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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: 1064760-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) sent sexually inappropriate pictures of his/her genitals to a vulnerable adult (VA) after the VA discharged from the facility. During the investigation, it was also reported that the VA was sexually assaulted at the facility. Date of Incident(s): Prior to April 4, 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 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 four interviews conducted with the VA, the SP, a facility management person (P1) and a facility staff person (P2). Although this investigator contacted the VA’s case manager (CM), the CM did not respond to requests to be interviewed. The facility provided intensive residential treatment and crisis stabilization services to adults who had been diagnosed as having a serious mental illness. Length of stay in the crisis stabilization program ranged from one to ten days and in the intensive residential treatment program up to 90 days with reauthorization for individuals requiring longer lengths of stay. The VA’s Treatment Plan showed that the VA was “artistic” and had plans to “manage [his/her] depression and anxiety better.” The VA’s Diagnostic Assessment showed that the VA previously engaged in “substance [use]” and was diagnosed with “major depression” and anxiety. The VA’s Discharge Summary, written by the SP, showed that the VA discharged from the facility on April 28, 2023. P1 said that on an unspecified date in the middle of March 2024, the facility received a grievance, related to the VA, from the CM and that the CM assisted the VA with writing the grievance. The content of the grievance was that the SP sent sexually inappropriate photographs of his/her genitals to the VA through email after the VA discharged from the facility and that the SP and the VA communicated through email after the VA discharged from the facility. P1 said that while the VA received services from the facility, P1 was not made aware of any concerns between the SP and the VA and P1 did not have any concerns related to the SP’s employment. P1 said that the VA was “very honest” in terms of being able to provide information. The VA provided the following information to this investigator: · While the VA was at the facility (approximately April and May 2023), the SP “kept everything professional” with the VA. The VA denied that any sexual activity occurred at the facility. The VA did not mention anything about being sexually assaulted. · A few days after the VA was discharged from the facility, the VA realized that the SP sent the VA an email the day before the VA discharged from the facility. The content of that email was the SP asking the VA what his/her plans were after discharge. · About a week later, the content of the email messages from the SP changed, in that the SP began sending “naked” picture of his/her genitals and other communication, but the VA did not remember the content and did not remember how s/he responded to the SP. At some point, the VA told the SP that s/he was going to focus on his/her “mental health.” The VA asked the SP to stop send emails to the VA and the SP complied with that, but then in February 2024, the SP sent another email to the VA that said, “I know we left on bad terms.” The grievance, written by the CM with input from the VA, stated that the VA expressed concerns that a staff person (the name of the SP was not identified) who was the opposite gender as the VA, “tried to sexually assault” the VA while the VA was at the facility and “harassed” the VA by email “while” the VA was at the facility and after the VA discharged. As a result of receiving the grievance, P1 provided a written response to this investigator, reviewed documentation, and was not able to determine that anything happened because the VA “did not bring any of these concerns about [the SP] to me while [s/he] was at the facility.” In addition, P1 called the VA to ask questions about the alleged sexual assault and obtain the name of the person in the report. The VA told P1 the SP’s name and when the VA was asked about the alleged sexual assault, the VA said, “[The SP] was staring at me in [his/her] office when I discharged.” In addition, the VA provided P1 with email communication between the VA and the SP. The CM did not respond to requests to be interviewed. The VA provided this investigator with email communications between the VA and the SP. The following is a summarization of those emails: · On April 27, 2023, the SP sent an email that said, “You have one night here left, what will your decisions be?” The following day, the SP sent the following email to the VA, “I am happy with the decision that you chose to make. I’m sure it was not an easy one, but it was a good step forward for you and your journey. Please take care and let me know if there is anything else that I can do to assist you.” · On May 3, 2023, the VA responded to the SP saying, “I don’t know why I’m just seeing this.” · On May 4, 2023, the VA sent an email to the SP (it was not known what initiated this because that portion of the email communication was not shared with this investigator) saying, “Yesss please,” and “I’ll let you do whatever,” and the SP responded, “Don’t give me that power if you don’t know what you’re getting into. What if I choke you unconscious?” When the VA responded, “This isn’t fun anymore,” the SP said, “Okay. I apologize if I have gone too far or made things weird.” · On May 7, 2023, the SP emailed a picture of his/her genitals to the VA. The VA responded, “Wow [you] look so good [daddy/mommy] I want that all in my ass.” The VA sent excerpts of his/her email communication with the SP to P1, which included the following: · On May 6, 2023, the SP sent an email to the VA, which stated, “Let me see all of you touching yourself and I’ll tell you what I would do.” The VA responded that the SP would “have to wait for the video.” Words, used by the SP included, but were not limited to: “fuck your brains out” and the VA saying, “I wish I knew you [were] like this I would always wanted to have meetings with you lol.” · On June 12, 2023, the SP sent an email to the VA, which stated, “Not sure if you are still getting these or not, but I hope everything worked out with your housing and things keep looking up for you. If you want to chat about anything or want some more expert advice, please let me know. If you really would like me to just leave you alone though, I would appreciate a message letting me know and I won’t bother you again.” · On February 7, 2024, the SP sent an email to the VA which stated, “Hey, I know we ended on a bad note, but I wanted to check in and see how things are going. The door is open if you would like to talk about anything or want some support.” The facility provided “Professional Boundaries and Ethics” training to staff persons, which stated that “[Staff persons] must maintain a balance between being supportive, empathetic, and understanding, yet professional at the same time.” The facility had an Employee Standards of Conduct which stated, “We have no personal, sexual, or social relationship with a current or former client of service.” P2 did not have concerns related to the SP’s work performance and had not seen any inappropriate interactions between the VA and the