|
MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”
License Number and Program Type: 1108472-CRF (Children’s Residential Facility) Investigator(s): Kim Anderson/Van Mulheron Suspected Maltreatment Reported: It was reported that a staff person (SP) kissed an alleged victim (AV) and sat underneath a blanket with the AV. Date of Incident(s): On an unknown date prior to November 23, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 20; and subdivision 15, paragraph (a), clauses (1) and (2): "Sexual abuse" means the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, or by a person in a current or recent position of authority to any act that constitutes a violation of section 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse. Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. Summary of Findings: Pertinent information was obtained during a site visit conducted on January 17, 2024; from documentation at the facility and law enforcement records; and through 13 interviews conducted with six supervisory and administrative staff persons (P1-P6), six staff persons (P7-P11 and the SP), and the AV’s family member (FM). The AV was interviewed by a Law Enforcement Officer and that information is included below. The facility was a residential treatment center for youths ages 12-18 years with substance abuse and mental health concerns. In addition to providing treatment and counseling, the facility had a gym in the basement for residents to use with supervision. The gym had a stage area and staff only restrooms. The facility had six cottages where residents lived. The AV resided in a cottage and upon entry into that cottage was a kitchen. Past the kitchen, were tables for dining and activities and to the right of the tables was a hallway. In the hallway, on the left was a living room which had a television, chairs, sofas, and blankets and on the right side, was a door to a staff office and stairs that lead up to the residents’ bedrooms. In the hallway upstairs, between the bedrooms were two desks where staff persons stayed to supervise the residents overnight. There was a hallway outside of the cottage that connected it to other parts if the facility. The AV’s Client Information stated that at the time of the incident the AV was 16 years old and diagnosed with major depressive disorder and substance use disorder. The AV enjoyed hunting and fishing. The AV “struggled to build and maintain healthy relationships, and one of his/her goals at the facility was to develop healthy relationship skills and friendships.” The AV resided at the facility between September 17 and December 2, 2023. The law enforcement report provided the following information: · On November 28, 2023, at 7:26 p.m., the SP called law enforcement because s/he was having suicidal thoughts and had taken an overdose of medication with alcohol. The SP said that s/he was “fired” from his/her job for “being in a relationship with an underage client,” “kissing an underage client,” and/or “performing oral sex on a 16- year-old [fe/male] client.” (Note: There was approximately a nine-year age difference between the SP and the AV.) The law enforcement officer was unable to obtain additional information due to the SP’s level of intoxication and the SP was taken to a hospital. · A few hours after the SP was admitted to the hospital, the SP provided a statement to a law enforcement officer. The SP stated that in October 2023, after the SP ended a relationship with a community person (CP) unrelated to the facility, s/he and the AV “expressed feelings” for each other and for approximately three weeks the SP and the AV “kissed” each other “daily.” Once in late October, the SP and the AV were kissing in the gym area and the AV asked to go into the staff only bathroom with the SP. They went into the bathroom and the SP performed oral sex on the AV for about a minute but stopped because they were afraid of getting caught. The SP said the relationship with the AV included kissing and passing notes to each other. They continued the relationship and would take walks and pass notes. The relationship continued until about one week prior when the SP was transferred to work with other clients. The SP was then suspended while the facility looked into concerns regarding the SP’s interactions with clients. The SP also said s/he had notes in his/her purse that were from the AV, but they were not collected at the time of the SP’s statement. · On November 29, 2023, a law enforcement officer contacted the facility and spoke to P2. P2 stated that the facility had received information from the CP that the SP had “feelings” for a client at the facility. · On December 1, 2023, a law enforcement officer went to the facility and spoke to P2. At that time, P2 said that there was a recent incident where the SP was seen underneath a blanket with the AV in a group setting. P2 said the SP was moved to a different cottage after the incident and that the SP also requested to be moved to a different cottage. · The law enforcement officer also talked to P1. P1 stated that around November 