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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: 1116303-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: It was reported that a staff person (SP) brought a vulnerable adult (VA) to the SP’s home on multiple occasions, discussed explicit sexual preferences and other “explicit and inappropriate topics” with the VA, used the bathroom in the presence of the VA, took the VA to a nightclub, messaged the VA on his/her private cell phone, and asked the VA to stand on a corner with a sign and ask for money. Date of Incident(s): Ongoing prior to June 14, 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)2, paragraph (c)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 July 18, 2024; from documentation at the facility; and through five interviews conducted with a facility supervisory staff person (P), the VA’s family member (FM), the VA and the SP. Attempts were made to contact and interview the VA’s guardian, but the guardian did not respond. The VA lived at the facility under a commitment order due to his/her “cognitive vulnerabilities and mental health issues.” The VA was diagnosed with bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, borderline personality disorder, and attention-deficit hyperactivity disorder. The VA required 24-hour awake 1:1 staff supervision. The VA enjoyed fishing, listening to music, and shopping. There was no information provided in the VA’s plans that limited his/her sexual activity or alcohol use and there was no information that the VA was at risk in these areas. The facility was a split-level home. The VA’s personal space was on the lower level and included a living area, bathroom and bedroom. There was also a staff office on the lower level. The FM provided the following information: · The VA lived at the facility for “a couple years.” The VA had a history of cutting him/herself and the FM believed that the VA’s mental health was “not getting better.” The FM stated that the VA needed to “do something with [his/her] life” and needed “intervention,” such as getting a job and having positive supports. · The VA told the FM that sometime in March 2024, s/he went to a bar with the SP for an event called “Freaky Friday.” When the FM brought up his/her concerns about the outing with the P, the P stated that the VA requested to go, however, the FM did not think that the VA would have wanted to go without influence from the SP. · “After months of no contact” between the VA and the FM, the VA called the FM and told him/her that the VA went to the SP’s house on multiple occasions and met a family member of the SP. The VA also attended bonfires at the SP’s home. Additionally, the SP texted with the VA and asked the VA to download “FetLife” which the FM described as “an application where people submit lewd photos of submission and dominance kinks.” The SP also “asked” the VA to “stand on the corner with a sign and ask for money.” The FM believed the SP had a “lack of boundaries.” According to fetlife.com, “FetLife is the world’s largest and most popular social network for the BDSM [bondage, dominance, submission, and masochism], kink community, and fetish community.” The mission of FetLife is to “help people feel comfortable with who they are sexually.” The VA provided the following information, · On an unknown date in March 2024, shortly after the SP started working, the VA and the SP went to a club in downtown Minneapolis. The SP drove the VA and on the way to the club, the SP stopped at his/her house to pick out an outfit for the VA and him/herself to wear to the club. The VA provided this investigator with the SP’s address and a description of the SP’s home, which was accurate. · The VA stated that s/he “did not know what to expect” at the club and that night there was an event going on called “kinky Friday.” While the SP and VA were at the club, the SP went on stage at the club and the event staff “undressed” and “stripped” the SP. The VA “saw [the SP] naked” including his/her “private areas.” · The VA stated that following their outing to the club, “things got weird” and the VA “felt uncomfortable” with the SP. For example, the SP discussed and told the VA “sexually inappropriate” things in detail about the SP’s personal sexual experiences and sexual lifestyle. On an unknown date, the SP encouraged the VA to download the “FetLife” application that the VA understood to be an app to “solicit yourself for a good time” and “sell yourself.” The VA then distanced him/herself from the SP. The VA stated that s/he never brought up sexual topics with the SP. · The VA stated that the SP took the VA to do the SP’s personal errands. The SP also took the VA to the SP’s house “at least ten times” in addition to the time s/he took the VA to his/her house before going to the club. While at the SP’s house, the SP introduced the VA to the SP’s spouse and pets, “hung out” with the VA, and gave clothes to the VA. The VA stated that s/he did not like the clothes that the SP gave him/her and no longer had the clothes, stating also that the SP gave the VA a pair of thong underwear that belonged to the SP. · The VA stated that on more than one occasion s/he “panhandled” for money with the SP. The VA stated that it was his/her idea to stand on the corner and ask for money, and the SP told him/her to make a sign. The VA also stated that on an unknown date “right before” the SP no longer worked at the facility, the SP “went to the bathroom” in front of the VA. The VA was in the bathroom doing his/her makeup when the SP used the toilet, which made the VA “very uncomfortable.” The P provided the following information, · On June 14, 2024, the VA told the P about concerns s/he had with the SP. The VA told the P that the SP took the VA to the SP’s home on “at least ten occasions” and introduced the VA to the SP’s spouse, that the SP discussed “BDSM” with the VA and showed the VA “inappropriate” images of him/herself, and that the SP gave the VA with “inappropriate” clothing that belonged to the SP including lingerie. The VA also told the P that the SP used the bathroom in front of the VA. Prior to this, the P was unaware of any of concerns about the SP. · On an unknown date, the SP took the VA on an outing to a club. Prior to the outing, the P met with the VA’s interdisciplinary team and discussed the VA’s desire of