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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: 1070658-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070559-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon Suspected Maltreatment Reported: It was reported that a staff person (SP) inappropriately touched and wanted to have sex with a vulnerable adult (VA). Date of Incident(s): Ongoing until April 9, 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): 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 April 29, 2024, and May 1, 2024, from documentation at the facility; and through and through ten interviews conducted with the VA, the VA’s family member (FM), the VA’s guardian (G), the VA’s case manager (CM), one Emergency Medical Technician (EMT), one supervisory staff person (P1) and four staff persons (P2 – P4 and the SP). The VA’s diagnoses included psychosis, schizoaffective disorder, disruptive mood dysregulation disorder, borderline personality, and reactive attachment disorder. The VA experienced audio and visual hallucinations in the form of voices and shadows, but the CM said it was “not very prevalent” and the VA was able to distinguish what was real and what was not. The VA might be physically aggressive towards others, elope, and damage property. The VA enjoyed watching TV and movies, using his/her tablet, listening to music, and being out in the community. The facility was a rambler style home in a residential area. The living room was directly in front of the main door with a couch on the exterior wall to the right and a hallway to the left. The hallway had a bathroom to the left and the supervisor’s office directly ahead. On the right side of the hallway was the staff office and further down was a bedroom converted into a cooking and supplies space. Across from the living room was a wall and doorway that led to the kitchen area. There was a security door in the corridor between the kitchen and living room area that had a deadbolt key lock on both sides and metal rails spanning it from near the top to near the bottom, which opened toward the living room space. Items were able to be passed between the rails or through the gaps at the top or bottom of the door. Staff persons unlocked the door for the VA whenever s/he wanted. On the living room floor there was a taped off area approximately three feet from the security door. When the VA was in the kitchen, staff persons were not to stand in the taped area in order to remain outside the VA’s reach if s/he put his/her arm through the door spaces. A stairway led from the kitchen down to a lower level that had a living area for the VA, laundry space, bathroom and shower, and the VA’s bedroom. The VA requested the security door be put in place as it was successful at his/her previous facility. The VA was initially given his/her own copy of the security door key to use but later gave it back to staff persons because s/he did not want it. The CM said the VA “might not trust [him/herself]” and “want[ed] the barricades around [him/her] to not launch [him/herself] at staff.” The VA provided the following information: · The VA moved into the facility on December 18, 2023. The VA said the facility was “better” than his/her previous facility and the staff persons were “nice.” The VA enjoyed shopping, going to parks, and taking walks; and watching movies and listening to music with staff persons. · On two unknown dates in February 2024, the SP “touched [the VA] inappropriate.” · On the first date, around 8 or 9 p.m., the SP was working with P2. The SP was in the living room and P2 was in the staff office with the door closed. The VA thought P2 was on the computer or phone. The SP approached the security door and used the staff key to unlock it. The SP then “sneaked” about five steps into the kitchen to where the VA stood. · The SP told the VA to take his/her clothes off so the SP could touch the VA’ genitals and chest. The VA was “scared” and lifted his/her shirt, exposed his/her chest, and pulled down his/her pants and underwear. The SP then touched, squeezed, and pinched the VA’s chest and said that s/he liked the VA’s chest. The SP also touched the VA’s genitals and pulled on the VA’s pubic hair. After touching the VA, the SP kissed the VA on the mouth. The SP asked the VA to put his/her mouth on the SP’s genitals and the VA said no. · The SP said s/he wanted to have “sex” with the VA. The SP told the VA that when s/he was in the shower, the SP planned to tell the other staff person s/he was going to do the laundry, go downstairs, and “have sex” with the VA in the bathroom. (Note: The facility laundry setup was on the lower level of the facility near the VA’s bedroom, living room, and bathroom. Two staff