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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: 1072143-H_CRS (Home and Community-Based Services-Community Residential Setting) 1072139-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) engaged in sexual contact with a vulnerable adult (VA). Date of Incident(s): December 17, 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 December 29, 2023; from documentation at the facility; and through five interviews conducted with the VA, facility staff supervisors (P1-P2), the VA’s case manager (CM), and the SP. Facility documentation showed the VA liked going into the community, swimming, painting, and playing video games. The VA was independent with most of his/her activities of daily living, but needed reminders to dress in “appropriate[ly]” sized clothing. The VA “really” liked attention from other people, and enjoyed being a “jokester,” however some interactions could become “too intense” for other persons. The VA had recently started meeting community persons online, and needed support to develop “reasonable boundaries” while pursing relationships. The VA was diagnosed with developmental disabilities, depression, and fetal alcohol syndrome, as well as multiple physical health concerns. The VA was subject to guardianship. The facility completed an Internal Review which provided the following information: · On the overnight of December 16-17, 2023, there was allegedly a sexual interaction between the VA and the SP. The SP allegedly exposed him/herself to the VA, and they engaged in sexual contact, both manual stimulation and oral sex. · The VA said there were two incidents of sexual contact; one occurred while in the living room common area, and the other in the VA’s bedroom. The VA said after the sexual contact in his/her bedroom both the SP and the VA returned to the living room and the SP proceeded to “fondle” the VA on the couch. · The SP was removed from the facility schedule and spoke with the facility regarding the incident. The SP said the VA made “sexually inappropriate verbal approaches” towards the SP throughout his/her shift on December 16-17, 2023. The SP said the VA told the SP s/he was attractive and wanted the SP to “take [the VA’s] virginity.” The SP attempted to verbally redirect the VA, and around 5 a.m., the VA came downstairs wearing only underwear, and the SP requested the VA put on pants. The VA continued to make sexual comments about him/her being aroused, and asked the SP to assist the VA as s/he had spilled something in his/her bedroom. The SP went upstairs to assist the VA, however when the SP went into the VA’s bedroom the VA was laying on the bed. While the SP was cleaning the spilled item, the VA grabbed the SP by his/her genitals outside of his/her pants. The SP moved away from the VA and requested the VA not touch him/her. The SP attempted to finishing cleaning the item, but the VA grabbed the SP’s pants, and pulled the SP onto the VA’s bed, and put his/her hand down the SP’s pants and touched the SP’s genitals. The SP moved away from the VA and left the VA’s bedroom, and there was no further sexual contact between the VA and SP. · The SP said his/her “personal integrity was violated.” The SP said s/he did not document the incident or share the information with staff persons who worked the shift after the SP. The SP said s/he did not want the VA to get in trouble and did not want to make “waves.” The SP said s/he was “overwhelmed” by the situation and was not sure how to respond to it. The VA provided the following information: · The VA said there was incident that happened at night, but was not sure what time. The VA said prior to the incident the VA, a housemate, and the SP were watching a movie, but the housemate left the living room multiple times to do laundry. The VA said s/he decided to go to bed because s/he was tired. However, the SP followed the VA upstairs because s/he needed to clean the bathroom, but came into the VA’s bedroom instead. Once inside the VA’s bedroom the SP shut the VA’s door, and sat down on the VA’s bed. The SP pulled down his/her pants, and asked the VA to “do it again.” The VA said the SP stood up, in front of the door, and the VA got on his/her hands and knees. The SP asked the VA if s/he had ever performed oral sex, and thereafter the VA performed oral sex on the SP. During the sexual contact the SP moved to the VA’s bed, and the SP ejaculated on his/her own clothing. · After describing the above incident, the VA said that while in the living room earlier, the SP asked the VA if s/he had seen genitals and unzipped his/her pants exposing his/her genitals. The SP then placed the VA’s hand on the SP’s genitals and had the VA manually stimulate the SP. The VA said the incident occurred on the couch