be trusted.” A caption above the other photo stated, “This face is not a trustworthy face. This is a face that smiles and lies at the same time.” There was also a screenshot of what appeared to be an undated text message from the SP to the VA posted to the VA’s Facebook page. This included a (clothed) photo of the SP standing in front of a home next to a car and the VA stating, “Check you out. Got yourself a Nissan.” · P1 said that the photos of the SP were taken at the facility (due to the background) and were “selfies” of the SP. P1 did not know how the VA obtained the photos of the SP but said that it looked like the VA accessed them from the SP’s Facebook page. The photos were not inappropriate in nature and did not include the VA. P1 said that the VA would not have had his/her phone at the facility to take those photos so P1 thought the SP had taken them him/herself and posted them on his/her own Facebook page. · On June 5, 2023, the VA left P1 a voicemail stating that s/he had “information about staff” and left a phone number that P1 could call the VA back at. On June 6, 2023, around 6:10 p.m., the VA again called P1 and P1 spoke to the VA. The VA said that s/he had “information about staff.” P1 had “no idea what [the VA] was talking about” and the VA “did not want to tell” P1 who s/he was talking about. The VA was “very general” and “not specific” when talking. The VA also said that this staff person “accused” the VA of getting him/her “fired.” P1 did not recall if the VA then named the SP or if P1 named the SP. However, P1 then realized that the VA was talking about the SP since the facility had “terminated” the SP a few days prior and also due to the VA’s Facebook post. · The VA then began telling P1 about an “alleged relationship” that occurred with the SP while s/he was a client at the facility, including that the VA and the SP had been “touchy feely.” The VA described this as kissing and hugging one another “intimately” in areas of the facility that were out of view from the cameras. This included in empty client bedrooms or the kitchen. The VA did not specify where the kisses occurred, including if they were on the lips. The VA did not say how many times s/he and the SP kissed or when the relationship started. The VA said there was no sexual intercourse or any other sexual interactions between them. The VA did not provide any specific dates of when these incidents took place. · The VA also told P1 that when the VA left the facility, the VA and the SP continued communication, including “visits,” and talking with one another. However, this communication stopped as of June 2, 2023, because the SP “blamed” the VA for the SP being “fired.” The VA was “really upset” that the SP had “cut off” communication. P1 did not want the VA to know s/he saw the VA’s Facebook posts so did not bring those up. However, the VA did not say why the SP was a “liar” and could not be “trusted.” The VA did not provide additional information. · There was always another staff present when the SP worked, and the SP most often worked with P2. P2 would have said something if s/he saw anything concerning. No client’s or staff persons, including P2, said that they saw anything inappropriate between the VA and the SP. The VA did not bring up any concerns when s/he was a client. · P1 saw the VA and the SP interact at the facility but did not see anything concerning. The VA was a “social butterfly” and had a “flirty” smile in general with anyone s/he interacted with. · The VA was “pretty honest.” However, P1 could see the “potential” regarding the VA providing inaccurate information about the SP, including when the VA was “hurt.” · P1 did not know if the VA and the SP were friends on social media. P1 was not aware of the VA or the SP communicating via text message. Staff persons were trained not to exchange phone numbers with the clients. Additionally, staff persons were trained not to be friends on social media. Staff persons were not to maintain contact with clients after they left the facility due to staff persons having “authority” or “power” over the clients because of their roles. P2 provided the following information: · P2 had concerns with the SP’s boundaries with clients and staff persons. The SP would talk about his/her “sexual exploits” and “preferences in [men/women].” The SP also made “inappropriate jokes” and made staff persons “uncomfortable.” The SP showed P2 “risqué” photos of him/herself. Staff persons spoke to the SP about these things. However, P2 never saw anything to believe that the VA and the SP were in a relationship together, including the VA and the SP kissing. It would not be appropriate for staff persons and clients to kiss. The SP never told P2 that the VA kissed him/her. However, the SP often went into clients’ bedrooms and closed the door behind him/her, which staff persons were not supposed to do as that was how “rumors start.” · P2 was not aware of any clients or staff persons, including the VA and