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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: 1100930-DS (Detoxification Center) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) had a sexual relationship with a vulnerable adult (VA) while the VA received inpatient services at the facility. Date of Incident(s): Prior to June 21, 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 three interviews conducted with the two facility staff persons (P1 and the SP) and VA. The VA’s diagnoses included severe depressive disorder, post-traumatic stress disorder, anxiety, attention deficit hyperactivity disorder, and chemical use disorder. The facility’s Program Abuse Prevention Plan stated that clients admitted to the detoxification and withdrawal management units were seeking help for substance use disorders and may be intoxicated or experiencing withdrawal from alcohol or drugs. Facility information showed the following information regarding the VA: · Admitted on June 1, 2023, discharged with staff person approval on June 2, 2023. · Admitted on June 2, 2023, discharged against medical advice on June 2, 2023. · Admitted on June 9, 2023, discharged with staff person approval on June 10, 2023. · Admitted on June 12, 2023, discharged with staff person approval on June 21, 2023. · The VA stated s/he received inpatient and/or outpatient treatment at various facilities over 12 times. · A comprehensive assessment dated June 16, 2023, showed that it was recommended that the VA enter and complete a residential treatment facility or outpatient with sober living of his choice. The VA stated that s/he relapsed recently after having “eight months of sobriety.” The VA sated s/he did not feel s/he needed inpatient treatment but was “willing to do outpatient with sober living.” · Upon discharge on June 21, 2023, the VA went to a sober living facility in another town. The VA provided the following information to this investigator via an interview, text messages, and email: · The VA said that s/he was a client at the facility for “a couple years on and off.” The VA believed s/he first met the SP in October 2022 at the facility. The VA was discharged from the facility on an unidentified date and moved to another town for seven months. In May 2023, the VA relapsed and then returned to the facility in June 2023. At that time the VA had a cell phone and the SP and VA sent messages back and forth. An initial text message from the VA to the SP was dated June 12, 2023, at 2:32 p.m. The conversation was regarding a book that the SP gave to the VA and the SP thanked the VA for listening to him/her. The VA replied s/he would listen whenever s/he was “needed” and said s/he was “a friend.” The VA’s admission documents for that day were signed by him/her at 2:03 p.m., indicating the VA was receiving services at the time of the texts between the VA and the SP were exchanged. · During one of the VA’s June 2023 admissions, the VA “took a long nap for four days” and the SP “started to check on [the VA].” (Facility information showed that the only time the VA was at the facility for four days or more was after his/her admission on June 12, 2023.) The VA said that the SP checking on the VA was “not ordinary” because the SP was supposed to be at the front desk answering calls. One of the times the SP came into the VA’s room, (determined to likely be June 14, 2023), the SP brought the VA a “weed/THC pen.” (A rechargeable handheld vaporizer/pen that heats tetrahydrocannabinol/THC/cannabis oil into a vapor. The facility would consider a THC pen to be contraband.) The SP sat on the VA’s bed, reached under a blanket and “grabbed” the VA’s genitals outside of his/her clothing and asked the VA “how big [s/he] was.” The SP was in the VA’s room for approximately 15-20 minutes. The VA said that was the only sexual contact that occurred at the facility despite the SP coming into the VA’s room on four different occasions. · The VA provided this investigator with multiple photos of the SP, with two of the photos showing the SP unclothed. (The photos were not dated.) · The relationship with the SP continued until August 2023 and the VA provided multiple text messages and email messages dated between August 16 and 22, 2023, that showed contact between the SP and VA. In one text message the VA asked the SP about marrying the VA. (During that time in August 2023, the VA no longer received services at the facility). · The VA believed that after being discharged from the facility, the VA relapsed due to the “whole situation” with the SP. The facility’s Internal Investigation and an interview with P2, a supervisory person, provided the following information: · On June 13, 2023, a facility supervisory person (P1) observed the SP and VA outside on the patio smoking. The interaction “appeared secretive” since the VA was generally “off duty” 90 minutes prior to the observation. · On June 14, 2023, P2 observed the SP on site approximately two and a half hours after s/he was “off duty.” The SP was coming from the 10-bed unit and when asked what s/he was doing, the SP said s/he left his/her vape pen at the facility and was talking to another staff person (P3). However, P2 reviewed camera footage that showed the SP entering the VA’s room and leaving the VA’s room approximately 20 seconds later. · On June 15, 2023, P2 met with the SP regarding the incidents on June 13 and 14, 2023, and the SP admitted bringing candy to the VA on June 14 and coloring supplies on either June 12 or 13, 2023. P2 provided coaching to the SP regarding transparency, dishonesty, and inappropriate boundaries and the SP agreed not to have any more boundary violations with the patients. · Between June 15 and August 21, 2023, the SP’s interactions with all clients were closely monitored and no further concerns were observed or reported. (The VA was discharged on June 21, 2023.) · On August 21, 2023, P2 received an email from the VA that stated s/he had a relationship with the SP that “turned sexual” at the end of June 2023, that the SP visited the VA on four occasions after his/her discharge from the facility and said that