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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: 1120603-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that two vulnerable adults (VA1 and VA2) left the facility and engaged in sexual contact with a community person (CP) while two staff persons (SP1 and SP2), who were supposed to be awake, slept. Date of Incident(s): February 13, 2024 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 17, paragraph (a): 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 March 13, 2024; from documentation at the facility, and law enforcement records; and through ten interviews conducted with VA1, VA2, the CP, SP1, SP2, a facility client (C), a facility management staff person (P1), VA1’s legal representative (G1), VA2’s legal representative (G2), and VA1’s case manager (CM1). Although this investigator contacted VA2’s case manager (CM2), CM2 did not respond to requests to be interviewed. VA1, VA2, and the C lived at the facility. The facility was in a complex with several other twin homes. Each of the twin homes had a paved driveway that led to a back area where there were multiple garages used by the residents in the twin homes. The garages were visible from the inside of the facility. In addition, each of the twin homes had grass yards. A laundry room/office was on the lower level of the facility. Facility documentation showed that some of VA1’s diagnoses included generalized anxiety disorder, post traumatic-stress disorder, and a mild developmental disability. VA1’s Annual Plan showed that s/he enjoyed cleaning and was interested in volunteering in the community. The plan showed that VA1 had three hours of unsupervised time in the community. VA1’s Self-Management Assessment showed that s/he was diagnosed with asthma. VA1’s Individual Abuse Prevention Plan showed that VA1 “had relationships in the past” and had a “lack of understanding of sexuality.” The plan also stated that VA1 had a “long history of report[ing] of sexual abuse/rape dating back to childhood, with strangers and or family,” and “may not understand” when s/he was in an “abusive situation.” VA1’s documentation did not identify the type of supervision to be provided to VA1. VA2’s Self-Management Assessment showed that s/he enjoyed using “soft items like blankets and stuffed animals” when VA2 was “feeling overwhelmed.” The plan showed that VA2’s diagnoses included borderline personality disorder, adjustment disorder, and autism. VA2’s Individual Abuse Prevention Plan showed that s/he “struggles with understanding the dangers of meeting people online.” As a result, VA2’s “internet access is limited and [s/he] should not be given the Wi-Fi access in the home.” The plan further added that VA2 “may false report sexual encounters” with persons that were the opposite gender as VA2. A review of VA2’s plans did not identify unsupervised time in the community or within the facility, but his/her Self-Management Assessment stated that VA2 “understands it is important to notify staff [persons] before leaving [the facility] or group in the community.” The plans did not outline the type of supervision to be provided to VA2. The facility’s Investigation Report and Summary provided the following information: · When VA1 was interviewed, VA1 said that the CP was VA2’s “friend” and that VA1 and VA2 left the facility around midnight to meet the CP, who was parked “by the garage.” While they were together, “they smoked” with the CP and the CP “started touching them.” The CP sat in the driver’s seat, VA1 sat in the front seat, and VA2 sat in the back seat. VA1 stated that the CP “tried to have sex with” VA2 from the front seat by reaching over to VA2 who was in the back. VA1 and VA2 left the CP and went back into the facility about three hours later. SP1 “woke when they came in,” and “the other staff [SP2] was sleeping in the office.” At an unspecified time, the CP knocked on the facility’s door and stated that VA1 or VA2 “stole” the CPs vape. Later, the CP returned to the facility with law enforcement (discussed later in the report). VA1 was not asked what SP1 and SP2 were doing when VA1 and VA2 left. · When VA2 was interviewed, s/he stated that VA1 and VA2 were “hanging out” and that they “messaged” the CP on VA1’s phone and that they “met” the CP outside the facility at about 3 a.m., but the date was not provided. VA2 provided a description of where everyone sat that was the same as the description provide by VA1. When they got to the CP’s car, they “smoked” and the CP “got sexual” and wanted VA1 and VA2 to “stroke it,” so VA1 and VA2 “took turns.”