persons were to complete the laundry while the VA showered. Staff persons were never to be on the lower level without another staff person present.) The SP told the VA that if the VA told anyone, the SP would “do something” to the VA. The SP told the VA to “deny it” if anyone asked what happened. About five to ten minutes passed and the SP returned to the living room side of the security door. · “A couple days later” the SP again worked an evening shift with P2. When P2 was not around, the SP opened the security door, and came into the kitchen where the VA was. The VA told the SP to leave, but the SP did not. The SP again asked the VA to take off his/her clothes, which the VA did. The SP then touched the VA’s chest and genitals for ten minutes before s/he returned to the living room side of the door. · Approximately five days later, the SP worked in the evening with P3. When P3 was in the office the SP tried to touch the VA through the security door. The VA told the SP to “stop,” and then backed up away from the SP and told the SP that s/he did not want the SP to touch him/her. The SP said that if the SP could not touch the VA, the SP would not hug the VA anymore and that the VA could not touch the SP, and the SP backed away. Since that day, the SP did not attempt to touch the VA. (Note: When the VA first moved into the facility, the staff persons were allowed to hug the VA and then it later changed to “fist bumps” due to boundary concerns. The VA said s/he hugged the SP “a bunch of times” before the “change.”) After the SP left, the VA told P3 and P4 what happened with the SP. · The next day, the VA told P1 what happened with the SP. The VA later told the G and CM each what happened as s/he wanted the SP to stop trying to touch him/her. The SP never went downstairs alone while the VA showered. The SP provided the following information: · On February 28, 2024, the SP started working at the facility on a temporary trial run basis that was set to expire on May 1, 2024. The SP did not discuss with the VA the possibility that s/he might stop working at the facility. The SP was aware the VA got “crushes” on staff persons and s/he tried to maintain professional boundaries with the VA. When the VA told the SP things like the SP made the VA “blush” the SP did not pay attention or respond to it. When the VA said, “I like you. I have a crush on you, and I am not going to hurt or attack you.” The SP responded, “I want to do my job and don’t want to be in any compromising situation with you that you end up attacking me.” Up until April 9, 2024, there were no issues between the VA and the SP. · On April 9, 2024, the SP worked an evening shift with P3. Around 9:30 p.m. the VA asked the SP to talk and for P3 to not be present. P3 went into the office and left the door open. The SP sat on the couch and faced the VA who was in the kitchen behind the locked security door. The SP asked what the VA wanted to discuss. The VA said, “I heard you were leaving, are you leaving me?” The SP said s/he did not want to talk about that. The VA asked questions about the other facilities the SP worked at such as what the residents were like and if the SP missed them. The SP said the other residents were “nice” and that s/he “missed them.” · The VA became upset and said that was the reason the SP was leaving. The SP said that s/he did not plan to leave, and the VA said, “Fuck you… get the fuck out of here,” to the SP. The SP tried to calm the VA, but the VA said, “I am going to get you fired, I am going to tell on you.” The VA paced back and forth in the kitchen and asked for his/her as-needed (PRN) medication, so the SP went into the office to get it. The SP denied s/he went through the security door that evening. · The SP told P3 what happened with the VA and prepared the PRN medication. Around 9:45 to 9:50 p.m., P4 arrived at the facility and came into the office with the SP and P3. The SP left the office, gave the VA the PRN, and returned to the office. The SP told P4 the VA was “not happy with me,” completed the shift notes, and left the facility as his/her shift was over. (Note: the SP’s documentation in the VA’s progress notes on April 9, 2024, was consistent with the information the SP provided during his/her interview.) · Around 11 p.m., the SP called P4 as s/he was supposed to document how the VA was after s/he got the PRN. P4 said the VA was calm, but making allegations the SP touched him/her. The SP texted P1 to connect about the VA, but did not hear back from P1 that night. · On the morning of April 10, 2024, the SP called P1 about the VA. The SP said s/he did not tell the VA anything about the possibility of him/her no longer working at the facility and was unsure how the VA was aware. The SP continued to work