downstairs and the SP’s bodily fluid was on the couch. The VA also said the SP used his/her fingers and touched the VA’s genitals while they were in the living room. · The VA said that “this happens” at all of the “places” the VA lives, and disliked living at the facility. P1 provided the following information: · P1 was not present for the incident, but spoke with the VA, the SP, a housemate, and the staff person the VA initially talked to about the alleged incident. · P1 said the VA told a staff person the SP made sexual comments to the VA and “coerced” the VA into performing oral sex on the SP. · P1 spoke with the VA and the VA said the SP was downstairs making inappropriate comments, and the SP exposed him/herself to the VA before a housemate walked in the living room. The VA said the SP told the housemate and VA to go to their respective bedrooms. The VA said the SP then went upstairs, near the VA’s bedroom, and started to clean a bathroom. The SP proceeded to go into the VA’s bedroom and the VA performed oral sex on the SP. The VA said the SP’s body fluid was on the VA’s bedspread. After the sexual contact the SP finished cleaning the bathroom, and left the facility at the end of his/her shift. The VA said the alleged incident took place “throughout the night.” · P1 attempted to observe the VA’s bedding, but the VA said s/he spilled milk and food on the bed. · While P1 spoke with the VA about the alleged incident, the housemate, who was limited verbally, looked at the VA and said, “You are an abuser,” and “You are lying.” P1 said s/he had never seen the housemate speak “to that extent.” · P1 said the SP told him/her the VA tried to expose him/herself to the SP, and the SP asked the VA to go upstairs. The VA remained in his/her bedroom the remainder of the night. The SP did not admit to any sexual contact occurring. · P1 said the SP was working his/her first overnight shift, and did not have any concerning interactions while P1 completed training shifts with the SP. · P1 said the VA was not an accurate reporter of information, and had “taken advantage” of staff persons in the past by not providing all of the information about the activities s/he was doing, or told staff persons s/he was able to go on a “date” with community person(s). · P1 said the VA had previously worn “very short shorts” and clothing that showed “a lot of skin.” The VA also had been going on dating websites and exchanged pictures with persons online. · The VA had a history of not trusting persons of the opposite gender and of a specific race. · P1 said the VA declined to have contact with law enforcement, and declined any medical evaluation. P2 provided the following information: · P2 said the SP was a new staff person, and the shift that the alleged incident occurred on was the SP’s first unsupervised shift. The SP told P2 that the VA had made sexual advances toward him/her during the shift, and the alleged incident occurred around 5 to 7 a.m. · The SP was in the living room and the VA was in his/her bedroom. The VA went to the living room and was not wearing pants. The VA made comments about being attracted to the SP, and how the VA wanted the SP to “take [the VA’s] virginity.” The SP attempted to redirect the VA, and the VA went to his/her bedroom. · The VA later asked the SP to assisted him/her with cleaning up some garbage in his/her room. The SP tried to redirect the VA to wait until morning, but eventually assisted the VA in his/her bedroom. The SP went upstairs to the VA’s bedroom, and the VA was laying in his/her bed, and while the SP picked up the garbage the VA continued to make sexualized comments. The SP said while in the VA’s bedroom the VA grabbed the SP’s genital through his/her pants, and pulled the SP by his/her pants onto the VA’s bed. The VA then forced his/her hand down the SP’s pants, and the VA touched the SP’s genitals. The SP told the VA to stop, was able to move away from the VA, and remained away from the VA the remainder of the shift. The SP said the incident was “extremely weird,” but said s/he got up and “put a stop to it,” and told the VA, “That was not okay.” The SP said there was no further sexual contact or approaches from the VA the rest of the shift. · P2 said that the information the SP provided was “believable.” The SP was the only person working during the alleged incident. · The VA had recently started making sexually explicit comments to people, especially staff persons of the opposite gender. The VA was “pretty adamant” in expressing his/her interest in pursuing relationships and sexual acts. · Since moving into the facility, the VA had started engaging in concerning behaviors with unknown community persons s/he met online. The CM said the VA had made a similar allegation previously while living at a different