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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: 1103246-SUD (Substance Use Disorder) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a staff person (SP) was suspected of having an inappropriate relationship with a vulnerable adult (VA). Date of Incident(s): August 1, 2024, prior and ongoing 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 15, 2024; from documentation at the facility; and through seven interviews conducted with four facility staff persons (P1, P2, P3, P4), the VA’s probation officer (PO), the VA’s significant other (SO), and the VA. This investigator made attempts by phone and mail to request an interview with the SP. Attempts were unsuccessful. The VA was receiving services at the facility for substance use disorder starting on June 27, 2024. The VA had symptoms consistent with anxiety and depressions which created a “barrier” to recovery. The VA’s goals were to become a “better” person and regain relationships and trust from others. The Individual Abuse Prevention Plan indicated that the VA was susceptible to sexual and emotional/mental abuse because the VA was likely to seek or cooperate in an abusive situation. The VA provided the following information: · The VA said that the SP and the VA had a “connection” at the facility and started talking, playing cards, and flirting. This led to the SP and the VA kissing on one or more occasions in the janitor closet and in the “wait” room. The VA also slapped the SP on the butt. · On one occasion, the VA’s laundry was in the wash and s/he did not have any clean underwear. The SP gave the VA some extra underwear that the facility gave out to clients. The SP asked for a photograph of the VA in the underwear. The VA took the SP’s phone into the shower and took a video of the VA in the shower on the SP’s phone. · The SP made comments about seeing the VA after the VA left the facility. The VA left the “door open” and said, “We will see.” · On one occasion the SP mentioned that s/he was going to get some cocaine and have someone drop it off at the facility. The SP asked if the VA wanted any. The VA did not say much to the SP but went back to his/her bedroom. The next day the SP told the VA that s/he had “missed out.” The VA was not sure if the SP shared the cocaine with any clients. P1-P4 provided the following information: · The SP typically worked the 3-11 p.m. shift at the facility with one other staff person. During his/her shift the SP would be responsible to complete hourly rounds, assist with getting chores done, and make sure the clients were following the rules. · On August 2, 2024, a staff person reported that the SP touched the VA’s face. Supervisory staff persons reviewed camera footage from the facility for the last several days and noticed several incidents of inappropriate interactions between the VA and the SP. · P2 said it was clear from the first time P2 worked with the SP that the SP and the VA were flirtatious with each other. The SP and the VA laughed with each other, giggled, and put hands on one another’s shoulders. · On July 14, 2024, P2 worked with the SP and could not find the SP for two hours. P2 finally found the SP in the gym with the door closed sitting on the floor with the VA and another client. There were no cameras in the gym area. · The SP had been talked with in the past about wearing inappropriate clothing. The SP also had one occasion of a urine analysis that was positive for cocaine in February 2024. The SO provided the following information: · While at the facility the VA had a phone that previously belonged to the SO. The SO found a friend request on social media from the SP, along with photos and messages from the SP to the VA on the phone. The messages talked about the SP missing the VA and how the SP could not “wait to be together.” · There were also photographs/videos of the VA and the SP inside the facility. In one video the SP zoomed in on a client and then onto a board with the SP’s plus the VA’s initials on it and it said “this bitch just literally put our initials on the board” with a laughing face. Another video was in the workout room that said, “Getting a lap dance right now.” A third video was the SP in front of a computer in the staff person area with the VA right behind the SP. (The SO provided copies of these videos to this investigator as described however this investigator could not make out the words written on the videos). · The VA told the SO that the VA and the SP kissed and hugged while at the facility. The VA also slapped the SP’s butt. The SP brought cocaine into the facility and offered some to the VA. The PO said that s/he was informed of the allegation by a staff person. When the VA met with the PO, the VA mentioned that a staff person brought cocaine into the facility and when asked if this was the same staff person that the VA was having “sexual relations” with, the VA said, “Yes.” The SP did not respond to this investigator’s attempts for an interview. Video footage from the facility showed the following interactions: · The VA touched the SP’s elbow and then tickled the SP’s waist. The SP gave something to the VA on the VA’s finger and the VA licked it off. · The VA and the SP were sitting outside on a bench, and it appeared the VA had his/her hand on the SP’s lower back area. The SP and VA moved very close together, but it was