s/he received over $1000 from the SP over the past couple of months. The VA provided photographs that were “provocative in nature.” · P2 spoke with the SP via telephone and the SP admitted a “friendship” with the VA that “turned sexual” around June 2023, after the VA was discharged from the facility. The SP provided the following information when interviewed by this investigator: · The SP’s responsibility at the facility was mainly sitting at a desk and greeting people as they came in, assisting clients with filled out forms and making sure the necessary forms were signed and at times that entailed going into the client rooms. · The SP believed that s/he first met the VA around December 2022 or January 2023. The VA left the facility on an unidentified date and returned to the facility around the end of April or beginning of May 2023. (Information showed the VA returned to the facility on June 1, 2023.) · On an unidentified date, the VA told the SP that s/he was “on edge” and mentioned that s/he enjoyed drawing so the SP brought the VA some drawing pencils and books from the SP’s own supply. The SP “dropped off” those items in the VA’s room and left. The SP denied touching the VA’s genitals over clothing while the VA resided at the facility. · The SP denied bringing the VA a THC pen when s/he was at the facility; however, said that the VA did get a “vape” pen from the SP after the VA left the facility. · After the VA left the facility, the SP sent the VA money for food and cigarettes. The SP estimated s/he sent the VA at least $900 “just so that [the VA] could get things [s/he] wanted.” · The SP admitted s/he “crossed rules” while the VA was at the facility, specifically “having communication” with the VA. · Within a “couple of days” of the VA leaving the facility, the VA “reached out” to the SP via social media. The SP admitted sending pictures of him/herself to the VA and having a sexual relationship with the VA. However, those incidents did not occur until after the VA was discharged from the facility. When the SP “tried to end things,” the VA was “vindictive.” The SP’s job description stated that s/he was the “first point of contact” for clients and was responsible for coordination of the day-to-day office activities as well as managing the front desk, greeting clients, interacting positively in a caring manner, answering phones, and other projects as assigned. The facility’s Code of Conduct and Professional Ethics policies and procedures stated that staff persons must conduct themselves at all times in a professional manner in accordance with applicable laws, regulations, professional codes of ethics and standards of conduct. Staff persons were expected to maintain appropriate boundaries with clients and not socialize with clients when off duty, including phone/text messages, social media, etc. In addition, “under no circumstances” were staff persons to initiate or participate in sexual relationships with clients “for a period of at least two years following discharge.” Staff persons received training regarding the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures including Code of Conduct, Professional Ethics, client rights, and staff/client relationships. Conclusion: Regarding sexual abuse: The VA said that sexual contact occurred on one occasion at the facility when the SP entered the VA’s room and touched the VA’s genitals over clothing. On that occasion, the VA said the SP was in his/her room for about 15-20 minutes. Information showed that P2 reviewed camera footage and saw that the SP was in the VA’s room on June 14, 2023, for approximately 20 seconds. The SP admitted bringing the VA drawing supplies and candy on two separate occasions between June 12-14, 2023. As of June 15, 2023, the SP’s interactions with clients were closely monitored and no further concerns were observed or reported. Although the SP had reason to deny sexual contact with the VA, the SP admitted having a sexual relationship with the VA after the VA’s discharge. Without witnesses or further information to corroborate that sexual contact occurred at the facility, given that the sexual contact that the SP admitted to occurred while the VA was no longer receiving services and that the SP did not meet the definition of a caregiver at that time, there was not a preponderance of the evidence as to whether sexual contact between the SP and VA occurred at the facility. 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: The VA stated the SP brought the VA a THC pen when the VA resided at the facility, sent the VA nude photos of the SP, sent multiple email and text messages, gave the VA between $900-1000, and engaged in a sexual relationship after the VA was discharged from the facility, causing the VA to relapse. The SP denied giving the VA a THC pen and there was no further corroboration to confirm or dispute the VA’s or the SP’s statement. Regarding the nude photos, there were no dates on the photographs to show when they were taken or sent. There was one text message, dated June 12, 2023, (while the VA was admitted at the facility) that showed it was initiated by the VA and the conversation was innocuous, the remaining text messages and emails that had dates were sent after the VA no longer received services at the facility and showed correspondence was back and forth. The SP admitted to giving the VA over $900 after the VA’s discharge. Although the SP’s conduct was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and was a violation of the facility’s policies and procedures, given that the instances occurred after the VA was discharged and the SP was no longer a caregiver, there was not a preponderance of the evidence whether the SP’s behavior represented a failure to provide reasonable and necessary care and services to the VA. 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; however, the Code of Conduct and Client Patient Relationships policies were not followed. The facility determined there was no need for additional training because the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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