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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: 1070830-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman/Van Mulheron Suspected Maltreatment Reported: It was reported that a staff person (SP) touched a vulnerable adult’s (VA’s) genital area and lower back. Date of Incident(s): Unknown prior to May 19, 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 May 31, 2023; from documentation at the facility and law enforcement records; and through nine interviews conducted with the VA, a facility supervisory staff person (P1), two staff persons (P2 and the SP), a staff person from the VA’s day program (DP1), the VA’s case manager (CM), a resident (R) who also lived at the facility, the VA’s family member (the FM), and the VA’s guardian (G) who was also the VA’s family member. Facility documentation showed the VA was diagnosed with moderate intellectual disability, bipolar disorder, and behavioral disorder. The VA resided at the facility with three other residents, including the R, and worked one day a week at a day program. The VA liked to watch movies, listen to music, and do crafts, and was “very social.” It was important for the VA to maintain a strong relationship with his/her family, friends, and team members. The VA’s Coordinated Service and Support Plan stated that the VA required 24-hour care with staff persons on the premises. The VA was accompanied by staff persons in the community to ensure his/her safety. The VA relied on formal and informal support to identify dangerous situations, respond to emergency situations, and required help to maintain his/her health and personal safety. The VA’s plans did not identify any risks for sexual abuse. The VA’s Client Annual Plan stated that the VA had a history of inaccurately reporting incidents. This included that the VA would call 9-1-1 and ask to go to the hospital when s/he felt like staff persons were not paying enough attention to him/her. DP1 and the day program’s Internal Vulnerable Adult Report provided the following information: · On May 17, 2023, the VA told a day program staff person (DP2) that on the Friday prior (May 12, 2023), a facility staff person touched his/her genital area and lower back. The VA told DP2 that the incident happened in the living room and that no one else saw it. The VA said that s/he “did not know” the staff person’s name but also said that the staff person who touched him/her “only worked on Fridays.” (Note: Based on these details and a description the VA provided of the staff person, the SP was determined to be the staff person.) When the VA was asked if this occurred when the SP assisted him/her with cleaning or wiping his/her genital area, the VA replied, “No.” The VA then told DP2 that after the incident occurred, s/he called law enforcement to his/her house and kicked the law enforcement officer (LEO) when the LEO tried to get him/her into the ambulance. The VA was then transported to the hospital. · DP2 then told DP1 about the conversation s/he had with the VA. · DP1 stated that the VA could be a “false” reporter but that there was “truth to [what the VA said] at times.” The VA may also “embellish” the reports s/he made. However, this incident was not similar to any past incidents regarding the VA. The VA provided the following information: · The VA said that a staff person (who the VA did not identify by name but provided a description that matched the SP), who worked every Friday, “grabbed” him/her “everywhere.” The VA demonstrated by standing up and grabbing his/her genital area and grabbing the back and front of his/her pants. The VA stated that the SP did this more than once and on different days. · During one of the incidents, the R was in the living room and saw what happened. The R told the VA that “[the SP] was teasing [the VA].” · The VA could not remember if s/he called law enforcement and said that s/he did not tell his/her family members what happened because it was “private.” P1, P2, the R, and the facility’s Investigation Report provided the following information: · On May 20, 2023, a staff person (P3) told P1 that in the morning, P3 overheard a phone conversation between the VA and the FM. The VA told the FM that a staff person was “teasing” him/her about his/her genital area. After the VA’s phone call, P3 spoke with the VA. The VA told P3 that the “Friday staff” that worked in the “afternoon” touched the VA’s genital area and was “teasing” the VA. The VA told P3 the incident took place in the dining room. P3 then called and told P1. · On May 20, 2023, in the afternoon, P1 went to the facility and spoke with the VA about what P3 overheard. When P1 talked to the VA, the VA pointed between his/her legs and said, “Staff yesterday,” (Sunday, May 19, 2023) but was not able to name the staff person. P1 asked the VA twice, “Did a staff touch you?” The VA replied, “No,” and that the staff person was “teasing [him/her].” P1 asked the VA a third time and the VA replied that the staff person was “teasing” him/her and that the staff person “touched” the VA. The VA then pointed between his/her legs. P1 asked the VA where the incident happened, and the VA said in the living room. P1 then asked again if it happened in the living room or dining room. The VA again said the living room and that the R was there. · P1 said the SP worked both Fridays. (May 12 and 19, 2023) · P1 stated that the VA had the ability to accurately report including that the VA would be able to provide the same information to someone when asked at a later date. The VA also had a “habit” of contacting 9-1-1 “for attention” and the majority of the calls to 9-1-1 were due to the VA’s “behaviors tantrums.” · P2 said that on May 19, 2023, s/he worked at the facility and was not aware of the incident. When P2 arrived at approximately 10 p.m., the SP told him/her that the VA called law enforcement and was at the hospital. P2 said that at approximately 10:20 p.m., s/he received a call from the hospital and was told, “The [VA] was at the hospital and was concerned about a staff kicking [him/her],” Because the