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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: 804048-SUD (Substance Use Disorder) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that a staff person (SP) had sexual contact with a vulnerable adult (VA). Date of Incident(s): July 22 to August 1, 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 was obtained during a site visit conducted on August 12, 2024; from documentation at the facility, screen shots of video footage provided by the facility, and law enforcement records; and through four interviews conducted with two facility staff persons (P1 and P2) and two clients (C1 and C2). The VA, the SP, two additional staff persons (P3 and P4), and a community person (CP) who was an acquaintance of the SP’s were interviewed by law enforcement and that information was included below. Attempts were made to contact and interview the SP, but the SP did not provide additional information.
The facility had multiple bedrooms that each had a bathroom. The VA, C1, and C2 shared a bedroom. The facility also had a main desk and an adjacent nurse desk down a hall from the bedrooms. P3 provided the following information to law enforcement: · On August 1, 2024, at approximately 9:10 a.m., the VA came to P3 and said that the SP previously “approach[ed]” the VA and “ask[ed] for sexual favors.” The VA said that on multiple previous occasions, the SP waited outside the VA’s bedroom and then followed the VA inside. The SP performed oral sex on the VA “at least twice.” · The SP gave the VA a cell phone to keep in his/her bedroom that the SP used to text and send the VA pictures of him/herself. The SP also wrote letters to the VA. · Shortly after this conversation with P3, the VA went to his/her bedroom and the SP followed. The VA said that the SP told him/her that s/he was “going to jail” because earlier that morning at a group meeting the VA wrote a note to another staff person. The VA went back and told P3 about this interaction. The VA provided the following information in his/her interview with law enforcement: · On multiple occasions, the SP walked into his/her bedroom, rubbed the VA’s chest, and kissed the VA. The VA told the SP to “back off” but the SP “pushed more.” · On a previous occasion, the SP brought a cell phone into the facility and gave the phone to the VA. The SP wanted the VA to shower and take unclothed pictures of him/herself afterwards. The SP and the VA also texted on the phone. Later, the SP told the VA s/he would factory reset the phone so there was no evidence. · On one occasion, the VA was lying on his/her bed and the SP walked in and performed oral sex on the VA. On another occasion, C1 walked in the bedroom while the VA was in bed and the SP was next to the VA. C1 asked if s/he should knock on the door prior to entering the room. · The VA felt “threatened” because the SP found out about a letter that the VA wrote to another staff person and the SP threatened the VA that s/he would go back to jail so the VA went and spoke to P3 about the incidents. · The VA denied sexual intercourse with the SP because the SP said s/he needed to wait until after the VA left the facility. At one point, the SP told the VA they needed to keep their relationship “professional.” P4 told law enforcement that on August 1, 2024, the VA told P4 the following information: · On a previous occasion, there was an incident with the VA’s family member that the VA told the SP about. The SP responded that the VA was “sweet.” The VA said after that, there were “little touches here and there” between the SP and the VA. On multiple occasions, the SP went inside the VA’s bedroom when the VA was in there. · The SP brought a cell phone into the facility and gave it to the VA. Later on, the SP asked the VA for a picture of his/her genitals, so the VA sent the SP one. On one occasion, the SP touched the VA’s genitals, and, on another occasion, the SP performed oral sex on the VA. · During one of those incidents, C1 came into the bedroom. The VA grabbed his/her blood sugar monitor and acted like the SP was testing his/her blood sugar. C1 told the VA afterwards that s/he “did not see or hear anything.” · The VA told P3 earlier that morning that the SP followed the VA into the VA’s bedroom, that s/he was aware that the VA wrote a letter to another staff person, and the SP took the cell phone from the VA. The SP then told the VA that s/he was “going to jail.” P1 provided the following information: · On August 1, 2024, at 9:43 a.m., P1 received a phone call from P4 saying that the VA said s/he had sexual contact with the SP. P1 drove to the facility and arrived at 9:51 a.m. P4 showed P1 letters that the VA gave P4 that were written by the SP to the VA. · P1 went and spoke to the VA and requested that they walk around the parking lot. When they were outside the facility, the VA provided the following information: o The VA told P1 that s/he “didn’t know where to start.” The VA said s/he afraid of getting kicked out of the facility and going to jail. P1 “assured” the VA that no persons discussed that with P1. o The VA said that when s/he arrived at the facility, approximately one week prior to the conversation, the SP began “making sexual advances” toward the VA. The VA said that the SP came into the VA’s bedroom, closed the door behind him/her, and performed oral sex on the VA. The SP also lay on top of and next to the VA “multiple times,” and kissed the VA. After oral sex, the SP “promised [the VA] more” once s/he was out of the facility. o On one occasion, when the door was closed, the SP tried to kiss the VA and another client (P1 did not say which client) walked into the room. The SP told the client to “keep [his/her] mouth shut about what [s/he] saw.” P2 provided the following information: · On August 1, 2024, at approximately 9 or 9:15 a.m., P3 contacted P4 and P2 about the allegations and P4 and P2 drove to the facility separately. During that time, P2 called the facility and told the SP s/he was not allowed to work in the facility but could work in another licensed facility operated by the license holder that was located in the same building pending the internal investigation. The VA’s name was not mentioned so the SP did not have that information. P2 later found out that during that time, the SP accessed the facility’s security cameras and watched the VA and P1 on video “all the way zoomed in” while they talked. · At 10:30 a.m., there was a conference call between P2 and other supervisory staff persons. P4 explained s/he had a letter that was given to him/her by the VA. The letter was “absolutely” the SP’s handwriting, distinct pen, included a photo of the SP, and the SP’s signature. It was decided that the SP was suspended pending the internal investigation. After arriving at the facility, P1 discussed the allegations with P2. · P2 reviewed additional video footage and saw the SP speaking to the VA outside in a smoking area where staff persons “never” were; on another occasion, the SP had two cell phones on video and put one of the phones inside his/her shirt before walking into the VA’s bedroom; and on August 1, 2024, the SP went into the VA’s bedroom multiple times and P2 believed this is when the SP took the cell phone back and was looking for the letter s/he wrote the VA. It was “very uncommon” for the SP to go into bedrooms because of his/her role at the facility. The VA had diabetes and checked his/her blood sugar independently. If the VA did need assistance with it, the VA went to the nurse desk to have staff persons check his/her blood sugar. The facility had video cameras throughout the facility including the hall but not inside the bedrooms. The facility was not able to save and upload all video camera footage. P2 went through the video footage and took screen shots of the interactions between the VA and the SP which were provided to this investigator. The screen shots showed the following: · On July 23, 2024, from 12:45 to 12:48 a.m., the SP and the VA were in the appointment room together with the door closed. There were ten other times that day when the SP and the VA spoke to each other in the hall, fitness center, and/or lounge for brief periods of time. During one of those interactions, the VA gave the SP a piece of paper that s/he later read. There were nine times when the SP watched the VA on video around the facility. · On July 24, 2024, at 12:18 a.m., the SP went outside and gave the VA a piece of paper. From 4:32 to 4:33 a.m., the SP and the VA were inside the VA’s bedroom. At 4:41 p.m., the SP removed a white object from his/her back pocket and gave it to the VA. There were multiple short interactions between the SP and the VA during that time and multiple times that the SP watched the VA on video. · On July 26, 2024, the SP and the VA had the following interactions: o At 3:13 p.m., the SP followed the VA into his/her bedroom and exited one minute later. o At 4:47 p.m., a community person dropped off a white bag at the front desk. The SP carried the bag to the VA’s bedroom. o From 5:20 to 5:23 and 6:23 to 6:24 p.m., the VA and the SP were inside the VA’s bedroom alone. o At 8:46 p.m., the SP walked up to the VA in the hall and gave the VA a piece of paper. o At 8:56 p.m., the SP and the VA were alone in the laundry room where there were no cameras for less than one minute. They both walk to the VA’s bedroom and were inside for one minute. o At 9:21 p.m., the SP went out to the parking lot and got a bag from a vehicle. The SP then walked to the VA’s bedroom where they were alone for three minutes. o There were multiple other interactions between the SP and the VA and multiple times that the SP watched the VA on video. · On July 27, 2024, from 3:07 to 3:11 p.m., the SP and the VA were in the VA’s bedroom alone. There was one occasion where the SP watched the VA on camera. · On July 28, 2024, the SP and the VA had the following interactions: o At 12:23 p.m., the SP brought a white bag to the VA’s bedroom and left without it. o Shortly after, the SP took a cell phone out of his/her shirt and charged two cell phones on his/her desk. At 1:06 p.m., the SP put the cell phone back in his/her shirt and walked to the VA’s bedroom. One minute later, C1 went into the bedroom and exited one minute later. At 1:14 p.m., the SP left the VA’s bedroom and went and talked to C1 in the lounge. o At 2:30 p.m., the SP and the VA were alone in the bedroom for seven minutes. o Between 5:03 and 10:59 p.m., the SP and the VA were alone in the VA’s bedroom on eight different occasions ranging between one and eight minutes each. o There were multiple interactions between the SP and the VA and multiple times that the SP watched the VA on video. · On August 1, 2024, at 7:45 a.m., the SP went into the VA’s bedroom alone for approximately one minute. At 9:17 a.m., the