going to the club because the VA wanted “to start exploring different communities.” The interdisciplinary team, including the P, then approved for the VA to go to the club. After the outing, the P followed up with the VA, and the VA “reported nothing concerning” about the outing. In addition, after the outing to the club, the P consulted with the facility’s Human Resources department, and they “recommended that this activity should not be approved due to the company policies regarding visiting establishments whose primary function is alcohol sales.” · On an unknown date, the VA and the SP returned from another outing. When the P asked where the SP and VA went, the VA stated that they went “panhandling” and that it was the VA’s idea to do so. The P approached the VA later that day and asked if it was “really [the VA’s] idea” to go panhandling, and the VA affirmed that it was his/her idea. The P stated that s/he “left it in the hands of the guardian” as to whether or not “panhandling” would be an approved activity for the VA. · The SP worked at the facility from March to June 2024 and had multiple “boundary” issues during his/her employment. The P met with the SP on multiple occasions prior to June 14, 2024, and the SP “said [s/he] understood and would stop.” When the P called the SP on June 14, 2024, to discuss the SP’s employment, the SP stated, “Okay,” and hung up the phone. The SP provided the following information: · On an unknown Friday in March, the SP took the VA to a club in Minneapolis. The SP stated that the VA’s interdisciplinary team approved the outing prior to them going. The SP drove the VA to the club and made a stop for gas along the way. When asked if s/he made any stops to his/her house prior to going to the club, the SP stated that the day prior, s/he took the VA to his/her house so that the VA could “pick out an outfit” to wear to the club. While the VA and the SP were at the club they “pretty much stayed in the dancing room,” and did not drink any alcohol or go on stage and/or strip that night. · The SP said that s/he took the VA to his/her house on only one occasion and that was prior to going to the club. The SP did not take the VA to the SP’s house any other times, but took the VA to the SP’s neighbor’s house an unknown number of times to “chill” and “listen to audiobooks.” The SP also took the VA to bonfires at his/her neighbor’s house, at which time(s) the SP’s spouse was present. · The SP stated that s/he gave the VA his/her personal phone number when they were at the club in case they got separated. The SP told the VA to delete the SP’s number from his/her phone after they left the club, but the VA did not do so. · The SP had clothes s/he was planning on donating to a thrift store. The SP gave the VA some of the clothes that s/he thought the VA would like. · The SP stated that the only time s/he discussed sexual topics with the VA was when the VA asked the SP about a bumper sticker that referenced polyamory. The SP explained it to the VA what polyamory was. The SP denied that s/he encouraged the VA to download the fetlife app and said that s/he told the VA not to do so. · On an unknown date, the VA “decided [s/he] wanted to go panhandling.” The VA made a sign and the SP took the VA out for 30 minutes and stood on a corner. The SP stood across the street watching the VA. The SP stated that s/he “wanted [the VA] to have that [panhandling] experience.” The VA panhandled $8 that day. On another unknown date, the VA asked the SP to accompany him/her while s/he went out panhandling again. The SP watched the VA for about 15 or 20 minutes, but the VA did not receive any money so s/he asked to go fishing and they did. The SP stated that s/he did not talk to any supervisory staff person or the VA’s team regarding the VA panhandling. · The SP denied using the bathroom in front of the VA and stated that two people would not be able to use the bathroom at the same time. The SP went on to describe an incident in which the VA burned him/herself using a hair removal product and the SP went into the bathroom with the VA to assist him/her. Facility information showed that the SP and the P were each trained on the reporting of Maltreatment of Vulnerable Adults Act and the SP was trained on the VA’s support plan. Conclusion: The VA provided consistent information to the FM, the P, and this investigator that the SP took the VA to the SP’s house, took the VA to a club and stripped on stage in front of the VA, discussed explicit sexual topics with the VA, took the VA panhandling, and used the bathroom in front of the VA. The P and the SP provided consistent information that the outing to the club was discussed with and approved by the VA’s interdisciplinary team. Shortly after the outing, the P talked to the VA and the VA did not provide any information regarding concerns at that time. The SP stated that while at the club, s/he did not drink alcohol or go on stage and/or strip. Consistent information provided by the VA, the P, the FM, and the SP showed that the SP crossed boundaries with the VA on more than one occasion by bringing the VA to his/her house and his/her neighbor’s house and by discussing sexual topics and the SP’s sexual experiences with the VA. Information provided by the VA, the P and the SP showed that it was the VA’s idea to panhandle, however, the SP did not talk to anyone about the VA’s request prior to taking the VA. The aforementioned actions of the SP were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. The SP denied using the bathroom in front of the VA. While there were occasions when the SP’s interactions with the VA were likely not therapeutic, given that the VA’s team approved for the SP to take the VA to the club, that the VA’s and the SP’s accounts of the SP’s interactions conflicted, and that there was no information to support or refute either account, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services which were reasonable and necessary to maintain the VA’s physical, mental health, or safety. 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 found that policies and procedures were adequate and followed. All staff persons received additional training regarding boundaries, mandated reporting, and the VA’s treatment plans. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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