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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: 1091053-SUD (Substance Use Disorder) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a sexual relationship with a facility staff person (SP). Date of Incident(s): April 2024-July 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 five interviews conducted with two facility staff persons (SP, P), two non-facility service providers (CP1, CP2), and the VA. The VA was diagnosed with major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, and substance use disorder. The VA enjoyed listening to podcasts, exercising, and art. The VA received services at the facility for substance use disorder. The VA was admitted on February 14, 2024, on medium intensity services and then began low intensity services on April 15, 2025. On June 7, 2024, the VA was discharged and moved out of the facility. The VA provided the following consistent information to this investigator, CP1, and CP2: · The VA went to the facility in February 2024 and around Mid-April 2024, s/he started a sexual relationship with the SP. Around that time, the VA made a comment that it looked like the SP had a great night or weekend. The SP said that s/he had used his/her vibrator. The following week the VA asked if the SP knew anyone that could cut the VA’s hair. The SP gave the VA a phone number which was the SP’s. · The VA worked in the community typically in the evenings. On Fridays the VA did not work and went to the SP’s apartment instead and had sex with the SP on multiple occasions. Sometimes the SP gave the VA rides to and from the facility or the VA took an Uber to and from the SP’s apartment. · The SP often made excuses for the VA so s/he did not get in trouble at the facility for being late to meetings and got the VA name brand clothing from the donated clothing at the facility. · The VA left the facility in June 2024, and moved to an apartment in the community. The SP and the VA continued their relationship and the VA apartment sat for the SP when s/he went out of town for several days. The VA took care of the SP’s animals and was paying for groceries and pet food. The VA ended up relapsing because the SP had alcohol and marijuana at his/her apartment. · A friend of the VA’s told the VA that the SP was taking advantage of the VA. The VA left the SP’s apartment when the SP returned from his/her trip and took the VA’s things. The SP was upset with the VA and called the VA a “piece of shit.” The SP wanted his/her carpet cleaner that s/he had borrowed to the VA. The carpet cleaner was returned to the SP. The VA and the SP stopped communicating shortly after that. The P provided the following information: · The VA resided at the facility from February 14 through June 7, 2024. When the VA arrived s/he was on “medium intensity” and moved to “low intensity.” This meant that the VA participated in programming in the mornings and could find employment in the afternoon and evenings and leave the facility to go to work. The VA gained employment at some point during his/her stay and was working “quite a bit.” The facility clients signed in and out when they left the facility and when they returned. · Toward the end of the VA’s admission s/he had secured an apartment, got furniture, and saved up money for rent. The P thought the VA had a good experience at the facility and did well while s/he was there. The P did not hear about any inappropriate interactions or relationships involving the VA and the SP while the VA was at the facility. · After the P learned of this investigation (September 2024), s/he mentioned to the SP that there was a report of an inappropriate relationship reported between the VA and a staff person. About a half an hour later, the SP said that s/he was not feeling well and that s/he needed to go home. The SP went home and shortly after the SP sent s text message to the staff person that handled scheduling at the facility. The SP said that s/he needed to be taken off the schedule because it was too stressful. The staff person tried to reach back out to the SP, but the SP did not respond, and other staff persons said that they could no longer see the SP on social media. · The SP’s schedule was Monday through Thursday and every other weekend with Fridays off. The SP’s job responsibilities included assisting with medication compliance, signing individuals in and out of the facility, monitoring performance of program expectations and redirecting as necessary, administering breathalyzers and urine analysis tests, performing room cleanliness checks, monitoring completion of daily house tasks, assisting individuals with online meetings and/or appointments, transporting individuals to appointments, meetings, or other destinations, and leading weekly morning meditation. The SP provided the following information: · On one occasion, the SP ran into the VA in the community after the VA had left the facility. The VA mentioned that his/her new apartment smelled like dog. The SP told the VA that s/he had a carpet shampooer that the VA could borrow. They exchanged phone numbers and then set up a time for the SP to drop off the shampooer at the VA’s apartment. The SP dropped off the shampooer on the landing of the VA’s apartment building. · After “quite a while” the SP was able to get the carpet shampooer back from the VA. The VA left the shampooer on the landing of the VA’s apartment building and the SP picked it up. · The VA never went to the SP’s apartment or watched the SP’s animals when the SP was out of town. The SP said s/he did not have sexual intercourse or other sexual contact with the VA. · When asked about text messages that showed a more intimate relationship, the SP said that s/he had no idea why the VA sent those texts and was “confused.” The SP did not want to “feed into” it. Text messages sent between the VA and the SP starting July 20, 2024, showed the VA saying that the VA wanted to still be friends. The SP responded that was fine but that s/he needed his/her shampooer back or money for it. The SP said s/he paid $110 for the shampooer and sent a screenshot with the item and price on Amazon. On July 27, 2024, the SP said, “Nothing to say now?” The VA said that s/he had to work that night but was available on Monday. The SP said that s/he needed the shampooer back and that Monday worked. The VA said, “If I was just a fuck that’s all you had to say.” The SP responded with, “If that’s what you think. Ok.” The VA said that s/he felt the SP “kinda played” the VA to the SP’s “advantage.” The VA said that s/he missed being with the SP and asked if the SP wanted to pick up the VA from work. The SP said s/he wanted the shampooer, asked how s/he “played” the VA, and asked when the SP worked and when