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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: 1090406-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) digitally penetrated a vulnerable adult (VA). Date of Incident(s): Prior to July 29, 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 11, 2023; from documentation at the facility; and through interviews conducted with facility staff persons (P and the SP). This investigator contacted the VA, but s/he declined to complete an interview regarding the allegations and said that s/he did not want a copy of this report. A law enforcement agency was aware of the allegations in this report but did not investigate them. The facility provided structured comprehensive around the clock mental health residential programs for adults with serious mental illnesses, and developed individual treatment plans for each person served based on an assessment of their strengths and needs. Skills and resources that might be offered to individuals included medication administration, health and wellness skills, transportation, social, emotional, and interpersonal skills, wellness management and recovery, integrated dual diagnosis treatment, crisis intervention and assistance, and psychiatry support. To qualify for assistance from the facility, individuals were to need a 24-hour supervised, monitored, and focused treatment approach to improve functioning to avoid relapse that would require higher levels of treatment, be at risk of significant functional deterioration if intensive services were not received, and have one or more of the following: · History of two or more inpatient hospitalizations in the past year, · Significant independent living instability, · Unhoused, or periods of being unhoused, or · Frequent use of mental health and related services yielding poor outcomes in outpatient or community support treatment. Facility documentation showed that the VA was admitted to the facility on July 21, 2023, and was diagnosed with bipolar disorder and paranoia. The VA had episodes of aggressive behavior, had a history of providing inaccurate information, and often declined to provide information regarding his/her past experiences. Facility checks and notes for the VA showed that s/he had difficulty adjusting to residing at the facility and felt bullied/frustrated. The VA did not sleep well and spent extended periods of time in his/her bedroom at the facility. Staff persons were to spend one to one time with the VA during his/her first 10 days at the facility to help him/her acclimate. The VA was encouraged to participate in groups at the facility and to familiarize him/herself with the schedule of events/activities at the facility. The VA chose not to attend some of the groups at the facility and sometimes voiced concerns including saying that s/he was anxious, irritable, thought that staff persons and individuals at the facility were threatening him/her, and that his/her family members were coming to visit him/her when no plans to visit existed. On August 1, 2023, the VA was discharged from the facility, and admitted to a unit at a hospital that provided services to persons with mental illness dues to “escalated symptoms, including heightened paranoia, sleep deprivation, and episodes of aggression.” Facility documentation, the facility’s Internal Review, the VA’s medical records, and interviews with this investigator provided the following: · The VA did not complete an interview with this investigator but provided information to a community health care professional (CHCP) on July 28, 2023, that the SP digitally penetrated the VA two days earlier when the SP brought the VA to a hospital. The VA was unable to provide detailed information regarding his/her contact with the SP but was evaluated and admitted to a hospital on July 28, 2023. · The facility’s Van Log showed that at 4:45 p.m. on July 24, 2023, the SP took the VA to an urgent care clinic and returned to the facility at 5 p.m. but no information specified the reason for the visit. Progress Notes for the VA showed that the VA often expressed health concerns and was frequently upset, and on July 26, 2023, s/he had difficulty sleeping, stated that s/he was having delusions, and was anxious. Staff persons spent one on one time with the VA, and s/he calmed. On July 27, 2023, the VA said that s/he did not want to remain at the facility and asked to be discharged. The VA and his/her case manager discussed options for the VA, but the VA was unable to move from the facility immediately and remained there that night. On the morning of July 28, 2023, the VA was upset and did not understand why s/he could not have alternative housing right away. Later that day, the VA’s family member (FM) took him/her to a hospital at his/her request, where s/he was admitted. · The VA’s hospital records showed that the VA stated that the SP entered his/her bedroom at the facility and sexually assaulted him/her two days ago. The VA said that when s/he awoke at the facility, the SP was standing over him/her, was breathing fast, and had flushed cheeks, but s/he did not recall details of the sexual assault according to the records. The VA denied having paranoid thoughts, but his/her case manager told hospital employees that the VA had paranoid thoughts during the last week, that were primarily focused on facility staff persons. The VA was evaluated for sexual assault but was admitted to a unit of the hospital that provided care and services to persons with mental illnesses “due to psychosis and likely cannabis induced psychosis.” No information in the records showed the results of the sexual assault examination. Medical records for the urgent care clinic near the facility (which was part of the same health care system as the hospital) were requested but no records for the VA existed according to the clinic’s health information system. · The SP said that s/he remembered working with the VA and described him/her as “neurotic” and a “high needs” person. The VA’s moods and thoughts often fluctuated between being grateful for the assistance s/he received at the facility and saying that s/he received no benefit from them. According to the SP, the VA often thought others were following him/her and trying to kill him/her, but the VA’s thoughts were not based in reality. The SP recalled taking the VA in the facility van to an urgent care clinic that was closest to the facility in late July of 2023, but was “blindsided” by the concerns in this report. The SP did not remember which urgent care clinic the VA visited and said that s/he dropped the VA off and did not wait for him/her. It was a quick trip. The SP denied that s/he had any physical contact with the VA and denied that s/he digitally penetrated the VA. · A law enforcement agency was made aware of the allegations investigated in this report but did not investigate them. · The P, who was a supervisory staff person, said that there were no concerns regarding the SP’s work at the facility, and added that the SP was an exemplary employee. Personnel files showed that the facility trained its staff persons on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s plans of care prior to July of 2023. Conclusion: The facility provided residential mental health services to persons with serious mental illnesses based on their individual needs. The VA was admitted to the facility on July 21, 2023, discharged from it on August 1, 2023, and then admitted to the unit of a hospital that provided services to persons who had escalated symptoms of mental illness including heightened paranoia, sleep disturbances, and periodic aggression. According to the CHCP, the VA said that the SP digitally penetrated him/her when the SP brought the VA to a hospital. The VA declined to complete an interview with this investigator. The Van Log at the facility showed that shortly before 5 p.m. on July 24, 2023, the SP took the VA to an urgent care clinic which the SP recalled as being the clinic closest to the facility. However, the SP did not recall the clinic’s name and denied that s/he digitally penetrated the VA. The VA’s medical records showed that the VA said that the SP entered his/her bedroom at the facility and sexually assaulted him/her. The VA recalled that when s/he awoke at the facility, the SP was standing over him/her, was breathing fast, and had flushed cheeks, but did not recall details of the sexual assault. The VA’s case manager said that the VA recently had paranoid thoughts that were focused on staff persons. The VA was evaluated for sexual assault but admitted for care and treatment for mental health symptoms, and no information showed the results of the sexual assault evaluation. No medical records from the urgent care existed according to the clinic’s health information system. The P did not have concerns regarding the SP and the law enforcement agency did not investigate the allegations in this report. Although the VA said that the SP digitally penetrated him/her and information was consistent that the SP transported the VA to a medical facility, given that the VA had a history of providing inaccurate information and that there were no witnesses to the incident, there was not a preponderance of the evidence whether there was sexual contact between the VA and the SP. 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). Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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