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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: 1071900-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 supervisory staff person (SP) “made fun of” two vulnerable adults (VA1 and VA2) including making jokes about masturbation and calling VA2 names including “dumbass”. Date of Incident(s): Unknown, prior to August 13, 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 (b), clause (2): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 27, 2024; from documentation at the facility; and through nine interviews conducted with three facility staff persons (P1, P2 and P3), a facility administrative staff person (P4), the SP, VA1’s and VA2’s guardian (G), VA1, VA2, and another client of the facility (C). According to VA1’s Coordinated Services and Supports Plan (CSSP), VA1 lived at the facility for services and supports related to activities of daily living and was diagnosed with intellectual disabilities. According to VA1’s Individual Abuse Prevention Plan (IAPP), VA1 was susceptible to emotional abuse and “not even realize that it is emotional abuse.” VA1 “may not always tell the truth when [s/he] is being confronted about things and then at times will come back later and be accountable.” VA1 enjoyed watching sports, playing video games, and hanging out with his/her partner. According to VA2’s Person Summary, VA2 was diagnosed with severe intellectual disabilities. According to VA2’s IAPP, VA2 was susceptible to emotional abuse. VA2 “may receive communication from others differently than what is intended and also may embellish what someone has said to turn around the situation to suit [his/her] needs or wants.” VA2 “may at times ask staff personal questions which could lead to inappropriate conversation. [VA2] knows [s/he] is not supposed to ask personal questions and staff will not discuss personal issues.” VA2 enjoyed watching dirt racing, going to church, and shopping. VA1 provided the following information: · When the SP “first started” working at the facility, VA1 and the SP “got along.” As the SP worked more, s/he “started with [his/her] anger issues.” VA1 stated that “every time [the SP] came in” to work, the SP complained and brought his/her “personal life” into work. When the SP “got mad” s/he called VA2 a “dumbass,” “lazy,” and “retarded,” (R-word) but did not call VA1 any names. VA1 could not provide details regarding the incidents between the SP and VA2. · On August 7, 2024, VA1 was on the phone with his/her partner when the SP said “inappropriate stuff about masturbation” that VA1’s partner could hear, including commenting on VA1’s tendency to masturbate frequently. VA1 “just kept talking [on the phone] and left the room.” VA1’s partner told VA1, “I really don’t like that [person],” and that s/he did not like the way that the SP talked to VA1. VA1 stated that the SP’s comments about masturbation were not “a joke,” were “so fucked up” and that it made VA1 “so pissed off.” VA1 stated that was the first and only time the SP made jokes about VA1 masturbating. · On an unknown date, the SP said “sexual things” about the G, including that the SP offered to pay money to the G for a sexual encounter. VA1 asked the G about this, and the G stated that it was not true. VA1 expressed concern that the SP’s lied about the G which could endanger the G’s job. VA1 stated that the SP was a “compulsive liar” and told stories of his/her sexual partners that VA1 did not believe were true. On other occasions, the SP talked about his/her genitals and told VA1 about “how long” his/her sexual encounters lasted. VA1 stated that s/he did not want to hear about the SP’s sex life. VA2 provided the following information: · On an unknown date after VA2’s annual meeting, s/he and the SP were “talking and bullshitting” when the SP “brought up” an incident when VA2 had lied and VA2 had not “made peace with.”. The SP proceeded to tell VA2 that the SP did not have to be VA2’s “friend” and that the SP did not have to and would not “do anything” for VA2. · On unknown dates, the SP swore at VA1, VA2 and the C. When asked what words the SP used, VA2 stated that the SP said the clients needed to “back off,” asked, “What the fuck is your problem?” and called the VA2 a “smartass.” The SP also called other clients (unknown) “assholes,” and at first VA2 thought the SP was joking, but later “realized” that the SP was not joking. VA2 was not able to provide additional details about the incidents. · On an unknown date after an outing to Walmart, the SP told VA2 that the SP had sexual relations with a Walmart cashier and that s/he was “doing the dirty deed” with other people as well. The SP told VA2 that s/he had “dirty pictures” of naked people and showed the photos to VA2. When asked if the SP discussed other sexual topics, VA2 stated s/he was not aware of any other incidents. · VA2 stated that the SP told him/her that if VA2 “did anything like tried to get [the SP] in trouble,” the SP would take outings away from VA2. The C provided the following information: · The C stated the SP talked about his/her “sex life” with clients, including the C. The C stated that during an outing at Walmart, the SP told the C that the SP was “sleeping with” a person they saw at the store. The C stated that the “sex thing” made him/her feel “awkward.” · The C heard the SP say that VA2 was a “dumbass” a “few times,” but did not know if the SP ever said it to VA2 or in VA2’s presence. The C never heard the SP call any client any other names. The SP never called the C any names, but “if [s/he] did,” the C was “fine with it” because the SP was “just kidding.” The C stated that no staff persons spoke to the C in a way that s/he did not like. P1 provided the following information: · The clients at the home have sexual desires that they take care of “behind their bedroom doors.” On August 7, 2024, P1 and the SP were working at the facility when P1 heard the SP comment to VA1 in front of other clients about VA1 masturbating. P1 could not recall what exactly the SP said. When P1 asked the SP, “Why would you say that?” the SP responded, “Because I can.” Around 7 p.m. the same day, P1 asked VA1 if s/he was offended by what the SP said. VA1 “tried to play it off” and said, “If you live in a group home long enough you get used to it.” · The next day (August 8, 2024) VA1 asked P1 if they could talk in the garage. VA1 and P1 went to the garage and VA1 told P1 that what the SP said about VA1 masturbating the day before “bothered” VA1. P1 did not ask VA1 additional questions because P1 did not want to “pry.” P1 and VA1 left the garage, and P1 went to speak with P2 about what VA1 reported, and they decided that they “needed to say something” to management. · At the time of the incident, P4 was on vacation so on August 9, 2024, P1 told P5 about the incident. The same day when P1 went to work, the SP “confronted” P1 said that P1 should have spoken to the SP about it before going to management. P1 stated that the SP made him/her feel “very uncomfortable” and that the SP’s actions “took a toll” on clients’ mental health. P1 said that s/he “could tell it made the clients feel like shit,” and described VA1 and VA2 as “avoiding [the SP] like scared children.” · P1 stated that the SP had “no filter” and talked about his/her personal life in a “very explicit way” including his/her “sexual life” which made staff persons and clients feel “uncomfortable.” · P1 stated that VA1 told him/her that VA1 heard the SP call VA2 a “dumbass” on one occasion but P1 did not have additional details regarding the incident. P1 stated that when the SP first got hired, s/he used the R-word at work, but that was reported and “resolved in some way.” P1 did not hear the SP call any clients any other names. P1 stated that s/he “knew [VA1 and VA2] well” and could tell when they were lying or telling the truth because s/he “knew these [guys/gals].” P2 provided the following information: · P2 stated that the SP “always” talks about people s/he had sexual contact with in “graphic detail.” P2 “confronted” the SP about it and the SP told P2, “Nothings gonna happen.” The SP also said that s/he had sexual contact with the G, but the SP “lied a lot,” so P2 did not know if it was true. · On August 8, 2024, P1 told P2 that VA1 got a phone call and the SP “totally made fun” of VA1 in front of the other clients when the SP made a comment about VA1 masturbating frequently. P1 also told P2 that s/he tried to talk to VA1 but VA1 did not want to talk about it. The next day, P1 told P2 that VA1 approached P1 and told him/her that VA1 “did not appreciate the way [the SP] was talking to [him/her].” · P2 stated that on multiple occasions during P2’s shifts VA1 and VA2 told him/her “horrible things” about the SP’s treatment of them that included the SP calling them “dumbasses,” “pussies,” and “bitches.” P2 did not have additional details regarding the incidents. P2 also stated that the SP “yelled” at the clients using a “brutal” tone of voice and that the SP had “no filter.” P2 described the way that VA2 felt after the incident as “terrified.” P2 did not witness the SP’s actions as described by VA1 and VA2 because P2 did not work the same shift as the SP. · P2 stated that s/he never told P4 about what VA1 and VA2 said because the SP seemed “untouchable.” In the past, when the SP threatened to quit, P4 “tucked [his/her] tail between [his/her] legs” and “begged” the SP not to quit. P3 provided the following information: · P3 stated that when s/he worked with the SP “sometimes shouted” at VA2. P3 thought it was a “joke” but added that “[yelling at the clients] was not right.” P3 stated that the SP “threatened” VA2, stating that the SP was going to have VA2 kicked out of the facility because s/he lied about the SP. P3 stated that s/he “could see in their faces” that the clients felt “uncomfortable.” The SP told P3 that s/he yelled at VA2 with his/her “army voice.” P3 did not have additional details regarding the incidents. · P3 stated that s/he was unaware of any other concerns regarding the SP. P4 provided the following information: · On August 9, 2024, P4 was on vacation when s/he received a text from P1 stating there was an “issue” at the facility. P4 asked P1 if it was urgent, which P1 stated that it was. P4 then asked P5 to meet with P1. P4 later learned that P1 told P5 that the SP was calling clients names and said something about VA1 masturbating. · When P4 returned from vacation, s/he asked VA1 and VA2 about what happened and VA1 said that the SP made “some comment about [VA1] masturbating.” VA1 stated that the SP’s comments did not “really” bother him/her, however, P4 added that VA1 is not always “open or truthful” with information about how s/he feels. VA2 stated that the SP called him/her a “dumbass” but that s/he didn’t “mean it.” VA1 and VA2 did not provide any additional details to P4 regarding the incidents. P4 stated that VA1 was “not always truthful or open about information,” and that VA2 “lied” about the SP’s actions in the past. · Approximately one year prior, the SP had “inappropriate” conversations with clients and staff persons. The SP shared information about his/her personal life with clients, used profanity, and said the R-word. At that time, the SP received training on boundaries and respectful treatment. The G said that s/he believed the care VA1 and VA2 received from the facility was “great” and they kept the G informed about “a lot of things.” VA1 and VA2 told the G that the SP “always bothered” and “tried to control” VA1 and VA2 because s/he called them names and did not allow them to do what they wanted to do. VA1 and VA2 did not provide any additional details to the G regarding the incidents. The SP provided the following information, · The SP and VA1 “joked around quite a bit.” The SP stated that VA1 called the SP a “dumbass” and an “asshole” and the SP responded similarly by calling VA1 a “dumbass.” The SP stated that the only client s/he “joked around with” in that manner was VA1. VA1 did not tell the SP that s/he did not like the interactions and if VA1 would have told the SP to stop, the SP “would have stopped.” · The SP stated that s/he joked with VA1 on one occasion, about VA1 masturbating, but that s/he was “just joking.” The SP stated that VA1 “never brought it up to anyone” until P1 asked VA1 how s/he felt about the jokes. According to the SP, VA1 told P1 that s/he “didn’t mind” the jokes and “knew” that the SP was “joking.” The SP added that if VA1 was bothered by the jokes, s/he would have told the SP. The SP stated that P1 overheard and “didn’t like” the interaction between the SP and VA1. The SP stated that P1 never discussed his/her concerns about the SP’s interactions with the SP. · The SP stated that VA2 overheard the SP “jokingly” call VA1 a “dumbass” and then told other staff persons that the SP also called VA2 a “dumbass.” The SP stated that s/he never called VA2 a “dumbass” or a “bitch” and that s/he did not call VA1 or VA2 any other names. The SP added that VA2 tried to “get [the SP] in trouble” and that VA2 “always lied” about the SP since s/he lived at the facility. Facility documentation showed that on September 7, 2023, a phone conference was held between the SP, P4 and another staff person (P5) regarding the SP having “inappropriate conversations” at the facility. The SP shared personal information about his/her marriages, boyfriends/girlfriends, and military background, as well as used the R-word and other derogatory language. At the conference, the SP stated that the concerning language was said over the phone and “not about or directly to any of the individuals or staff.” The SP was given the facility’s Code of Conduct to review. The SP provided consistent information regarding this incident to this investigator when asked about prior corrective action or discipline. The SP stated that s/he did not call any client the R-word but stated that VA2 overheard the SP call a trash can the R-word. Facility documentation P1, P3, P4, and the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, and that P2 and P5 did not have that training on file. Facility documentation also showed that P1, P3, P4 and the SP received training on VA1’s and VA2’s plans. Although P2 stated that s/he received training on VA1’s and VA2’s plans (which was in accordance with Minnesota Statutes, section 245.09, subdivision 4a), the facility had no documentation that supported P2’s training on either plan which was a violation of Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a), clause (2), which states in part that the license holder must maintain a personnel record of each employee to document orientation and training as required under section 245.09, subdivisions 3 to 5, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Relevant Rules and/or Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights include the right to be treated with courtesy and respect. Conclusion: P1, VA1, VA2, and the C provided consistent information that on September 7, 2024, the SP made a comment to VA1 in front of others about VA1’s frequency of masturbating. In addition, information from all sources, except the SP, was consistent that the SP called VA1 and/or VA2 names including “dumbass,” “lazy,” and/or “retarded.” P1, P2, P3, P4, and the G had no firsthand observations of the SP calling clients names and were provided the information from VA1 and VA2. VA1 said that the SP called VA2 such names but did not call VA1 any names. VA2 said that the SP asked VA2, “What the fuck is your problem?” and called the VA2 a “smartass” and called other clients (unknown) “assholes.” The C said s/he heard the SP say that VA2 was a “dumbass” a “few times,” but did not know if the SP ever said it to VA2 or in VA2’s presence. The C never heard the SP call any client any other names. No person had any additional details regarding the incidents when the SP called VA1 and/or VA2 names. The SP acknowledged that s/he called VA1 a “dumbass” but stated it was done solely after VA1 called the SP a “dumbass” and commented one time to VA1 about VA1’s masturbation. The SP denied calling VA1 any other names and denied calling VA2 names. The SP stated that s/he was only “joking” with VA1 and that VA1 “didn’t mind” the jokes. The SP’s interactions with VA1, including calling VA1 a “dumbass” and commenting on VA1’s masturbation, were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Humas Services and were a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that no person, including VA1 and/or VA2 could provide details of the incidents, and that there were no other persons who witnessed the SP calling any clients names, there was not a preponderance of the evidence whether the SP’s interactions included repeated oral language that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be expected to produce emotional distress. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening.) Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were not adequate or followed. There was a need for additional staff training, and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On October 24, 2024, the facility was issued a Correction Order for the violations outlined in this report.
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