|
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: 1072471-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) inappropriately touched a vulnerable adult (VA) on more than one occasion. The VA’s roommate (RM) witnessed the SP being in the VA’s room with the door locked. Date of Incident(s): Prior to November 27, 2023 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 7, 2023; from documentation at the facility and through six interviews conducted with two facility staff persons (the SP and P1), a case manager (CM), the VA, a roommate (RM) at the facility, and the RM’s family member (FM). The VA was very social and enjoyed spending time with others. The VA was talented in the kitchen as well as creative with arts and enjoyed drawing, painting, singing, and knitting. The VA enjoyed dressing fashionably. The VA’s routine included going to bed around 6:30 p.m. The VA had a history of inappropriate boundaries with strangers, staff persons, friends, and family. The VA’s diagnoses included schizoaffective disorder, major depression, intermittent explosive disorder, post-traumatic stress disorder, anxiety disorder, attention deficit hyperactivity disorder, and borderline personality disorder. The VA was not subject to guardianship. The VA’s Functional Assessment stated that poor boundaries made the VA vulnerable to abuse in all forms. The facility was a two-story townhome with three bedrooms on the upper floor. The VA and the RM shared a master bedroom and the two other clients had single bedrooms. The townhome had two entrances: one on the front side of the building and one on the back, with the back entrance being inside an attached garage. A staffing schedule showed that one staff person worked each shift. The overnight staff persons were not required to remain awake. According to P1, an administrative staff person: · On November 27, 2023, the VA told a day program staff person (DP) that “something” was going on with the VA and an unidentified staff person. The VA did not provide details, but said it was “bothering” him/her and the DP suggested the VA talk to P1. The DP talked to P1 and P1 went to the facility that evening to talk to the VA. · The VA told P1 that a staff person (identified as the SP) touched the VA inappropriately and would “dry hump” the VA in the VA’s bedroom. The VA also said that the SP put his/her hands in the VA’s pants and touched the VA’s genitals. · P1 asked about the RM because the VA and RM shared a bedroom. The VA said that s/he went to bed earlier than the RM and the SP came upstairs into their bedroom before the RM went to bed. The VA said that on one occasion, the RM tried to get into their bedroom, but the door was locked with the SP in the room with the VA. · When P1 talked to the RM, the RM said that s/he came up to his/her bedroom, the door was locked, and the SP was in the room with the VA. Neither the VA nor the RM were able to provide a timeline and/or date. · P1 said that the VA “never” said anything like this before; however, due to the VA’s diagnoses, the VA’s ability to accurately report information “can be jaded.” P1 said there were some prior concerns regarding an older person of the SP’s gender at a local YMCA and also said that the VA had a “history of infatuation” with “older” persons of the SP’s gender. The VA provided the following information when interviewed by a law enforcement officer (LEO) and this investigator: · The VA said that the SP was his/her least favorite staff person because on one occasion the SP called the VA “stupid.” When asked if there were any other reasons the VA did not like the SP, the VA said, “No. Oh, plus [the SP] touched me down there” (indicating his/her genital area). · The VA said the first incident occurred late summer of 2023. The SP came upstairs, entered the VA’s bedroom, and said the VA’s name. The VA was in his/her bed facing away from the door when s/he “heard” the SP lock the bedroom door. The SP then sat next to the VA on the bed. The VA was wearing night clothing that went to his/her knees and was covered with his/her comforter. The SP removed the comforter, pulled the VA’s underwear down, and “tried” to touch the VA’s “crotch.” The VA asked the SP to stop “a few times.” The SP digitally penetrated the VA, asked the VA to touch the SP’s genitals under the SP’s clothing, and also rubbed his/her genitalia on the VA’s “crotch.” The incident lasted about 20-30 minutes and at some point, while the SP was on top of the VA, the RM knocked on the locked door. The VA said s/he “ran” to the door and when the VA opened the door the RM asked the VA what s/he was doing. The VA told the RM that s/he and the SP were “just talking.” (The VA said that the RM told the VA that s/he did not remember knocking on the locked bedroom door due to the RM having a brain injury. During a follow up interview with the VA, the VA did not remember what s/he told the RM about the incident, but again confirmed that the RM told the VA that s/he did not remember knocking on a locked bedroom door.) · The SP said that s/he had to stop because s/he had an orgasm. The SP unlocked the bedroom door and went downstairs to “clean [him/herself up]” and the VA went to bed. · During the first interview the VA said there were “two to three” additional incidents similar to the first incident, with the last incident being “after” Halloween (2023). During a follow up interview, the VA said there were “three to four incidents.” The first incident was the only time the RM tried to enter the locked bedroom. Each time the SP told the VA not to tell anyone. The facility’s Incident Report and Internal Review provided the following information: · The VA said that the SP entered his/her bedroom to administer medications, closed and locked the door, and put his/her hands between the VA’s legs and rubbed the VA’s genitals. This occurred on more than one occasion and there was never penetration. The VA said that the incidents occurred when the RM was not at the facility. The VA said that when the most recent incident occurred, the RM attempted to enter the bedroom. · The RM said that on an unknown date, s/he returned to the facility and attempted to get into his/her bedroom, but the door was locked. The RM asked the VA to open the door and the SP opened the door. The VA was sitting on the edge of his/her bed and the SP left the room. The RM said s/he was upset about being locked out of his/her bedroom. The VA told the RM that the SP touched the VA’s genitals and was “trying to have sex” with the VA before the RM arrived. The