the SP, getting together, including for lunch, after the client was no longer at the facility. · P2 saw staff persons hug clients when the clients had “bad days” and said that “all” staff persons did so. · Staff persons were trained not to exchange phone numbers with clients for two years. P2 was not aware of the SP or the VA exchanging phone numbers. However, the SP and another client (C) exchanged phone numbers, which P2 told the SP and the C they were not supposed to do. Additionally, the SP and C would talk near the med room window and “walk the halls together.” However, P2 did not see anything sexual between the SP and the C. P2 also saw the VA and the SP talking at the facility but P2 thought it was because “every client had their favorite” staff person. · The VA had a history of providing inaccurate information including regarding “racism.” P3 provided the following information: · At some point, P1 told P3 that P4 saw the VA post in a Facebook group about the SP, including photos. P4 was “heavily involved” in the recovery “community” and was in a “lot” of Facebook groups for recovery, which is how P4 saw the VA’s Facebook post. P3 did not see this post. · P3 did not typically work with the SP. However, there were concerns from staff persons that the SP would sit with the clients in the “Crows Nest” area, which was not appropriate as it was a staff area. However, other staff persons did similar. P3 never saw the SP doing so with the VA. The SP had been talked to regarding this but it “continued to occur” after the SP had been told not to do so. · The VA was “centered on [his/her] recovery” and not “looking to hook up with a staff member.” The VA never told P3 about the concerns. Because of this, P3 was “surprised” when s/he heard about the concerns. However, P3 was “proud” of the VA for telling P1 and said the VA “probably felt” like s/he could not do so while s/he was a client at the facility. · P3 had “no idea” if the VA and the SP were Facebook friends. Additionally, exchanging phone numbers with a client was a “major boundary issue” and the SP would have been trained on that. There would be no reason that clients would have staff persons phone numbers (or vice versa). The SP provided the following information: · The SP said that s/he was “let go” from the facility “due to an accusation” but did not know which client it involved. The SP said that s/he was a “very friendly person” but did not do “anything other than talking” to the clients. · At some point, the C said that s/he would “need help” when s/he left the facility (regarding getting a phone) so the SP gave the C his/her phone number. However, the SP never saw the C outside of the facility and only talked to him/her via phone. · The VA wanted “more than friendship” with the SP and “hinted” at it when the VA was at the facility. However, the SP was “trying to be just friends” with the VA, since staff persons were trained not to have relationships with the clients and that was “not what [the SP] was looking for.” The SP also did not want to “get in trouble or lose” his/her job. While at the facility, the VA hugged the SP in the hallway. The SP told the VA that s/he “can’t be hugging staff.” On another occasion, the VA “kissed” the SP on the cheek and the SP told the VA it was his/her “last warning” or the SP would have to “report” the VA. However, the VA “did not try anything after that.” The SP told P2 about the hug and kiss and the SP asked P2 what to do. P2 told the SP that if the SP thought the VA would “do it again,” to “report it.” However, since the VA did not do it again, the SP did not “report it” and did not tell his/her supervisors. · Around the time the VA left the facility, the SP gave the VA his/her phone number to assist the VA with finding a sober living home. The SP did not think that the VA would contact him/her for a “while” as the VA did not have a working phone when s/he left the facility. However, approximately one to two weeks after the VA left, the VA began texting the SP, including wanting a relationship. The SP did not want to “take advantage” of “someone in that state of mind” who was “trying to heal.” The SP continued to tell the VA that s/he was “not interested.” · The SP also told this investigator that at some point, the SP told the VA that s/he “liked” him/her but the SP “never acted upon anything.” The SP said that this likely “confused” the VA and “played with [the VA’s] emotions.” · Approximately one month after the VA was no longer a client, the SP picked the VA up from his/her sober living home and brought the VA to lunch. The SP said that s/he met the VA for lunch to tell the VA that s/he was not supposed to be in contact with him/her and to “back up.” The VA then told the SP that if the SP “did not pursue things” with him/her, then the VA was going to “report” the SP. Because of this, the SP continued talking to the VA via phone but did not see the VA after that. It “finally got to the point” where the SP