SP. P2 also said that the VA, or any staff person, did not bring any concerns forward related to the SP’s work performance while the VA received services at the facility. When P1 learned of the grievance, s/he talked to the SP. The following was information from that discussion: · While the VA received services at the facility, the VA “was trying to meet in person” for sexual acts with the SP, but the VA “did not like my responses” and “did not want to maintain contact.” · While the SP was completing the VA’s discharge, the VA “offered to do sexual acts” with the SP and the VA “wouldn’t leave until I gave contact information.” · After the VA left the facility, the SP emailed the VA “to see how they were doing.” The SP and the VA communicated via email for about one week after the VA discharged from the facility and the content of those emails “were made both ways that were sexual.” There was no mention of the naked pictures of the SP’s genitals that were emailed to the VA. The SP provided the following information to this investigator: · While the VA received services at the facility, the SP and the VA had a “professional relationship.” · When the facility decided that the VA met the criteria to be discharged, the SP was the person that informed the VA of that decision. Because the VA wanted to “remain at the program,” the VA “made an offer to engage in sexual acts” with the SP. The SP told the VA that was “not appropriate.” Because the VA continued to ask and “would not leave the space,” the SP did eventually “cave” and provided his/her email address to the VA. After the VA discharged, the SP did not tell this to management because the SP was “ashamed.” · About a week after the VA discharged from the facility, the VA sent an email to the SP “trying to get me to meet up in person.” The SP again told the VA that s/he was “not comfortable with that.” When the SP said that to the VA, the VA wanted to know what the SP was “comfortable with,” which led to VA “describing various situations,” some of which were sexual, but the SP did not provide detailed information, to the SP and the SP “sharing details about those things.” · On some days, the SP chose to “decline” questions posed by the VA, but on other days, the SP “engaged in a little bit more by providing details” about certain sexual acts the SP and the VA could engage in, but the SP did not provide more detailed information. The SP stated that his/her actions were inconsistent with the training s/he was provided and that staff persons “were trained to not have communication with clients after they have discharged from the program for any reason, other than for reasons related to their treatment.” · After the VA and the SP exchanged email communication for about one week, the interactions ended because the VA “continued to press me to meet in person and I would not budge on that.” However, the SP acknowledged that s/he sent another email to the VA on February 7, 2024, because the SP wanted to know how the VA was doing, but the VA did not respond to that email. · The SP denied any type of a sexual relationship with the VA and denied sending naked pictures of his/her genitals to the VA. The facility’s training records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act (August 31, 2022, and again on August 31, 2023). Although there was no specific training that outlined that the SP was trained on the VA’s specific care plans, documentation from the facility showed that all staff persons were trained on the “specific needs of each client the staff person might serve.” In addition, the SP received training related to boundaries and ethics on February 8, 2023. Conclusion: Regarding Sexual Abuse: According to the grievance, received by P1 in mid-March 2024, the VA stated that a staff person tried to “sexually assault” the VA while the VA was at the facility (around April and May 2023) and “harassed” the VA via email while at the facility and after discharge. The VA did not name the staff person at that time. When P1 learned of the grievance, s/he called the VA, who confirmed that the staff person the VA was referencing was the SP and when P1 asked the VA about the alleged sexual assault, the VA said, “[The SP] was staring at me in [his/her] office when I discharged.” When this investigator interviewed the VA, the VA did not say anything about a possible sexual assault, stated that s/he did not have sexual contact with the SP, and that the SP “kept everything professional” with the VA while the VA received services at the facility. In addition, P1 and P2 each said that they did not have concerns related to the SP’s work performance while the VA was at the facility and that they did not have any information that the VA was sexually assaulted by the SP or any staff person. The SP denied any sexual contact with the VA. Given that the VA described the alleged sexual assault to P1 as the SP “staring” at him/her and did not provide further details and that the VA and the SP each told this investigator that they did not engage in sexual contact, 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: The VA stated that the night before the VA discharged from the facility, the SP sent an email to the VA about the VA’s plans after discharge, but the VA did not see the email until after s/he discharged from the facility. After that, the SP sent naked pictures of his/her genitals to the VA and information from the investigation showed that the SP sent sexually inappropriate comments to the VA regarding sexual acts. The SP stated that the night before the VA discharged from the facility, the VA tried to extend his/her stay at the facility by offering sexual acts to the SP. Even though the SP stated that s/he declined those offers and provided his/her email address to the VA, the SP did not tell management about the incident because the SP was “ashamed,” and the SP knew that his/her actions were inconsistent with the training provided by the facility. Although the SP denied sending naked pictures of his/her genitals, the SP told this investigator and P1 that s/he sent inappropriate sexual comments to the VA and email excerpts showed that the SP sent naked pictures of his/her genitals to the VA and sexually inappropriate messages to the VA after the VA discharged from the facility. Although the SP’s behavior was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and likely hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship, given that there was no information that the VA and SP had inappropriate boundaries while the VA was receiving services, that the VA and the SP each denied anything other than a professional relationship while the VA resided at the facility, that the content of the SP’s email the night before the VA was discharged was not sexual, and that the SP sent the emails with the picture of his/her genitals and sexual content after the VA was no longer receiving services from the facility, there was not a preponderance of the evidence whether the SP failed to provide the VA with reasonable and necessary care and services. 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 although policies and procedures were adequate, the SP did not follow policies “related to interactions with clients” and that no additional training was needed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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