s/he got off work. The VA responded with the place s/he worked and the time s/he got off. The VA also said that s/he left some clothing at the SP’s home and hoped the SP still had the clothing. The SP said s/he was not able to pick up the VA and that the VA did not leave any clothing at the SP’s home. The SP agreed to meet on Monday at 4 p.m. to pick up the shampooer. Uber records provided by the VA showed trips between the SP’s apartment building and the facility on the following dates: April 19, 2024, from 10:58-11:13 p.m., April 26, 2024, from 4:09-4:28 p.m., May 10, 2024, from 10:21-10:31 p.m., and from 10:14-10:25 p.m., and May 17, 2024, from 10:10-10:25 p.m. The VA’s Low Intensity Sign-Out Sheets showed the following check ins and check outs to “work” on April 19, 2024, from 12:55-11:15 p.m., on April 26, 2024, from 4:10-10:30 p.m., on May 10, 2024, from 1:57-10:35 p.m., and on May 17, 2024, from 12:57-10:40 p.m. The VA provided a photo dated July 17, 2024, which showed the VA with a dog which the VA said was the SP’s. The VA provided a video of the SP walking to the front of a building (likely the VA’s apartment) to get a shampooer and putting it into the trunk of a car. The SP then got into the vehicle and drove away. A text message to the staff person that handled the scheduling from the SP dated September 26, 2024, said that s/he was terminating his/her “passion” as of that day as the job was taking a toll on his/her health. The staff person responding asking if there was anything that the facility could do to make it a better work environment or give the SP some extended time off to focus on his/her health. There did not appear to be any response. The facility policies stated that staff persons were to not engage in any sexual behavior with a client including sexual contact and any physical, verbal, written, interactive, or electronic communication, conduct or act that may be reasonably interpreted to be sexually seductive, demeaning, or harassing to the client. All staff persons interviewed were trained on Reporting of Maltreatment of Vulnerable Adults Act and the facility policies prior to the incident. Conclusion: A. Maltreatment: The VA provided consistent information to this investigator, CP1, and CP2 that in mid-April 2024, while the VA was residing at the facility, s/he started a sexual relationship with the SP. The VA went to the SP’s apartment on Fridays when the VA was not working. Sometimes the SP gave the VA rides to and from the facility or the VA took an Uber to and from the SP’s apartment. When the VA left the facility in June 2024, the VA and the SP continued the relationship and the VA apartment sat for the SP when s/he was out of town. The VA ended up relapsing because the SP had alcohol and marijuana at his/her apartment. The relationship ended and shortly after the VA and SP spoke about returning a carpet shampooer that the VA had borrowed. After the SP got his/her carpet cleaner back the SP and the VA stopped communicating. A text message chain starting July 20, 2024, showed the VA saying that s/he still wanted to be friends. The SP said that was okay but needed his/her shampooer back. The VA said, “If I was just a fuck that’s all you had to say.” The SP responded with, “If that’s what you think. Ok.” The VA said that s/he felt the SP “kinda played” the VA to the SP’s “advantage.” The VA said that s/he missed being with the SP and asked if the SP wanted to pick up the VA from work. The SP said s/he wanted the shampooer, asked how s/he “played” the VA, and asked when the SP worked and when s/he got off work. The VA responded with the place s/he worked and the time s/he got off. The VA also said that s/he left some clothing at the SP’s place and hoped the SP still had the clothing. The SP said s/he was not able to pick up the VA and that the VA did not leave any clothing at the SP’s home. Uber records provided by the VA showed trips between the SP’s apartment building and the facility on the following dates: April 19, 2024, from 10:58-11:13 p.m., April 26, 2024, from 4:09-4:28 p.m., May 10, 2024, from 10:21-10:31 p.m., and from 10:14-10:25 p.m., and May 17, 2024, from 10:10-10:25 p.m. These records corresponded with the VA’s check ins and outs on the Low Intensity Sign-Out Sheets. The SP said that s/he ran into the VA in the community after s/he left the facility. The VA needed to borrow the SP’s carpet shampooer, so they exchanged phone numbers and the SP dropped off the shampooer at the VA’s apartment building. Later the SP arranged to come back and get it. The VA never came to the SP’s apartment or watched the SP’s animals when the SP was out of town. The SP said s/he did not have sexual intercourse or other sexual contact with the VA. When asked about the text messages that showed a more intimate relationship, the SP said that s/he had no idea why the VA sent those texts. The SP did not want to “feed into” it. Regarding sexual abuse: Although the SP denied having sexual contact with the VA, given that the SP had reason to minimize his/her actions for fear of consequences, that the VA provided consistent information to this investigator, CP1, and CP2 that the VA and the SP had a sexual relationship, and that text messages and Uber receipts confirmed the VA’s information, there was a preponderance of the evidence that the SP had sexual contact with the VA. 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 SP denied having a sexual or personal relationship with the VA, information provided including text messages showed that the SP and VA communicated via text message outside of the facility and Uber rides showed that the VA went to the SP’s home on four occasions while the VA received services from the facility. The VA provided consistent information that the SP and the VA were in a relationship which also included sexual contact. 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 sexual relationship with the VA while the VA received services at the facility and after. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and facility policies and procedures. 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 neglect that the SP was responsible for was not determined to be serious or recurring maltreatment because the VA did not sustain an injury and the relationship was a single pattern of behaviors. However, the substantiated sexual abuse the SP was responsible for was serious and recurring maltreatment because the SP and the VA had sexual contact on more than one occasion and sexual abuse meets the definition of serious maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was 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. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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