. VA2 stated s/he did not want to “do more” so at about 6 a.m., VA2 said that s/he needed to use the restroom and that VA1 “needs” to come with VA2. When they got inside, SP1 “confronted” them and stated that s/he “knew they snuck out” around 3 a.m. VA2 also stated that SP1 was “sleeping” (the review did not say when this was) and that SP1 and SP2 “always sleep” during the overnight shift. · When the C (the C did not leave the facility) was interviewed, s/he said that VA1, VA2, and the C were “hanging out” in VA1’s bedroom and that VA1 and VA2 “were trying to find weed or vape” and that they asked the C if s/he wanted to go with VA1 and VA2, but the C “declined.” The C stated that VA1 and VA2 left the facility at about 3 a.m. and when that happened, SP1 was “sleeping on the couch” and at some point, the C “called” SP1’s name “a couple times and told [him/her] they went out.” When that happened, SP1 told the C to “go after them.” The C told SP1, “No,” that was not the C’s “job.” After that, SP1 “fell back asleep.” About 20 minutes later, the C went to sleep. At an unspecified time, the C went to the office and after turning on the light, the C “startled” SP2, who was sleeping. VA2 told the C that VA1 and VA2 remained outside with the CP for about three hours before returning inside the facility. · The review also noted that a “little” before 7 a.m., a facility management staff person (P2) received a text message from SP1, which stated that at about 3 a.m., VA1 and VA2 went out the back door and SP1 thought they were going out to smoke, “but they did not come back in.” The review stated that VA1 and VA2 came back inside the facility, but the time was not identified. · Shortly after the incident, SP1 notified his/her supervisor that SP1 was “resigning” and further attempts to obtain information from SP1 were unsuccessful. When SP2 was interviewed, SP2 stated that s/he was in the office and that about 15 minutes after VA1 and VA2 left, SP1 told SP2, at about 3 a.m., that VA1 and VA2 had left the facility without supervision. SP2 also said that s/he “drove around” for 10 to 15 minutes looking for VA1 and VA2 but did not check behind the garages because SP2 thought that SP1 had checked that area. About 10 to 15 minutes after SP2 returned from looking, VA1 and VA2 had returned to the facility. · Information from the investigation showed that SP1 sent a text message to P1 that said, “I tried to cover [his/her] ass but I’m not, [s/he] was downstairs in the office the whole time. I let them go to smoke and I went downstairs to use the bathroom came back up and didn’t see them. I went out to look for them, didn’t see them [and] by the time I came back they were back in the house. I dealt with the whole situation by myself.” · The facility’s review determined, “It is more likely than not that both staff [persons] were asleep at the time the persons served went out.” The review also noted that SP1 and SP2 were no longer employed by the facility. VA1 provided information to this investigator that was like the information s/he provided in the facility’s Investigation Report and Summary but added that it was VA2’s idea to leave the facility and meet the CP and that it was VA2 that used his/her phone to give the CP the address to the facility. When VA1 and VA2 left the facility at about 1 a.m., SP1 was sleeping on the couch in the living room and SP2 was sleeping in the office/laundry room. VA1 told this investigator that when VA1 and VA2 returned to the facility about one hour later, SP1 was sleeping on the couch and had a blanket “over” his/her head and SP2 was sleeping in the office. When VA1 and VA2 were in the CP’s car, VA1 did not see anyone come outside to look for VA1 or VA2. VA2 provided information to this investigator that was like the information s/he provided in the facility’s Investigation Report and Summary but added that VA1 and VA2 used VA1’s phone to communicate with the CP and that VA1 asked the CP to come to the facility, but that VA1 asked VA2 to “type in the address.” When VA1 and VA2 left at about 3 a.m., through the back door, SP1 was sleeping on the couch and SP2 was in the office with the door closed and locked. VA2 believed that SP2 was sleeping because s/he knocked on the door and SP2 did not answer and because VA2 “heard” SP2 “snoring.” Later in the interview, VA2 said that they left at midnight and returned at 3 