|
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: 800611-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that a staff person (SP) and vulnerable adult (VA) had a relationship and kissed and “touched” one another while at the facility. Date of Incident(s): Unknown prior to June 27, 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 August 14, 2023; from documentation at the facility; and through three interviews conducted with a facility supervisory staff person (P1), a staff person (P2), and a person (P) who worked at another licensed facility that was operated by the same company as the facility. Attempts were made via phone, text, email, and U.S. mail to contact and interview the VA but the attempts were not successful. Attempts were also made via phone, email, and U.S. mail to contact and interview a staff person (SP). This investigator and the SP initially communicated but subsequent attempts to schedule an interview were unsuccessful. The facility had two buildings, each containing client rooms, counselor’s offices, and group rooms. There was a public park down the street from the facility that staff persons often took clients to for games or other activities. The VA was diagnosed with severe cocaine use disorder, moderate alcohol use disorder, and “paranoid” schizophrenia. The VA was a client at the facility on two occasions. This included from February 20 to May 3, 2023. The VA also received services from February 19 to May 19, 2022. The VA’s Individual Abuse Prevention Plan did not identify any risks regarding sexual abuse. The VA enjoyed spending time with his/her family members, bowling, and going out to eat. The P and the Cochran Internal Review Form provided the following information: · On June 27, 2023, the VA told the P that s/he had a “relationship” with the SP at some point during the VA’s first admission to the facility (February 19 to May 19, 2022). The VA told the P that s/he and the SP initially exchanged phone numbers and communicated via text and phone communication. Then, the VA and the SP began hand holding, “touching,” and “kissing” but did not engage in “sexual intercourse.” The “touching and kissing” occurred in the SP’s office or at the nearby park. The VA then “attempted to end” the relationship but the SP became “more persistent” in his/her communication. Additionally, the VA said that there was “gift giving” but the P did not know who purchased the gifts or what the gifts were. · The VA told the P that as of June 27, 2023, s/he had not been in contact with the SP for “quite some time.” However, the VA did not want other “vulnerable people to be taken advantage of in similar ways.” The VA did not provide additional information, including what the touching entailed, and did not want to speak “further on the matter.” · The P said that there was “no reason” why the VA would “fabricate” the concerns and the P was not aware of any “benefit to [the VA] making it up.” Additionally, the more the P tried to ask the VA for information, the “more uncomfortable [the VA] became.” The VA did not show the P any text messages or anything to show that the VA and the SP were in a relationship. The P had not met the SP. · The VA also told the P that s/he “informed the director” of the facility at some point of the relationship but P1 was the “director” and told the P that s/he was not aware of the concerns. · There were no concerns from staff persons regarding the VA and the SP and no “inappropriate boundaries were observed.” Additionally, the VA did not “file any grievances that supported the possibility of an identification of an inappropriate relationship” during the time the VA received services from the facility. P1 provided the following information: · At some point, the P called P1 and said that while the VA was at the facility (and the SP was the VA’s counselor), they had “some sort of romantic relationship.” This included holding hands and kissing but “nothing sexual beyond that.” The P asked P1 if s/he knew anything about this and P1 said it was “all news to me.” · P1 described the VA as “friendly.” While the VA was a client at the facility, there were no concerns regarding the VA being in a relationship with a staff person. The VA never mentioned being in a relationship with the SP. The SP was the VA’s counselor but P1 did not typically see them together. P1 never saw the SP kiss a client or touch them inappropriately. P1 did not know if the VA and the SP maintained contact after the VA left the facility. · Although there were no concerns regarding the SP’s interactions with the VA, at some point, the SP was texting (on his/her personal phone) with another client as the other client was coming back “late from a pass” and missed group. P1 gave the SP a “written warning” for “boundary breaking” as staff persons were not to give clients their phone numbers “under any circumstances.” The facility had phones so clients could reach staff persons. The SP said that s/he gave the other client his/her phone number as s/he “was not thinking.” · As of October 2022, the SP no longer worked at the facility due to not holding the clients “accountable with guidelines.” This included if a client lost a pass, the SP said it was “fine.” The SP also “struggled” with documentation. Staff persons tried to retrain the SP on these things but it was “not sticking.” · P1 said that it was “surprising” that the VA did not bring up the concerns with the SP during the VA’s second stay at the facility (February 20 to May 3, 2023), when the SP was no longer employed. P1 did not know the VA “well enough” to know if the VA had a history of providing inaccurate information. · There would be no reason for a staff person and client to be at the park alone. However, there were times that staff persons took up to 40 clients at a time to play games at the park. · Gift giving was “always discouraged.” Additionally, staff persons should never give a gift to an “individual client.” However, there were times that a staff person may bring in a “dessert” but it would be for “everyone.” P1 was not aware of the VA or the SP exchanging gifts. P2 worked with the VA during the VA’s second admission (February 20 to May 3, 2023). P2 described the VA as “pleasant” but said that s/he “struggled a bit with emotional reactions.” The VA never told P2 about the relationship with the SP. However, the VA “mentioned” the SP a “couple times” when the VA was “recalling” his/her prior stay and asked P2 if s/he knew the SP. During this conversation, the VA was “fairly neutral.” P2 thought that the VA could provide inaccurate information due to “emotional veracity” as the VA wanted to “move on in treatment sooner.” However, P2 thought the relationship was a “real possibility” since the VA “mentioned” the SP during his/her second admission but did not bring up other staff persons. Staff persons were trained not to give clients their phone numbers. P2 did not know what the policy was regarding exchanging gifts with clients but P2 would not do so. P2 was also not aware of the VA or the SP exchanging gifts. P2 did not have any concerns with the SP’s interactions with the clients. Staff persons were trained not to have a sexual relationship with a client, including kissing, touching, or sexual intercourse. The Personal Involvement with Clients said that it was facility policy for staff persons not to engage in sexual contact with current or former clients (within two years of being a client). Staff persons were to report if they suspected any staff persons engaging in sexual contact. The Guidelines for Personal and Ethical Conduct said that no staff person was to receive or agree to receive any compensation or gift except from the facility. Facility documentation showed that the SP, P1, and P2 received training on the facility’s policies and procedures, including Personal Involvement with Clients and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The P said that on June 27, 2023, the VA told him/her that s/he had a “relationship” with the SP while at the facility during the VA’s first admission (February 19 to May 19, 2022). The VA said that the relationship included hand holding, “touching,” and “kissing” but that no sexual intercourse occurred. The VA said that s/he and the SP also communicated via text and phone communication and that they exchanged gifts. When the P tried to ask the VA for additional information, the VA became “more uncomfortable” and did not want to provide additional information. No staff persons were aware of the relationship and staff persons did not have any concerns with the SP’s interactions with the VA. Regarding Sexual Abuse: Although the VA did not respond to this investigators attempts for an interview, the VA told the P that s/he and the SP did not have sexual intercourse. However, the VA told the P that “touching” occurred between the VA and the SP but the VA did not tell the P additional details regarding this. Without additional information from the VA, the SP, or witnesses or any other information, there was not a preponderance of the evidence whether the SP had sexual contact with the VA. 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: Although the VA told the P that s/he had a “relationship” with the SP including communicating via text message and phone and exchanging gifts, the VA did not provide additional information to the P and the VA and the SP did not respond to this investigator’s attempts for an interview. Given that the extent of the SP’s relationship could not be determined; that while there were concerns with the SP’s boundaries with 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. There were no similar incidents involving the VA or the SP. However, there were prior instances of “poor boundaries” between other staff persons and clients. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