23, 2023, P7 contacted P1 and told P1 the SP had “feelings” for clients. P1 then met with the SP who “indicated [s/he] was struggling to maintain boundaries with [fe/male] clients. On November 28, 2023, P1 again met with P7 who had screenshots of message where the SP referred to kissing the AV. · The law enforcement officer and P2 met with the AV. The AV denied “feelings” for the SP and denied that they had a “romantic relationship.” The AV said s/he “kissed [the SP] once” and they wrote notes to each other that were usually “have a good day” or something “similar.” The AV no longer had the notes as they were thrown away. The AV denied any sexual contact with the SP or that the SP performed oral sex on him/her. The AV “was emotional during the interview, remained composed but was crying tears throughout.” The AV “strongly denied [s/he] was lying to protect [the SP] and insisted [s/he] was telling the truth.” · On December 5, 2023, the law enforcement officer talked to P7. P7 said that the SP told him/her that s/he “had feelings” for the AV but that “nothing had happened between them.” P7 also text messaged the CP who told P7 that s/he had seen text messages between the SP and the AV that talked about the SP kissing the AV. · On December 12, 2023, the law enforcement officer talked to the CP. The CP stated that s/he saw messages the SP had sent that talked about “having a crush on [the AV] and that [s/he] had kissed [the AV].” The CP provided the text messages to law enforcement who documented that the messages “were consistent with” the CP’s information. · On December 21, 2023, in a follow-up interview, the SP did not recall talking to law enforcement officers while in the hospital. The SP said s/he had “feelings” for the AV and that they “kissed.” The SP denied having oral sex or any other “physical contact besides kissing” with the AV. The SP said that at time s/he was off his/her prescription medications at the time which affected his/her behavior. · The case was sent to the county attorney’s office for review of potential charges of Criminal Sexual Conduct 3rd Degree-Position of Authority. P1-P11 and text messages provided the following information: · P1 and P2 provided information that was consistent with the law enforcement report that on November 23, 2023, P7 called P1 with information that the SP had “feelings” for the AV. P1 spoke with the SP and the SP said, “I do admit that I have had some poor boundaries recently.” P1 then called P2. P1 and P2 were aware of another incident involving the SP and the AV being under a blanket together and they decided to move the SP to another cottage away from the AV with the understanding that the SP was not allowed near the AV. · P10 said that s/he had not seen the SP or the AV under a blanket with each other but, in October or November 2023, s/he noticed “odd” interactions between the SP and the AV. P10 saw the AV sitting “too close” to the SP once or twice a shift when P10 worked with the SP. The SP and the AV sat “too closely” in the living room several times while sharing a foot stool, and upstairs near the bedrooms while listening to music on a laptop they were “almost touching.” P10 also saw the SP and the AV on the gym stage sitting next to each other “too closely” listening to music on the SP’s phone and whispering to each other. P10 told P5 about the incidents to P5 and then later told P4. · P8 worked with the SP on an unknown evening in October or November 2023, during a movie night. P8 was in the dining room area and the SP was in the living room. P8 conducted a 15-minute headcount check to make sure all the clients were accounted for and when P8 walked into the living room s/he saw the SP and the AV sitting closely together underneath a blanket. The next day P8 told P4 and P6 about what s/he saw. · P9 said that on an unknown evening prior to the AV’s bedtime when they were upstairs, s/he saw the AV sitting closely next to the SP whispering to each other. On November 20, 2023, P9 saw the SP and the AV sitting “too close” to each other in the living room. P9 said that the SP seemed too “favorite” the AV. · P5 said that s/he walked into the living room and saw the SP and the AV sitting closely together, like “a couple,” watching a video with the rest of the clients. P5 turned off the video because it contained “inappropriate” media content that was not allowed by the facility and then sent the clients upstairs to get ready for bed because it was after curfew. P5 then spoke with the SP about respectful boundaries with the AV and that it concerned P5. The SP replied, “I know I get it, I get it” and apologized to P5. P5 then logged the incident and documented his/her conversation with the SP. (P5 was not able to provide this investigator with any documents regarding his/her conversation with the SP.) On November 20, 2023, at 11:20 p.m. P5 received a text message from P9 regarding “unhealthy boundaries” between the SP and the AV and the SP was removed from the AV’s cottage within the next few days. · The text message between P5 and P9 said the following: o P9 “[the AV] loves taking walks with [the SP]. They are on another one now…between painting [his/her] nails and these before bedtime walks. Something is rubbing me the wrong way.” o P5 “[AV] seriously needs to stop.” o P9 “More like [SP] might need to set some boundaries” o P5 “I’m mad at P4 for not switching [him/her] to another cottage” · P4 and P6 provided consistent information that on an unknown date in November they received a lead shift report about an incident when the SP was under a blanket with the AV. P4 said that s/he had “limited contact” with the SP, but had no prior concerns and was not aware of any other incidents between the SP and the AV other than long evening walks between the SP and the AV. P4 held a meeting with staff persons and a separate meeting with clients from the cottage about “boundaries.” P4 told staff persons and the clients that they were not to share blankets or sit next to each other on the couches. P6 said that the information provided did not include any physical contact, so the decision was made to complete “boundary coaching” with the SP and move the SP to work with different clients. · P7 spoke with the SP on an unknown date prior to Thanksgiving and the SP told P7 that s/he had “feelings” for the AV. P7 told the SP to remove him/herself from the client “ASAP” and to talk to his/her supervisor within the next couple of days. On November 23, 2023, P7 told P1 what the SP said about having “feelings” for the AV. On an unknown date after Thanksgiving, P7 was contacted by a mutual friend of P7 and the SP who told P7 that s/he saw a text message on the SP’s phone that said that s/he had “feelings” for the AV and that the SP had “kissed” the AV. P7 told P5, and they told P1-P3 and P6. P1-P3 then decided to remove the SP from the facility while they conducted an investigation. · P3 said that on an unknown date after Thanksgiving, P1 and P2 told him/her that the SP had “feelings” towards the AV. P3 said that s/he was aware that the SP and the AV shared a blanket and that the SP had received “counseling” from other staff members. · P11 worked with the SP but was not aware of the allegations. · Prior to this incident P1-P4 had no prior concerns about the SP’s interactions. · P1-P11 provided consistent information regarding professional boundaries between clients and staff persons. Staff persons were to keep relationships work related, there was to be no touching clients unless absolutely necessary, staff persons should be an arm’s length away from clients, were not to share personal information with clients, and were not contact clients outside of work. The SP provided the following information: · The SP said that s/he worked with the AV for about two and half months, talked to the AV more than other clients, and “kind of” developed a “relationship” with the AV. The SP. There were a few times when the AV was talking about his/her parent and was “sad” and other times the AV was “upset” and the AV hugged the SP, so the SP hugged the AV back. · On an unknown date one evening in the living room, the SP and some clients were watching a movie. The SP was sitting on a couch next to the AV when the AV took a blanket and covered both the SP’s and the AV’s legs. The SP “let it happen” and did not remove the blanket or him/herself from the area. The SP continued to sit next to the AV until the movie ended. The SP said s/he also spent time alone with the AV in the gym and on walks in the hallway that lasted about ten minutes. · On an unknown date in November, the AV told the SP that s/he had “developed feelings for me” and the AV kissed the SP on the mouth and the SP kissed the AV back. The SP said that they were in the hallway in front of the staff office and that no one else saw them. The SP said that there was only the “one kiss” and there was no other sexual contact between them. The SP denied having performed oral sex on the AV. · On an unknown date around Thanksgiving 2023, the SP requested to be transferred to another cottage because, “I knew what I did was wrong and if I stayed over there, I didn’t want anything else to happen.” The SP said that during the time s/he was not taking his/her mental health medications and “knew it wouldn’t be good for me to stay over there.” · The SP said that staff persons were to have no physical contact with clients and “the most you could do was a high five.” · The SP stated that no supervisory staff persons spoke with him/her about his/her interactions with the AV. The FM said that s/he was not made aware of any concerns about the AV until two days prior to the AV’s discharge. Prior to being informed of the incident, the AV had never mentioned the SP to the FM and had not “shared” much information with the FM but had been talking with his/her therapist. The FM was happy with the facility and had no prior concerns. The facility’s Code of Conduct stated that all staff persons must “maintain a professional relationship with clients,” “not become romantically or sexually involved,” “not engage in any type of relationship including electronic