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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: 1090406-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that a staff person (SP) had sexual contact with a vulnerable adult (VA). Date of Incident(s): March 27, 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): 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 for this investigation was obtained remotely, including documentation from the facility; and through interviews conducted with the VA, three facility staff persons (the SP, P1 and P2), a case manager (CM) for the VA, and a mental health professional (MHP) from an outside agency. The facility provided intensive residential treatment and crisis stabilization services to adults who have been diagnosed as having a serious mental illness. Length of stay ranged from one to ten days in the crisis stabilization program and up to 90 days in the intensive residential treatment program, with reauthorization available for individuals requiring longer lengths of stay. The VA lived at the facility from November 30, 2023, until March 29, 2024. On April 9, 2024, it was reported that the VA called a mental health support center crisis line and said that the day prior to his/her discharge from the facility (March 28, 2024), s/he had sex with a staff person in the company vehicle. The VA did not want the incident reported and did not want to get the staff person in trouble. The MHP provided the following information: · On April 10, 2024, the VA told the MHP that while the VA was at the facility, s/he engaged in a consensual sexual relationship with a staff person. The VA told the MHP that sexual conversations with the staff person began when the staff person was driving the VA to look at housing options. The VA also said that s/he had contact with the staff person after s/he left and had contact information for the staff person. The VA declined to provide the name of the staff person (it was later determined to be the SP). · On April 16, 2024, the VA told the MHP that the facility started an investigation, and the SP (the VA still did not disclose the name of the staff person to the MHP) was suspended. The VA would not confirm or deny whether s/he was still in contact with the SP. The VA said that sexual pictures were taken of the VA and sent to the SP. The CM provided the following information: · On April 16, 2024, the VA told the CM that s/he was having a relationship with the SP (the VA did not provide the name of the SP to the CM). The VA told the CM that the VA and the SP had been texting and emailing and that it was a romantic relationship. The VA planned to go on dates with the SP. The VA also said that s/he had sex with the SP, but did not provide any additional details. · The VA showed the CM a picture from the SP’s Facebook page. The VA told the CM that the SP had his/her personal email address but the VA did not provide pictures from email. The VA said that the SP told the VA that s/he said s/he had an aggressive side which worried the VA because the SP knew where the VA was going to live because the SP was with the VA when s/he looked at housing. · The VA’s mental health declined after the VA initially told the MHP about the relationship on April 10, 2024. The VA provided the following information in the facility’s internal review report: · On April 15, 2024, when the facility contacted the VA about the allegations, the VA declined to confirm or deny the allegations and did not provide any details. · On April 18, 2024, the VA was more open about talking about the allegation. The VA said that the VA and the SP had consensual sex at a local park while the VA was still receiving services at the facility. After the VA was discharged from the facility, the VA took pictures of him/herself and shared them with the SP via text message. The VA declined to show the facility the pictures and did not show anyone else the pictures or text messages. The VA said that s/he already deleted the pictures. The VA sent communications of a sexual nature to the SP and was hoping to continue the relationship with the SP. The VA’s last contact with the SP was on April 17, 2024, and at that time, the SP told the VA to delete all emails and texts of a personal nature between the two. The VA provided the following information to this investigator on April 24, 2024: · Toward the end of the VA’s stay at the facility, the VA and the SP exchanged emails with links to blogs that each had written. The VA also sent the SP some drawings that s/he completed. The emails were initially exchanged with the SP’s work email and then after a couple days they switched to the SP’s personal email. When the emails became sexual in nature, the SP had the VA delete the emails. The SP also had the VA delete text messages between the two. (The VA provided both the SP’s work and personal email addresses.) · The VA believed that s/he went on apartment tours three different days with the SP. The last day they went on a tour was March 28, 2024, the day before the VA was discharged. That day it was icy out and they could not get the van into the parking lot of an apartment the VA planned to tour, and the VA decided that s/he did not want to complete the tour as it was in a “sketchy” part of town. At some point, the VA and the SP were talking about sex. The VA asked the SP if s/he wanted to have sex and the SP said yes. After leaving the apartment they drove around, then the VA suggested that they go to a park. The first park they went to was “packed” so they