facility, but the VA “recanted” his/her statements. The CM said the VA had become “very focused” on having a significant other and engaged in “risky” sexual behaviors such as leaving the facility with unknown persons s/he met from a dating website. The SP provided the following information: · The SP said an incident occurred on his/her first unsupervised overnight shift at the facility. The SP was the only staff person working and a couple hours into the shift the VA changed clothing. The VA changed into a t-shirt and underwear/short shorts. The VA proceeded to repeatedly ask the SP for assistance, including cleaning his/her bedroom. The SP was interacting with the VA in the facility’s common area and the VA grabbed the SP’s genitals. The SP described the VA as “big,” and “forceful,” and there were no other staff persons or vulnerable adults that witnessed the incident. · The SP said the VA “grabbed on a couple of times,” and the SP tried to explain to the VA without “demeaning [the VA] or hurting [the VA] feelings.” The VA told the SP s/he wanted the SP to “take [the VA’s] virginity,” and the situation made the SP feel “uncomfortable.” The SP felt “violated,” and denied touching the VA in a sexual manner. The SP said s/he tried to redirect the VA after the incident. · The SP said s/he was “novice” so that was why s/he did not contact a supervisor after the incident occurred. · The SP did not provide further information and did not respond to attempts to conduct a follow up interview. LE was contacted during the investigation, however LE did not complete an investigation. P1, P2, and the SP were trained on the VA’s plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: It was reported that on December 16-17, 2024, the SP and the VA had sexual contact. The VA provided descriptions of the alleged sexual contact to this investigator, P1, and P2. Within those descriptions the VA shared details of the alleged incident, however the VA provided some differing information to each. The VA stated that sexual contact occurred in the living room first and then in the VA’s bedroom and also stated that sexual contact occurred first in the VA’s bedroom and then in the living room. The VA told P1 said the SP’s bodily fluid was on his/her bedding, but when P1 tried to observe the bedding, the VA said s/he had spilled milk on the bedding. The VA told this investigator the SP’s bodily fluid were on the SP’s own clothing. Additionally, the VA told this investigator s/he manually stimulated the SP and the SP’s bodily fluid was on the couch, however the VA did not provide information of sexual contact occurring on a couch to P1 or P2. The VA told this investigator that the SP touched the VA’s genitals; however, the VA did not provide that information to P1 or P2. The SP provided mostly consistent information except was inconsistent with information regarding where sexual contact occurred. The SP told P1 and P2 consistently that the VA touched the SP’s genitals in the VA’s bedroom but told this investigator it was in the common area of the facility. The SP said during the shift the VA changed into a t-shirt and underwear/short shorts, repeatedly asked the SP for assistance including cleaning his/her bedroom, and the VA made “sexually inappropriate verbal approaches” toward the SP during the shift. The SP said the VA asked for help cleaning something in the VA’s bedroom, however once inside the bedroom the VA pulled the SP onto his/her bed and reached down the SP’s pants and touched the SP’s genitals. The SP felt violated by the VA’s contact with his/her genitals. The SP denied any other sexual contact with the VA. The SP did not notify a supervisor of the incident immediately. The SP denied touching the VA’s genitals and denied asking the VA to engage in sexual contact. Although the SP had reason to minimize his/her actions, given that the SP denied the allegations, that there was information that the VA did not always provide accurate information, that both the VA and the SP provided differing information, and that there was no further information to confirm or dispute either account, there was not a preponderance of the evidence whether the SP and VA had sexual contact that was intentional with sexual or aggressive intent. 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 and determined that the policies and procedures were adequate, but were not followed as the SP did not document the alleged incident or notify the facility. The facility did not complete additional training with the SP as the SP was no longer employed at the facility. The facility took no further corrective action to protect the persons that received services. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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