a.m. While VA1 and VA2 were in the CP’s car, VA2 did not see anyone come outside to look for VA1 or VA2. When VA1 and VA2 decided to come back inside the facility, VA1 went in first and VA2 came in a “couple of minutes later.” Once inside, SP1 “confronted” VA2 and stated that s/he knew that VA1 and VA2 had left and SP2 was “walking around” on the lower level looking for the VAs, but VA2 did not see SP2. VA1 and VA2 each denied to this investigator that they took the CPs vape. The C provided information to this investigator that was like the information s/he provided for the facility’s Investigation Report and Summary but added that before VA1 and VA2 left, the C saw VA2 using his/her iPad. The CP provided limited information to this investigator but stated that VA1 and VA2 were in the CP’s car, by the garages, for one to two hours and during that time, the CP did not see anyone looking for VA1 or VA2. Although the CP was asked about alleged sexual contact with VA1 and VA2, the CP did not provide a response. The CP also stated that at an unspecified time, after VA1 and VA2 returned to the facility, the CP went to the door because the CP believed that VA1 or VA2 took the CPs vape. When the CP knocked on the door, the CP was “greeted by staff [persons].” The CP asked the staff person to check if VA1 or VA2 had the CPs vape. When the staff person told the CP that VA1 or VA2 did not have the vape, the CP called law enforcement, who told the CP that they would meet him/her at the facility so law enforcement could ask VA1 and VA2 about the vape. The law enforcement Incident Report showed that the CP called law enforcement at 6:07 a.m., on February 13, 2024. The report stated that law enforcement talked with “[female/male],” who “denied taking” the vape. P1 provided the following information to this investigator: · On an unspecified date, P1 talked to VA1 and VA2. VA1 told P1 that they met the CP by using VA1’s social media account. VA1 told P1 that they were gone for 30 to 40 minutes and that SP1 and SP2 were sleeping when they left, that SP1 was awake when they returned, and that SP2 remained asleep when they returned. VA2 also told P1 that they were gone between 30 and 40 minutes and when they left, both SP1 and SP2 were sleeping and when they returned, SP1 was “awake” and “sitting in the house,” and that SP2 was sleeping in the office. · When P1 talked to SP1 and SP2 about the incident, they both denied sleeping. · When P1 was asked about VA1’s ability to provide information, P1 stated that it was “iffy” and that VA2 had a history of “storytelling.” SP1 provided the following information to this investigator: · SP1 did not remember the date, but at about 3 a.m., VA2 asked SP1, who was “cleaning” at the time, and if s/he and VA1 could go outside and smoke a cigarette. SP1 said that was fine. At the time, SP2 was in the office, but SP1 did not know what SP2 was doing. SP1 said that s/he previously saw SP2 at about midnight. · After VA1 and VA2 went out to smoke, SP1 went to the lower-level bathroom to use it and to clean it. When SP1 realized that about 20 minutes had passed since SP1 saw VA1 and VA2, SP1 went outside to the front and back yards, to look for VA1 and VA2, but did not see them. When SP1 could not find VA1 and VA2, SP1 called both of their phones, but neither answered. At 3:46 a.m., both VA1 and VA2 came back inside. SP1 knew that was the time because SP1 looked at his/her phone when they came in. While SP1 looked for VA1 and VA2, SP1 did not notify SP2 that they were gone because “my co-workers don’t help me.” SP1 denied sleeping. SP2 provided the following information to this investigator: · While SP2 was in the office at about 3 a.m. “reading reports,” SP1 told SP2 that VA1 and VA2, who had gone out the back door to smoke earlier, were “not up there.” SP2 went into a “panic” and began looking outside for VA1 and VA2 for 10 to 15 minutes but did not see them. When SP2 got back from checking the yard and from driving to locate the VAs, s/he went back to the office. · At about 4 a.m., SP1 told SP2 that VA1 and VA2 had returned to the facility. After VA1 and VA2 returned, SP2 checked on VA1 and VA2 every hour. SP2 denied sleeping. G1 stated that although VA1 had unsupervised time in the community, VA1 was not supposed to access the community unsupervised during overnight hours and that VA1 had a history of leaving without supervision. G1 also stated that VA1 did not have the ability to provide reliable information and had a history of “lying.” CM1 stated that VA1 had a history of leaving without supervision, that VA1 had unsupervised time in the community, but that it was not supposed to occur during the overnight shift. When CM1 was asked to provide information about VA1’s ability to provide information, CM1 stated, “It’s not accurate.” CM1 also stated that VA1 did not require staff persons to check on him/her during the overnight hours because VA1 had not previously left during the overnight shift. G2 said that VA2 had a history of leaving without supervision, that VA2 “can lie,” and that VA2 had 15 minutes of unsupervised time in the community. The facility’s training documentation showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and on VA1’s and VA2’s support plans. Conclusion: VA1’s Annual Plan showed that s/he had three hours of unsupervised time in the community. VA2’s plans did not identify whether VA2 had unsupervised time in the community or within the facility, but G2 stated that VA2 had 15 minutes of unsupervised time in the community. The plans did not identify the type of supervision that was to be provided to VA1 and VA2 during overnight hours. The overnight shift was staffed with two awake staff persons. SP1 said that at about 3 a.m., the day of the incident, VA2 asked SP1 if s/he and VA1 could go outside to smoke a cigarette. About 20 minutes later, SP1 realized that VA1 and VA2 had not come back inside. SP1 went outside to the front and back yards to look for VA1 and VA2 but SP1 did not see them. SP1 stated that s/he did not tell SP2 that VA1 and VA2 were not in the facility but SP2 stated that SP1 told him/her around 3 a.m. and that SP2 also searched for VA1 and VA2. According to SP1, VA1 and VA2 came back into the facility at 3:46 a.m. There was conflicting information regarding the incident from everyone interviewed. In addition, VA1 and VA2 each provided different information to different people. VA1 and VA2 each stated it was the other who contacted the CP. VA1 told facility management that VA1 and VA2 left the facility around midnight to meet the CP, but VA1 told this investigator that VA1 and VA2 left about 1 a.m. VA2 and the C each stated that VA1 and VA2 met the CP outside the facility at about 3 a.m. VA1 and VA2 each stated they were with the CP about three hours but then each told P1 they were with the CP for 30 to 40 minutes. The CP stated VA1 and VA2 were with the CP for one to two hours and SP1 said the VAs left at 3 a.m. and returned at 3:46 a.m. VA1, VA2, and the C each stated that SP1 and SP2 were sleeping when they left, but VA1 stated that SP1 woke up when VA1 and VA2 entered back into the facility but then told P1 that SP1 was awake when they returned. VA1 and VA2 each stated that they had sexual contact with the CP, VA1 stated the CP “starting touching” the VAs and VA2 stated that the CP wanted VA1 and VA2 to “stroke it” and they “took turns.” The CP did not provide information regarding sexual contact. Although VA1 and VA2 went to the garage area of the facility without supervision and allegedly had sexual contact with the CP, information was conflicting and inconsistent regarding how long the VAs were gone and if sexual contact occurred. SP1 and SP2 denied sleeping during their awake shift and had reason to minimize their actions but SP1 provided consistent information regarding the interaction with the VAs at 3 a.m. when they wanted to go outside to smoke. In addition, information showed that VA1 and VA2 might not be accurate when providing information. Even though VA2 had only 15 minutes of unsupervised in the community and VA1 had three hours unsupervised time that was not supposed to be overnight, given the aforementioned conflicting and inconsistent information, that the VAs remained on the facility property, and that there was not information that either VA was injured, there was not a preponderance of the evidence whether there was a failure to provide the VAs with reasonable and necessary care and supervision.
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’s Investigation Report and Summary showed that although policies and procedures were adequate, they were not followed because staff persons “did not follow responsibilities outlined in the DSS job description to remain awake and alert to the individual’s behavior/physical changes and notify supervisor as appropriate.” SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No action taken at this time.
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