drove to Como Park. · After arriving at Como park, the VA and the SP talked for a while and around 11 a.m. they had sexual intercourse in the front seat of the van. Afterward, they returned to the facility at about lunch time. The VA did not remember anything else about that day. That was the only time the SP had sexual contact with the VA. The following morning, a family member of the VA picked the VA up and the VA left the facility. · The VA enjoyed cooking, camping, hiking, and snowshoeing. The VA also made clothes for pets. The SP provided the following information in the facility’s internal review report: · The SP first provided information on April 15, 2024. The SP stated that s/he took the VA on housing tours but did not know the dates. The SP used the company van and documented the tours. Outside of normal interactions, the VA only communicated with the SP via his/her work email regarding housing tours and the emails did not contain anything “inappropriate.” · In a follow up interview on April 18, 2024, when the SP was asked if s/he had communication with the VA since the VA discharged, the SP said nothing that would be in his/her work email. The VA had the SP’s personal email and sent emails to the SP “just a few times to follow up.” The SP said that s/he would provide copies of the emails but later said s/he accidentally deleted them. When asked if there was any sexual content in the emails, the SP replied, “[The VA] tried. I told [him/her] no.” The emails did not have photos in them. The SP stated that s/he did not have any physical contact with the VA or any sexual contact with the VA while in the company vehicle. The SP provided the following information to this investigator: · The SP assisted the VA with attending groups and worked with the VA on mental health coping skills. The SP also took the VA for housings tours. The tours were always set up in advance. · While the VA was at the facility, the VA “flirted” with the SP and the SP believed that the VA had a “crush” on the SP. The SP redirected the VA from those behaviors. · The VA exchanged messages with the SP on the SP’s work emails. In the emails, there were sexual advances by the VA and “stuff like that.” The SP tried to redirect the VA away from those types of conversations. The SP did not show or report those emails to the facility. · After the VA left the facility, the SP had some conversations with the VA via the SP’s personal email. The SP wanted to make sure the VA was doing alright. The SP shared his/her personal email with the VA a couple days prior to the VA’s discharge. · The SP took the VA on three different days to look at three different apartments as potential places for the VA to live. The last day the VA and the SP looked at an apartment on the east side of St. Paul. They could not find the office and the van got stuck on a hill in the snow. The SP and the VA then returned to the facility. The SP did not go to any park including Como Park with the VA. The only time the SP was a Como Park with the VA was part of a group outing on an earlier date. · The SP never had sexual contact with the VA. On the last outing, the VA brought up having sexual contact and the SP redirected the VA and they returned to the facility. The SP did not tell anyone at the facility or document anything about the VA talking about having sexual contact. The SP believed that the VA made the allegation because the VA liked the SP “a lot.” · The SP received training on the facility’s boundary policies including that relationships with individuals served by the facility were to be strictly professional. The facility’s internal review report provided the following information: · The SP’s work emails were obtained and showed that on March 24, 2024, the VA and the SP communicated via emails. The emails were of a personal nature and referred to conversations regarding sex toys. The emails were sent from the SP’s personal phone on a day that the SP was not working. · The VA’s progress notes showed that the SP took the VA to look at apartments on March 21, 22, and 27, 2024. The mileage log for the van showed that the SP used the van on March 22 and 27, 2024. (The facility provided copies of the mileage log and documentation by the SP from the VA’s file on March 27, 2024.) The SP documented that on March 27, 2024, that s/he took the VA to look at an apartment in St. Paul. The VA did not like the apartment and did not like the location where the apartment was located. The facility provided copies of emails from the SP’s work email that showed multiple emails exchanged between the SP and the VA on March 24, 2024. The content of the emails included the following: · The exchange included a drawing of a house by the VA. The emails exchanged were an ongoing conversation about what each of them were up and discussions about social events at the facility. The VA said that s/he enjoyed the apartment tour on March 21, 2024, and that his/her feelings of anxiety were nonexistent. · At one point the VA asked the SP question about his/her attire s/he wore at work and the SP answered the question (it was not in a sexual context). After the SP answered the question and added that s/he could chose not to answer any question, the VA stated that the SP had that right and that the VA respected that right. The VA then wrote “I figured the table was a bit more open after our discussion about sex toys.” The statement was followed by a smiling face. The SP responded, “Valid point.” The VA asked who started the conversation and that s/he thought it