SP followed the VA into his/her bedroom and was in there for one minute before leaving. A copy of a letter written by the SP to the VA stated s/he had an “attraction” to the VA; in “the little time” the SP knew the VA, s/he could tell that the VA was a “great” person; and asked why they could not have met prior to the facility. The SP also included a list of identifying items about him/herself. C1 stated on a previous occasion, s/he walked into his/her bedroom. The SP sat on the edge of the VA’s bed as the VA lay on the bed. C1 saw the blood sugar device to monitor the VA’s diabetes and went inside the bathroom. The VA later mentioned to C1 that s/he was “involved” with the SP but C1 did not pay attention. The VA always had the door closed when inside the bedroom and C1 was not aware if the VA had a cell phone in the bedroom. C2 stated that on a previous occasion, the VA had a cell phone given to him/her by the SP, that the SP snuck into the facility. The VA showed C2 two pictures of the SP on the cell phone, one was the SP’s chest and the other was the SP’s buttocks. The VA told C2 that on one occasion, C1 walked into the bedroom when the SP was touching the VA’s genitals. The CP provided the following information to law enforcement: · The SP thought s/he and the VA were a “couple.” On a previous occasion, the SP gave the VA a cell phone and phone cards and texted the VA using an app. · The SP “admitted” to having oral sex with the VA. The SP told the CP that C1 “liked to watch” what was going on between the SP and the VA. · The SP told the CP that s/he had written “love letters” to the VA multiple times. On August 1, 2024, the SP and the VA got in an argument about the VA writing letters to another staff person and things escalated “quickly.” Messages between the SP and the CP provided the following information: · On July 23, 2024, at 9:22 p.m., the SP texted the CP that s/he was “in trouble.” The SP left a voice message saying that s/he looked for the VA on the facility cameras, went to where the VA was, and spoke to him/her. The VA was “flirting” with the SP and asked if s/he “had a chance” with the SP. The SP sent the CP a screen shot of a computer screen with the VA’s picture and demographic information. · On July 26, 2024, at 4:54 p.m., the SP sent a picture of a letter about being in a relationship and texted “[The VA] gave me this.” The SP said s/he wrote the VA back but did not take a picture of it. At 5:02 p.m., the SP sent a voice message saying that s/he told the VA that s/he was “a little bit attracted to [him/her].” The SP said that during the conversation, the VA was on his/her bed and “pulled [the SP] in for a hug.” · On July 27, 2024, at 1:39 p.m., the SP texted that s/he “officially ended it” with the VA and that the VA was “upset.” The SP “wasted” money because s/he snuck a phone into the facility and gave it to the VA who was “probably” going to throw it away. · On July 31, 2024, at 8:38 a.m., the SP left a voice message saying the following: o The night prior (July 30, 2024) the VA started “acting weird” and had “huge mental health issues.” The SP said s/he “ended it,” and the VA got “upset,” and said s/he was going to “report” the SP to the facility. o The SP was “scared” because s/he sent the VA some inappropriate pictures so s/he came up with a story if the facility spoke to him/her about the allegations. The SP considered contacting a supervisory staff person about it but then s/he also did not want to admit to the relationship. o The SP checked the VA’s chart from home that morning to see if there were any notes about him/her. The SP considered driving to the facility to take the cell phone back from the VA. · Later that same day, in a message without a time stamp, the SP said s/he saw an email that the VA did his/her “first circle” earlier that day. The SP questioned why the VA would do that if s/he was going to leave the facility. The following day (August 1, 2024) the SP planned to get the cell phone from the VA and would be “deleting any trace of [the SP]” on it. · At 2:53 p.m., the SP left a voice message about how “anxious” s/he was about the VA telling supervisory staff persons about the SP and showing the text messages and pictures s/he sent. At one point, the SP said if the facility got a complaint about him/her having “inappropriate relations” with the VA, staff persons would have notified a supervisory staff person. The SP discussed needing to get the cell phone from the VA and getting rid of it. The SP “obsessively” checked his/her work email from home and the facility computer system for updates. · At 3:19 p.m., the SP left a voice message about calling a supervisory staff person at the facility and “fishing” for information to see if the VA said anything. Once the SP got the cell phone, s/he would be “good” because the VA would not have “any evidence” and it would then be “[the VA’s] word against mine, they will back me up, all will be well.” The SP thought about “planting” illegal drugs in the VA’s bedroom, “tip[ping]” off another staff person so the VA’s bedroom was searched and sent back to jail. · On August 1, 2024, at 9:01 a.m., the SP texted that s/he looked for the cell phone in the VA’s bedroom twice but was unable to find it. At an unknown time, the SP texted that the VA went into P3’s office and then texted that s/he got the cell phone and factory reset it. The SP provided updates about P3 contacting