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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: 1067244-SUD (Substance Use Disorder) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a staff person (SP) and a vulnerable adult (VA) had a relationship while the VA was receiving services at the facility. Date of Incident(s): Unknown dates between May 28 and July 2, 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, a facility staff person (P1), a supervisory staff person (P2), the VA’s drug and alcohol counselor not associated with the facility (DAC), and the VA. Attempts were made to contact the VA’s parole officer, but s/he did not respond. Before attempts could be made to contact the SP for an interview, on August 20, 2024, the SP unexpectedly passed away. Law enforcement was contacted, but due to the SP’s passing, law enforcement did not investigate further. The VA received substance use disorder services from the facility from May 28 to July 2, 2024. The VA was diagnosed with severe alcohol use disorder, moderate Cannabis use disorder, and severe hallucinogenic use disorder. The VA was not subject to guardianship. The facility’s website stated that the facility offered personalized treatment to match treatment goals that were unique to each person utilizing a full spectrum of evidence-based treatment methods. The VA enjoyed watching television, cooking, and listening to music. The VA’s Service Discharge Summary described the VA as “honest,” “friendly,” “caring,” and having “good communication.” The VA provided the following information: · The SP “took advantage” of the VA and “pursued a relationship” with the VA while the VA was at the facility. The SP’s duties at the facility were to administer medications to the clients. The VA denied that the SP and the VA had sexual intercourse while the VA was at the facility. · The SP’s behaviors toward the VA started five to six days after the VA arrived at the facility. The SP began making comments about various visitors that came to visit the VA. The SP would tell the VA that the VA’s visitors were the VA’s girl/boyfriend. The SP eventually began “flirting” with the VA by “grabbing” the VA’s hair, “brushing up” on the VA, and holding eye contact that was “not regular eye contact.” The SP grabbed the VA’s hair or brushed up on the VA several times per day until things progressed. · The SP began to let the VA sit in his/her office and one time sat on the VA’s lap, “acting like [s/he] fell,” then began to hold the VA’s hand and gave the VA his/her cell phone number. The SP would put his/her hand on the VA’s chest and knee. One time closer to the end of the VA’s services at the facility, the SP kissed the VA on the neck and “lingered” for three to four seconds. About two weeks prior to the VA’s discharge from the facility, the SP told the VA that s/he was his/her boy/girlfriend. When the VA had access to his/her cell phone, the SP and the VA would text when the VA was at the facility and the SP was not working. The text conversations were sexual in nature. Both the VA and the SP talked to one another about “having a relationship” prior to the VA leaving the facility. · One occasion, while the VA and the SP were in a nurse’s station at the facility, the SP “grabbed” the VA’s genitals underneath the VA’s clothing and continued to touch the VA’s genitals which “lasted a while.” Clients were not supposed to be in the nurse’s station to “just have conversations.” According to the VA, the VA was “in there a little too often.” · The VA was unsure if any other staff persons were aware of anything going on with the VA and the SP, but the VA felt like P1 had “some type of idea.” According to the SP, the SP was talking about a former client and P1 said, “You must be talking to [the VA’s name]. That’s your boo (a slang word for a person’s significant other).” The VA did not think any other clients knew about the behavior between the SP and the VA but said that other clients probably saw the VA by the SP’s medication window “a lot.” · The VA had been a client at the facility several times prior to this one and had never had anything like this happen before. Based on that, the VA’s “normal” interactions with someone in the SP’s role would be to get medications from him/her, ask him/her how s/he was doing, have a brief conversation, and then “nothing more than that.” The SP was not working at the facility during the VA’s prior stays at the facility. · The VA’s and the SP’s relationship “progressed further” and got “more intense” when the VA was discharged from the facility after completing the program and moved into another residence. After the VA left the facility, the SP and the VA continued to text and talk “constantly.” The SP had some “chaotic” things happening with his/her home life and was on vacation so the two did not see each other at that point. The SP began getting “more sexual” with what s/he would say to the VA. The SP sent the VA “explicit texts” with and without photos. The SP “wanted to be with” the VA and the SP and VA referred to one another as boy/girlfriend. · Two weeks after the VA was discharged from the facility, around the middle of July 2024, the SP and the VA saw each other in person. The VA and the SP did not have sexual intercourse, but there was a lot of “sexual contact,” “grabbing, touching, [and] kissing.” The sexual conversations and text messages were “every or every other day” until the “threats” from the SP began. The SP told the VA that s/he was going to the VA’s residence to “fight.” · The VA found out that the SP put a “device” on the VA’s phone because after the VA left the facility, the SP was able to receive all text messages that the VA was receiving and sending. The SP was also able to see where the VA was taking ride-share services to and from. The SP knew where the VA was when the VA did not tell the SP where s/he was going. The SP told the VA that s/he plugged a device into the VA’s phone when the VA was at the facility. The facility kept all client cell phones locked in a safe and the VA thought that the SP had access to the safe. · The SP also knew other things about the VA that the VA never told the SP. The SP showed the VA a picture of the VA’s childhood home. The VA had not lived there for “years,” and the SP would not tell the VA how s/he knew the address to the house. That information was not on any of the VA’s paperwork. · Approximately two weeks prior to the SP’s death, the