unclear if they kissed. When the SP got up and moved away it appeared that the VA’s hand was on the SP’s bottom. · The SP and the VA sat next to each other at a table. The SP leaned down to grab something under the table near the VA. They smiled at each other, and the SP put his/her head back down toward the VA’s crotch and the VA put his/her hand on the SP’s head. · The VA was sitting on a picnic table when the SP came up and stood between the VA’s legs. The VA put his/her arms around the SP’s waist and rubbed the SP’s back. · The SP laid on the bench of a picnic table with his/her legs propped up on the table. The VA came over and laid on the table with his/her head next to/touching the SP’s legs. The VA wrapped one arm around the SP’s legs. Phone screenshots between the SP and VA showed a photo of the SP with the VA standing behind the SP. The SP said, “I miss you sm (so much).” On August 14, 2024, the SP said, “Please get out soon, need some of you in my life,” “been missing you and thinking about your ass everyday ma [boy/girl].” On August 15, 2024, the SP said, “Literally think about you every day, I can’t wait to see you and be with you.” An Incident Report showed that on July 5, 2024, a client reported that the SP offered a client cocaine while the SP was working (it was unclear as to the identity of the client). The incident report was made after the SP no longer worked at the facility. A note dated July 18, 2024, showed that the SP was talked with about his/her boundaries and not being friends with the clients. The Personal Relationships with Clients policy stated that relationships between staff persons and individuals was strictly professional. Sexual contact between staff persons and individuals while receiving treatment or within two years after the individual left the facility was subject to civil liability to the individual and was grounds for immediate termination. The Prohibiting Client Abuse policy stated that any sexual contact or penetration between a staff person and an individual receiving services was prohibited. All staff persons were trained on Reporting of Maltreatment of Vulnerable Adults Act and the facility policies prior to the incident. Conclusion: A. Maltreatment: The VA said that the SP and the VA flirted while at the facility and kissed on one or more occasion. The SP asked the VA for a photograph of the VA in his/her underwear prompting the VA to use the SP’s phone and take a video of the VA in the shower. The VA slapped the SP on the butt. On one occasion, the SP brought some cocaine to the facility and asked the VA if s/he wanted some although the VA declined. P1-P4 said that it was reported that the SP touched the VA’s face. Video footage showed multiple inappropriate interactions between the SP and the VA. The SP and the VA were flirtatious at the facility touching each other’s shoulders and on one occasion were found in the gym with the door closed. The SP had tested positive for cocaine in a previous urine analysis. Video footage from the facility showed the SP and VA touching each other intimately on the elbow, waist, back, butt, and legs. Text messages showed the SP telling the VA that the SP missed the VA and wanted to be with the VA. Regarding sexual abuse: Although the VA denied having sexual contact with the SP given that the VA and the SP kissed on at least one occasion, touched each other intimately including the VA touching the SP on the butt, and had a flirtatious relationship while at the facility, there was a preponderance of the evidence that the VA’s touch to the SP’s butt which was an intimate part indicated sexual intent between the VA and the SP. 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: Although the VA denied having a sexual relationship with the SP, information showed that the SP and the VA kissed on at least one occasion, that the SP communicated messages to the VA while the VA received services that indicated a close relationship and flirted with the VA while at the facility, that the SP brought cocaine into the facility and offered some to the VA, and that the VA and the SP and the VA touched each other intimately. Given that the VA had a history of substance use, it was reasonable that s/he would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety, so the SP’s interactions with the VA likely 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 him/her with therapeutic services, both now and in the future. Therefore, there was a preponderance of the evidence the SP’s interactions with the VA were detrimental to the VA’s ongoing mental health and were a failure to supply the VA with necessary care and services to maintain the VA’s mental health and safety. 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 had a personal and/or sexual relationship with the VA during his/her time at the facility and participated in behaviors that were untherapeutic. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and facility policies and procedures, including the Personal Relationships with Clients policy. 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 contact with sexual intent 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. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate. All staff persons were retrained on relevant polices. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
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