was the SP. The SP responded that s/he thought they were talking about something else and the conversation took a “quick left.” That was the last email exchanged. P1, who was the primary staff person who worked with the VA, and P2, an administrative staff person, provided the following information in the internal review report and in interviews with this investigator: · P1 was not aware of the content of any of the VA’s emails. While the VA was at the facility, the VA did not make reports to P1 that “resembled maltreatment or would be reportable.” P1 was not aware of any concerns between the VA and the SP. P1 did not notice any behavior changes in the VA outside of the norm. · P2 was not aware of any concerns about any interactions between the VA and staff persons including the SP. P2 did not have concerns about the SP’s interactions with any individuals. · Staff persons received training on the facility’s’ boundary polices. Staff persons’ relationships with individuals were to be therapeutic and staff persons were not to share personal information with individuals. The facility’s policy on Professional Behavior and Boundaries stated: · Staff persons were not to have contact with a client after discharge unless the staff person was acquainted with the client before they arrived at the facility. Staff persons who were contacted by former clients were to report it to their supervisor immediately. · Staff persons were prohibited from sharing personal information with a client including personal contact information and prohibited from engaging in sexual contact with a client. Facility documentation showed that the SP received training on therapeutic boundaries and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: The VA, the SP, and documentation at the facility showed that on March 27, 2024, (note: the VA stated the date was March 28, 2024), the SP took the VA in the facility van to look at an apartment, the VA did not like the location of the apartment, and the parking lot of the apartment was snowy and icy. The VA stated that after leaving the apartment, s/he asked the SP if s/he wanted to have sex and the SP said yes. The SP and the VA stopped at one park, and it was crowded so they left and drove to Como Park. The VA said that at Como Park the SP and the VA had sexual intercourse in the front seat of the van. The VA did not tell anyone about the incident until a couple weeks after the incident. The SP stated that after leaving the apartment, s/he drove right back to the facility. While out, the VA brought up having sex with the SP, but the SP redirected the VA. The SP said that on the way back to the facility, the SP did not stop at any park including Como Park. The SP said that on a prior occasion, the SP took the VA to Como Park as part of a group outing. The SP denied that s/he had sexual contact with the VA. The VA and the SP each stated that they exchanged emails via the SP’s work email and personal email. Neither provided copies of the emails to anyone involved in the investigation. The VA also said that s/he exchanged texts with the SP, but did not provide copies of texts. The SP said that the emails contained sexual advances from the VA in which the SP redirected the VA. Emails between the SP’s work email and VA’s email provided by the facility showed that the VA mentioned a prior discussion that they had about sex toys, but there were no other details regarding the context and there were no other documented exchanges that were sexual in nature. Other than having sexual contact in the facility van, the SP and the VA provided consistent information about the outing that day. In addition, the VA and the SP each stated that they exchanged emails that contained content of a sexual nature. Given that there were no witnesses to the incident and a lack of information obtained from communications between the VA and the SP, credibility of the persons involved becomes a determining factor. The SP stated that the VA made sexual advances toward him/her via emails, and on the day of the incident, the VA asked about having sex with him/her. However, because the SP did not report those instances to any other staff persons nor did s/he document the incidents, the SP’s credibility was diminished as there was no therapeutic reason for the SP the hide those interactions with the VA. In addition, the VA did not have an apparent reason to fabricate that s/he had sexual intercourse with the SP and the SP had reason to minimize his/her actions. Therefore, the VA’s account about having sexual intercourse with the SP was determined to be more credible than the SP’s account denying sexual intercourse. Given the above, there was a preponderance of the evidence that the VA and the SP had sexual intercourse on one occasion. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP received training on therapeutic boundaries and on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of the VA. 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 abuse for which the SP was responsible was not recurring because it was a single incident. However, it was determined to be serious as the SP sexually abused the VA. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review of the allegation and determined that their policies and procedures were adequate, but not followed. Staff persons were to continue to receive annual mandated reporter training and training on staff persons to client boundaries. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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