communication via email, Facebook, SnapChat, Instagram...” and there will be “zero tolerance for sexual contact with clients or engaging in conversation of flirtatious nature or sexual innuendo.” Facility documentation showed that P1-P11 and the SP were trained in the Maltreatment on Minors Act and the facility’s Code of Conduct prior to the incident. Conclusion A. Maltreatment: Information from P5 and P8-P10 was consistent that they saw interactions between the SP with the AV that were not within the scope of appropriate boundaries between a staff person and a client. (Note: There was a nine-year age difference between the SP and the AV.) Regarding sexual abuse: Information from the AV and the SP was consistent that the SP and the AV kissed at least one time and likely “daily.” On November 28 and/or 29, 2023, the SP told law enforcement officers twice that s/he had performed oral sex on the AV. However, on December 21, 2023, the SP said s/he did not recall talking to law enforcement officers while in the hospital and denied having oral sex or any other “physical contact besides kissing” with the AV. Although the SP might have been freer to provide accurate information while under the influence of substances and that s/he had reason to minimize his/her actions for fear of repercussions, given that the AV denied having sexual contact with the SP and that kissing did not meet the definition of sexual abuse, there was not a preponderance of the evidence whether the SP and the AV had sexual contact. It was not determined that sexual abuse occurred (the subjection of a child by a person responsible for the child’s care, by a person who has a significant relationship to the child, as defined in section 609.341, or by a person in a position of authority, as defined in section 609.341, subdivision 10, to any act which constitutes a violation of section 609.342 – 609.3451 [criminal sexual contact in the first through fifth degree]. Regarding neglect: Information was consistent that the SP sat too close to the AV on multiple occasions in the living room, gym, and upstairs by the bedrooms. On November 20, 2023, P5 walked into the living room and saw the SP sitting “closely” on a couch next to the AV like “a couple.” P5 then spoke with the SP about respectful boundaries with the AV told the SP that it concerned him/her. The SP replied, “I know, I get it, I get it” and apologized to P5. P8 worked with the SP on an unknown evening during movie night and saw the SP and AV sitting closely together underneath a blanket. On a date prior to November 23, 2023, the SP told P7 that s/he had “feelings” for the AV. Then on a date prior to November 28, 2023, P7 was told by a mutual friend that they saw messages from the SP that the SP had “feelings” for the AV and “kissed” the AV. Although the AV denied “feelings” for the SP and denied a “romantic relationship” with the SP, the SP’s told law enforcement on different occasions that s/he was “in a relationship with an underage client,” that s/he and the AV expressed “feelings” for each other, and that s/he had “feelings” for the AV; and the SP told this investigator that s/he “kind of” developed a “relationship” with the AV and that the AV told the SP that s/he had “developed feelings” for the SP. In addition, information from the AV and the SP was consistent that the SP and the AV kissed at least one time and likely “daily.” The AV was at the facility for supports regarding his/her substance use and mental health disorders. The AV’s Client Information stated that the AV “struggled to build and maintain healthy relationships, and one of his/her goals at the facility was to develop healthy relationship skills and friendships,” so it was reasonable that the AV would likely continue to need supports to develop and maintain the necessary life and social skills to maintain and build healthy relationships. The SP’s interactions with the AV, who was 16 years old and nine years younger than the SP, likely hindered AV’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the AV, both now and in the future. Therefore, there was a preponderance of the evidence that the SP failed to maintain professional boundaries and that the SP’s interactions with the AV were detrimental to AV’s ongoing mental health and were a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health. It was determined that neglect occurred (a failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Reporting of Maltreatment of Minors Act and the facility’s Code of Conduct. The SP was responsible for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was not “recurring” or “serious” maltreatment because the SP’s overall interactions represented a pattern of behavior and therefore a single incident, and the AV did not require the care of a physician. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and found that their policies and procedures were adequate but not followed. Staff were retrained on Maltreatment of Minors Act and when to report inappropriate staff conduct. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
|