supervisory staff persons including P1 and that P2 called the SP saying s/he was not allowed the area of the facility because they were “looking into something.” · At 10:22 a.m., the SP said if a supervisory staff person asked the SP about going into the VA’s bedroom, the SP will tell them that s/he was checking the VA’s blood sugar and that the VA asked the SP about a relationship and was “upset” because the SP turned the VA down. The SP said s/he would deny anything inappropriate with the VA. If a supervisory staff person asked about the pictures s/he sent the VA, the SP would say s/he thought it was someone s/he met online and did not know how the VA got access to the pictures. · The SP sent the CP two pictures s/he had sent to the VA, including one of the SP’s chest and one of his/her face and a mirror showing his/her backside with his/her pants pulled down so part of his/her buttocks were shown. The SP then said s/he was sent home pending an investigation. · At 11:33 a.m., the SP sent a voice message saying s/he wrapped up the cell phone and threw it away in a garbage can at a gas station. · In an undated text message, the SP said s/he was “worried” about law enforcement finding out s/he called from a private number to the facility and disguised his/her voice to talk to the VA. The SP said s/he denied it to law enforcement when asked about it. · On August 3, 2024, at 1:42 p.m., the SP left a voice message about the cell phone, the letter that the VA had that the SP wrote to him/her, and camera footage from the facility. Along with what C1 saw and could possibly say. The SP said s/he could “make an excuse” or “come up with a story” for those things. · At 1:48 p.m., the SP said s/he did not have sexual intercourse with the VA. There were “other things that happened, other things that were said, that no one will know about.” The SP provided the following information to law enforcement: · In the evening of July 22, 2024, the SP wrote a letter to the VA prior to going out on the patio to discuss boundaries. The SP was “not good” with saying things so s/he wrote the words down first so s/he was “ready” when the VA approached the SP. The SP also wrote down “general information” about his/herself from a Facebook quiz. The SP thought s/he had shredded both papers but somehow the VA got them. The SP denied giving the VA letters about him/herself. · On July 23, 2024, when the SP walked into the lounge area, the VA called the SP over asking to look at the SP’s tattoos. The SP told the VA what each tattoo meant and “that was it.” A few hours later, the SP was “getting flirty vibes” from the VA and feeling “uncomfortable.” The SP told P4 about it and P4 reminded the SP to establish boundaries with the VA and because they were “busy” it was “swept it under the rug.”
· Later that day, the SP went outside to a patio area, the VA was outside smoking and the VA asked the SP if s/he “had a chance” with the SP once s/he left the facility. The VA said s/he was attracted to the SP and other “inappropriate stuff.” The SP told the VA s/he was not interested. · The VA continued to be “flirty” with the SP but the SP ignored it. The SP was on video footage “frequently” going into the VA’s bedroom because the VA asked the SP to come to his/her bedroom to check his/her blood sugar. The VA and the SP discussed blood sugar and how to control it. On one of those occasions, C1 walked into the room. The SP may have checked the VA’s blood pressure but otherwise was not near the VA because they were only talking. · On August 1, 2024, the SP went to the VA’s bedroom to check in on the VA about his/her hospital visit the day prior. The VA was “busy” changing his/her clothes so the SP left. Less than ten minutes later, the SP returned to the VA’s bedroom and asked how the VA was feeling. The VA asked the SP if s/he had “a chance” with the SP after the VA left the facility. The SP responded that the VA did not and reminded him/her that they already spoke about it. The VA got “upset” and asked the SP to leave his/her bedroom so the SP did without checking the VA’s blood sugar levels. · A few minutes later, the SP saw the VA go into P3’s office and had a feeling that something was “wrong.” P2 told the SP that s/he was not allowed to work in that area of the facility and that there was an open investigation. · The SP denied giving the VA a cell phone and said s/he was not aware of that until his/her interview with law enforcement. The SP denied having any pictures of the VA on his/her cell phone and denied calling the facility and disguising his/her voice to talk to the VA. · The SP denied touching the VA or having any sexual contact with the VA. When the law enforcement officer asked if the VA ever touched the SP, the SP initially denied any physical contact but then said “maybe” the VA rubbed the SP’s back. The SP said other clients had previous rubbed his/her back when giving them medications. The law enforcement report was submitted to the county attorney for review for possible charges. According to the facility’s Dual Relationships policy, contact between staff persons and clients was “professional and appropriate.” Any behaviors that were seen as violating professional boundaries, harmful, or detrimental to the client’s rehabilitation or recovery or negatively reflected the facility were not acceptable and subject to disciplinary action. Staff persons did not engage in