told the VA to “report” him/her because s/he would “not do anything” with the VA. The VA “kind of lost it” and began messaging the SP’s family members via Facebook. The SP’s family members “blocked” the VA but then the VA continued to make new Facebook profiles and contact them. · At some point, the SP “blocked” the VA from calling him/her but the VA called from a different number so the SP answered. The VA told the SP that s/he could not “sit and play with people’s emotions.” The SP told the VA that s/he “did not play with [his/her] emotions” and “only wanted to be [the VA’s] friend.” The VA then went “on and on” so the SP “hung up” and blocked the VA’s number and did not hear from the VA again. · When this investigator asked the SP what “touchy feely” meant, the SP said that s/he and the VA played “War,” a card game, a “few times” at the facility and the VA put his/her hands over the SP’s. The SP denied any sexual contact, including intercourse, with the VA. The SP denied touching the VA’s genital areas or the VA touching the SP’s. The SP denied any other times that s/he and the VA kissed, aside from the VA kissing the SP on the cheek. · The clients liked to talk to staff persons in the “Crow’s Nest.” At some point, the SP was told that s/he could not do so. · The SP was trained not to have “contact” with the clients for a year after they left the facility. The SP was also trained to be “professional” and not get “too close” to the clients. Staff persons were trained not to exchange phone numbers with clients. When this investigator asked the SP why s/he exchanged his/her number with two clients (the VA and the C), the SP said that both “needed more help” and “wanted to be friends.” Additionally, the VA and the C each did not have “support” from people including family members. · This investigator asked the SP to send any text messages s/he had between him/her and the VA but the SP said that his/her text messages “deleted” after 30 days and that s/he “did not have them.” Untitled progress notes from the facility showed four times that the SP documented s/he interacted with the VA. These times each included when the VA was not present for group and the SP found the VA in his/her room. The SP then “prompted” the VA to attend group and each time the VA said that s/he would not attend. The Personnel Policy Requirements stated that any “unprofessional conduct” with a client that was sexual or may reasonably be interpreted by a client as sexual or any verbal behavior that was “seductive or sexually demeaning” to a client was grounds for disciplinary action. Facility documentation showed that P1, P2, P3, and the SP received training on the facility’s policies and procedures, including ethical boundaries and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: P1 said that on June 6, 2023, the VA told him/her that s/he had a “relationship” with the SP at the facility, including that they kissed and hugged one another “intimately.” The VA did not specify where the kisses occurred and said that no sexual intercourse or any other sexual interaction occurred. The VA said that s/he and the SP continued to communicate after the VA left the facility, including visits and talking with one another. No staff person was aware of this relationship. Regarding Sexual Abuse: Although the VA did not respond to this investigators attempts for an interview, the VA told P1 that s/he and the SP did not have sexual contact. The SP also said that s/he and the VA did not have sexual contact. Therefore, there was a preponderance of the evidence that sexual abuse did not occur. It was determined that sexual abuse did not occur (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: The SP acknowledged communicating with the VA after the VA left the facility, including communication via text message, going to lunch with the VA, and telling the VA that s/he liked him/her. Having a relationship with the VA outside the facility was not consistent with the standards of a professional caregiver in a DHS licensed program. Although there was a relationship between the SP and the VA outside the facility, given that the extent of the SP’s relationship could not be determined; that while there were concerns with the SP’s boundaries with staff and clients in general, there were none specifically related to the VA; and that no information showed whether the services provided to the VA were affected by the SP’s actions, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or maintain the VA’s 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 and followed. The SP no longer worked at the facility. Following the incident, all staff persons were required to retake boundary training, which they also received “at minimum” of once per year. There were no similar prior concerns with the SP, including any physical or sexual relationship with a client. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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