VA “drew a line” with the SP and began to “distance” him/herself from the SP. The VA and the SP continued to keep in touch “here and there” and the VA told the SP that s/he hoped “things got better” for the SP. The DAC provided information consistent with the information the VA provided and added the following: · The VA “volunteered” information to the DAC regarding the VA and SP’s relationship and seemed “embarrassed” that it had occurred but understood that what occurred was “inappropriate.” The VA stated that the VA and the SP had been “together” since July 2, 2024, when the VA was discharged from the facility and “broke this off” on August 10, 2024. · The SP played “sexually suggestive” music when the VA was nearby, would rub the VA’s back, and touched his/her hair. The SP told the VA that s/he would “leave [his/her boy/girlfriend],” for the VA. The DAC did not get the impression that there was a “sexual relationship” between the VA and the SP until after the VA was discharged from the facility. The VA was not living with the SP at any time and never went to the SP’s house. · The VA was an “honest and reliable” reporter, however at first said that the relationship with the SP “wasn’t sexual” but eventually “told the truth” to the DAC that it was. · The VA told the DAC that s/he had “ended things” on August 10, 2024, due to the SP “bugging” the VA’s phone or having access to his/her “Apple ID” which made it possible for the SP to see the VA’s other text messages that were sent to and from other people. After that, the SP started getting “angry” at the VA and said that s/he was going to “cause a scene” to try to get the VA “kicked out” of his/her residence. The VA was “scared” and did not know if s/he was going to “get in trouble.” P2 was not aware of the SP being involved with any clients at the facility and stated that the SP was a good staff person, was vibrant, and was good with the clients. P2 did not have any “concerns” regarding the SP’s work performance. The SP passed medications, took clients’ vitals, and sometimes played basketball with clients. P2 never saw “inappropriate interactions” between the SP and any clients, but P2 did not work entire shifts with the SP. P2 did not know of and did not have information regarding which client the SP may have been “inappropriate with.” There were no “rules” about clients being back in the nursing station. P1 provided the following information: · P1 denied having any knowledge or ever witnessing any “inappropriate relationship” between the SP and any clients. Clients came to the medication window to get medication and the SP and P1 administered medications. There were no clients that came by the medication window more often. Clients did not come into the nursing station unless staff persons were taking “vitals” or getting a suboxone treatment. · P1 denied telling the SP that a certain client “was [his/her] boo,” and did not know who the SP would have been talking to more than other clients. · Staff persons received “boundary training” which discussed not sharing private information with clients and not socializing with clients when they were no longer at the facility. Facility documentation showed that P1, P2, and the SP were each trained on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information from the VA and the DAC showed that the VA began receiving services on May 28, 2024, and about five days after arriving at the facility, that the SP began touching the VA on the back and grabbing the VA’s hair. Things progressed between the SP and the VA and the SP “accidentally” fell on the VA’s lap, played “sexually suggestive” music while the VA was getting medications, kissed the VA on the neck for about three to four seconds, and touched the VA’s genitals, under his/her clothing, which lasted several minutes. The relationship progressed after the VA completed treatment and was discharged on July 2, 2024, and left the facility. After the VA left the facility, the SP and the VA had an intimate relationship with sexual “contact” including “grabbing, touching, [and] kissing,” and referring to one another as “boy/girlfriend” until the VA “ended” things with the SP on August 10, 2024. Although P1 and P2 each stated they did not witness or have knowledge of the SP and any clients having an “inappropriate relationship,” given that the VA provided consistent information to the DAC and this investigator, that the DAC stated the VA was reliable, and that it was reasonable that P1 and P2 would not witness every interaction between the SP and the VA including sexual contact, there was a preponderance of the evidence that the SP had sexual contact with the VA. In addition, given the VA’s history of substance use disorder, it was reasonable that the VA would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety. The SP’s interactions with the VA hindered the VA’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 VA 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 VA were detrimental to the VA’s ongoing mental health and a failure to provide reasonable and necessary care and services. It was determined that sexual abuse and neglect 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 and 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). 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 was trained 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 sexual abuse and neglect that the SP was responsible for was not recurring maltreatment because the SP had sexual contact with the VA on one occasion and the SP and the VA's relationship was a single pattern of behavior. However, although the substantiated neglect that the SP was responsible for was not determined to be serious because the VA did not sustain an injury, the substantiated sexual abuse the SP was responsible for was serious maltreatment because it met the definition of serious maltreatment. Had the SP not passed away, the SP would be disqualified from providing direct contact services. Action Taken by Facility: The facility’s Internal Review stated that policies and procedures were adequate and “based on the available evidence,” the facility “presumed” they were followed. Action Taken by Department of Human Services, Office of Inspector General: The SP would have been 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. However, given that the SP passed away no additional action will be taken.
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