SP was still at the facility, P2 gave the phone to the SP. The VA returned home later that night. · P2 said that the VA had never told him/her about concerns with staff persons but that the VA had a history of providing inaccurate information and had” lied” in the past. P2 provided an example that one week prior, s/he had given the VA medicine, but the VA told the day program s/he spit out his/her medicine and that P2 did not notice. P2 then asked the VA if s/he spit the medications out and the VA said, “Sorry [and that] it did not happen.” · The R said on an unknown date that she was in the living room with the VA and the SP, when they were “joking.” The VA said that the SP hit the VA in his/her genital area, but the R did not see that happen and did not see the SP touch the VA anywhere. The VA then called 9-1-1 because s/he “thinks the [VA] lied because [s/he] liked to go to the hospital.” Law enforcement records and a law enforcement officer (LEO) provided the following information: · On May 19, 2023, the VA called 9-1-1 and told them that s/he scraped his/her hand on asphalt causing his/her hand to bleed and that s/he wanted to go to the hospital. When asked by law enforcement officers “why [s/he] wanted to go to the hospital, [the VA] pointed to [his/her] hand and mentioned that [s/he] did not like the food [s/he] was given at the home.” · On May 22, 2023, the VA called 9-1-1 and said that on May 19, 2023, at 9 p.m., a staff person (who was not named) punched him/her in the genitals and then later said that the staff person touched him/her inappropriately. · The LEO stated that s/he was “super familiar” with the VA and the VA constantly called 9-1-1 because s/he liked to go to the hospital. The SP provided the following information: · The SP worked weekdays (Monday-Friday) from 8 a.m. to 2 p.m. On Fridays, the SP worked two shifts, with the second shift from 2 to 10 p.m. · The SP stated that on May 12, 2023, the VA had his/her pants on inside out. The SP told the VA and asked him/her to go change his/her pants. The VA said that s/he did not need help from the SP. The SP denied touching the VA’s genital area. However, the VA hugged the SP “twice” on May 12, 2023. · The VA had a history of calling 9-1-1. The SP stated that “when things get difficult for [the VA],” the VA called 9-1-1 so s/he could go to the hospital. On May 12, 2023, the VA called 9-1-1, and law enforcement arrived and took the VA to the hospital. The SP did not know what the VA told 9-1-1. Later that night, the hospital called to ask if the VA “was kicked or molested by a roommate” because that was what the VA told the hospital. The SP replied that there had been “no fight in the house.” · On May 19, 2023, the VA took the phone outside. Soon after, law enforcement arrived and took the VA to the hospital. The G stated that the VA had not told him/her about any incident. The VA had the ability to accurately report incidents unless s/he “wanted something.” The VA learned that if s/he did not get his/her way that s/he could go to the hospital. The G said that the VA attended a class regarding “inappropriate touching” at his/her day program the day before the incident was reported and “used that to get [his/her] way.” The FM stated that on June 4 or 5, 2023, the VA told him/her that a staff person, who the VA did not name, “kept touching [the VA] on [his/her] stomach, privates, and butt and that [s/he] did not like that.” The VA told and showed the FM that the staff person’s hands were “flat” when s/he touched the VA on his/her lower stomach and on his/her back near his/her “butt.” The staff person did not poke or pinch him/her. The FM stated that the VA had a “touch sensitivity” and that “the staff might have been trying to play with the [VA]” and the FM “did not think it was sexual at all.” The CM stated that s/he believed that the VA had the ability to provide accurate information and that the VA was “very truthful.” Facility documentation showed that P1, P2, P3, and the SP were trained on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On May 17, 2023, the VA told DP2 that a staff person touched him/her on his/her genital area and lower back in the living room and that there were no witnesses. The VA said the incident happened last Friday (May 12, 2023) and that the staff person worked only on Fridays. On May 20, 2023, the VA told P1 and P3 that the incident occurred “yesterday” (May 19, 2023), that the incident happened in the dining room and the living room, and that the R saw it. P1 asked the VA what happened, and the VA pointed to his/her genital area. The VA demonstrated to this investigator by grabbing his/her genital area and grabbing the front and back of his/her pants. The VA told P3 that the “Friday staff” that worked in the “afternoon” touched the VA’s genital area and was “teasing” the VA. The R stated that s/he was in the living room and that the SP and VA were “joking” and that s/he did not see the SP touch the VA anywhere. The VA showed and told the FM that the SP used “flat hands” and touched his/her lower stomach and back. The FM stated that the VA had a “touch sensitivity” and that “the staff might have been trying to play with the [VA]” and the FM “did not think it was sexual at all.” The VA was not able to name the staff person to any person but gave consistent descriptions that matched the SP and the SP worked on May 12 and 19, 2023. However, given the inconsistent information provided by the VA regarding the date, the location, and witnesses to the incident; that the SP denied that s/he had sexual contact with the VA; and that there was no other information to support or refute the allegations, 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). Action Taken by Facility: The facility conducted an interval review and determined that their policies and procedures were adequate and followed at the time of the incident. The SP was removed from the VA’s home but continued to work at other licensed facilities within the company. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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