RM provided the following information when interviewed by the LEO and this investigator: · On an unidentified date, the RM was “coming home from vacation” and the bedroom door was locked. The VA and SP were in the bedroom. The RM told the SP to let him/her in. When asked how the RM knew the SP was behind the locked door, s/he said the SP was not downstairs when the RM returned and s/he heard the SP say, “Just a moment” and it took “a few seconds” before the SP “answered the door.” The SP was standing, and the VA was sitting on his/her bed. The VA said they were “just talking.” When asked what the VA was wearing, the RM said, “pajamas” and then added, “I didn’t look. I was upset they would lock me out.” The SP looked “happy to see” the RM. The SP said the door was locked because s/he was used to locking the entry door from the garage. The VA and the SP were “acting normal.” · The RM was “upset” about being locked out of the bedroom and “threw [his/her] suitcase on the bed.” The RM remembered it was still “sunny” outside when s/he returned that day. · The RM said that prior to the incident, the VA “was acting very inappropriate” and watched “inappropriate sexual videos” at the facility. · The VA told the RM that s/he “felt like [s/he] was assaulted” by the SP “two weeks ago” and told the RM about being touched sexually by the SP. (The RM was interviewed the first week of December 2023.) · The RM said the VA told the RM’s family member (FM) about being assaulted by the SP. Prior to a follow-up interview with the LEO and this investigation, the RM said that the FM was “trying to help me remember” what occurred, and the FM talked to the RM twice and “had some questions” for the RM. The FM confirmed there were occasions between July and November 2023 when the FM and RM went out of town. The FM was also at the facility weekly to go shopping with the RM. The RM left and entered the facility through a service door inside the attached garage. While the FM said that the RM had a traumatic brain injury but “would not make things up.” The SP provided the following information: · The SP worked at the facility for approximately a year. On two occasions the VA did not come downstairs for his/her morning medications, so the SP brought them up to the VA’s bedroom. On one of those occasions the RM was also in the bedroom. · The SP described the VA as “always in a state of anxiety.” · The SP denied ever being in the VA’s bedroom with the door locked. The SP said that it “shocks” him/her that the RM would say the bedroom door was locked because the RM was “a responsible person.” The SP said there was a day when the RM was out of the facility with the FM and when the RM returned, the RM had to knock on the entry door inside the garage because that door was locked. The SP was sitting at a nearby table and unlocked the door for the RM to enter. · The SP also denied that s/he touched the VA’s genitals, denied that the VA touched the SP’s genitals, and denied being in the VA’s bed and ejaculating in his/her pants. The SP did not know why the VA would say such things occurred. The SP provided an example where the SP told the VA to “stop being stupid,” and the VA immediately called P1 and said that the SP called the VA “stupid.” The SP said that if such an incident occurred like the VA said, the VA would have immediately called P1. The CM worked with the VA for approximately four months and said that during a “casual conversation” with the VA, the VA said that a staff person had been touching the VA but “did not go into detail.” The CM talked to P1 and heard more about the incidents. The CM found some notes from 2022 that referred to concerns about an older person at a YMCA who was the same gender as the SP; however, no sexual allegations were mentioned. The LEO told this investigator that there were no charges regarding his/her investigation. Due to computer issues, the facility was not able to access any training records for staff persons. However, the SP provided information that s/he was trained regarding the VA’s program plans and received training regarding the Reporting of Maltreatment of Vulnerable Adults Act.
Conclusion: The VA provided varying information to the DP, P1, RM, the LEO, and this investigator regarding what occurred in his/her bedroom between the SP and the VA while the bedroom door was locked, as well as the number of times incidents occurred. Although the VA said there was only one time when the RM came to the bedroom and found the door locked, the VA provided inconsistent information when s/he initially stated that occurred during the first incident in the late summer of 2023 and later said that occurred during the most recent incident. The VA also said that when the RM knocked on the door, the VA ran to the door to open it. The VA said that when s/he talked to the RM about the incident, the RM said that s/he did not remember returning to the facility and finding their bedroom door locked. However, according to the RM, s/he remembered returning to the facility one day and the bedroom door was locked. The RM said that it was the SP who opened the bedroom door, and looked happy to see the RM. The VA was sitting on his/her bed and told the RM that s/he and the SP were “just talking.” The RM said the VA and SP were “acting normal.” The SP denied being in the bedroom with the VA with the door locked on any occasion. The SP said there was one occasion when the RM returned to the facility and was locked out; however, it was the door leading into the facility from the garage that was locked. The SP denied any sexual contact with the VA. Given the VA’s varying accounts of the incidents, the possibility that the RM’s account was hindered by his/her conversations with the VA, P1, and the FM prior to a final interview with the LEO and this investigator, the SP’s denial of the incidents, and that no additional information was provided that anyone observed any sexual contact between the VA and the SP, there was not a preponderance of the evidence as to whether the SP engaged in sexual contact with the VA. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were not adequate and staff persons were retrained regarding where medication administration should occur (not in bedrooms). Policies and procedures were followed resulting in a law enforcement report. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On December 26, 2024, the facility was issued a Correction Order for the license holder’s failure to meet the requirements of electronic record keeping as required.
|