behavior that could reasonably be interpreted as sexual or suggestive, sexual intercourse, or other physical intimacies with a client. Facility documentation showed that staff persons, including the SP, were trained on the VA’s plans, the Dual Relationships policy, and the Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Regarding Sexual Abuse: The VA provided information to P1, P3, P4, and the LEO that on previous dates, the SP performed oral sex on the VA. Although the SP denied sexual contact with the VA, the SP’s credibility was diminished for the following reasons: · Although the SP said s/he wrote down his/her thoughts about the VA, s/he denied giving it to the VA. Video footage showed the SP handing the VA a piece of paper. The letter that the VA provided the facility from the SP included information on the SP having an “attraction” to the VA. The SP told the CP about the letters. · The SP stated s/he only went into the VA’s bedroom to check his/her blood sugar. Video provided by the facility showed that on July 28, 2024, in a seven-hour timespan, the SP went into the VA’s bedroom eight times, and there was no information provided that the VA’s blood sugar had to be completed hourly or that frequently. P2 stated that the VA checked his/her blood sugar independently and that it was “very uncommon” for the SP to go in client bedrooms and clients went to the SP’s desk for assistance with medical concerns. If the VA did need assistance with checking his/her blood sugar, the VA went to the nurse desk to have staff persons check his/her blood sugar. · The SP denied giving the VA a cell phone. Video provided by the facility showed that the SP had two cell phones and at one point, put one inside his/her shirt before going to the VA’s bedroom. The SP told and texted the CP about giving the VA a cell phone. C2 also provided information that the VA showed him/her a cell phone and said that the SP had given it to him/her. · The SP denied to LEO that s/he called the facility and disguised his/her voice to talk to the VA. Text messages between the CP and the SP showed that the SP was “worried” about law enforcement finding out s/he called from a private number to the facility and disguised his/her voice to talk to the VA. · The CP provided information that the SP told him/her that s/he performed oral sex on the VA. Therefore, there was a preponderance of the evidence that the SP and the VA had sexual contact. 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). Regarding Neglect: In addition, given the VA’s history of substance abuse, 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 would likely hinder 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 evidence that there was a failure to maintain professional boundaries and that the SP’s interactions with the VA were a failure to provide the VA with reasonable and necessary care. It was determined that 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). 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 VA’s plans, the Dual Relationships policy, and the Vulnerable Adults Act prior to the incident. 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 for which the SP was responsible was not recurring maltreatment because although there was information that the SP performed oral sex on the VA more than one time, the VA stated that it was a single occurrence and the SP’s responsibility for sexual abuse and the SP’s responsibility for neglect was considered a pattern of behavior and therefore a single incident. However, the SP was responsible for sexual abuse of the VA which was serious maltreatment. D. Person Regulated by Health-Related Licensing Boards: Pursuant to Minnesota Statutes, section 245C.31, subdivision 1, when individuals regulated by a health-related licensing board are determined to be responsible for substantiated maltreatment under Minnesota Statutes, section 260E or 626.557, instead of the Commissioner of the Department of Human Services making a decision regarding disqualification, the licensing board makes a determination whether to impose disciplinary or corrective action under Minnesota Statutes, chapter 214. The SP is regulated by a health-related licensing board. The health-related licensing board was notified upon issuance of the investigation that the SP was determined to be responsible for serious maltreatment and would be disqualified from direct contact if s/he was not regulated by the board. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but not followed. The facility determined that the facility provided “sufficient” training on boundaries and policies prior to the incident. The facility was “committed to quality and safe care” and provided additional boundaries training to all staff persons. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was regulated by a health-related licensing board. The SP was notified that s/he was responsible for maltreatment and would be 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, if s/he were not regulated by the health related board. The determination that the SP was responsible for maltreatment is subject to appeal. The health related board that the SP was regulated by was notified that the SP was determined to be responsible for serious maltreatment and would be 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, if the SP was not licensed by the board.
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