his/her normal shifts at the facility without issue. · On the evening of April 29, 2024, the VA asked to talk with the SP one to one. The SP sat on the couch while the VA was in the kitchen behind the locked door. The VA said s/he was “sorry for the thing that happened a few weeks ago.” The VA told the SP that s/he hoped the SP was not mad at the VA. (Note: the SP’s documentation in the VA’s progress notes on April 29, 2024, was consistent with the information the SP provided during his/her interview.) · The SP denied that at any time s/he opened the security door without another staff person present. The SP denied s/he ever went downstairs without another staff person while the VA showered. The SP denied s/he ever told the VA s/he wanted to have sex with him/her, kissed or was kissed by the VA, asked the VA to remove or lift clothing, touched the VA’s chest or genitals, or asked the VA to touch the SP’s genitals. · The SP’s only physical contact with the VA was fist bumps and two incidents where the VA required the emergency use of manual restraint (EUMR). P1-P4 provided the following information: · On April 9, 2024, the SP and P3 worked the afternoon and evening shift with the VA. P3 interacted with the VA most of the shift and the SP was in the office. Around 9:30 p.m., the VA asked to talk with the SP one on one. P3 left the living room to use the bathroom and was in there for “a minute or two.” While in the bathroom, P3 was able to hear the conversation between the SP and the VA and did not hear anything unusual. After leaving the bathroom, P3 stood by the office door and saw the SP on the couch in the living room. From this location, P3 did not hear or see the security door being unlocked, opened, or anything unusual at this time, and P3 could not hear the conversation between the SP and the VA. When the one to one was over the SP and P3 went into the office. The SP said the VA asked when the SP was leaving, when the SP was coming back, and something about getting the SP fired. · On April 9, 2024, at 10 p.m., P4 came on shift and P3 left. P4 saw the SP had given the VA a PRN medication. The SP told P4 that the VA heard that the SP was going to “quit” and that the VA was going to get the SP “in trouble.” P4 said the VA thought every staff person quit if they did not work for a few days. After the SP left the facility, the VA asked to talk with P4. · The VA told P4 that when the SP worked with P3, the SP opened the security door, came through to the kitchen side, and “touched” the VA. The SP touched the VA’s genitals, tried to touch the VA’s chest, and tried to kiss the VA. The SP said s/he wanted to come downstairs while the VA showered, pretend to do laundry, and have sex with the VA. After talking to the VA, P4 texted P1. · On April 10, 2024, during the morning, the SP called P1. The SP explained the previous evening the VA wanted to talk with him/her one to one. The SP and the VA talked about how the SP’s shift ended at 11 p.m. The VA said s/he “cared” for the SP and did not want him/her to leave as it would make him/her “really sad.” P1 instructed the SP to “stay away” and not “physically interact” with the VA. The SP was asked and said s/he did want to continue to work at the facility. · Around noon on April 20, 2024, P1 talked with the VA about the incident. The VA said the SP “kissed and touched” him/her. The VA did not directly say, but “motioned” that it happened in the kitchen and “implied” that it occurred the previous night. P1 discussed when the SP worked next. The VA was “okay” with the SP continuing to work at the facility and asked that the SP “stay on the other side of the room.” P1 asked the VA to let him/her know if s/he was uncomfortable when the SP worked. The VA did not indicate that s/he had any additional concerns about the SP working with the VA. The VA did not specify what body parts the SP touched to P1, and did not tell P1 that the SP propositioned him/her to have sex. P1 talked with the G later in the day about what happened. · On April 11, 2024, P1 notified the CM and the G about the situation with the VA. · P2 never heard the security door unlock, open, or shut when the SP talked with the VA. P2 said around the time of the investigation, the VA said that the SP was not “happy” with the VA, but did not say why. P2 did not think there was ever an opportunity where the SP could have touched the VA inappropriately. The CM, the G, and the FM provided the following information: · On April 10, 2024, the FM talked with the VA on the phone. The VA said s/he had “crushes” on staff persons at the facility, particularly the SP. The VA said that two to three weeks prior, the SP touched the VA’s chest and “bottom” through the security door in the kitchen. At that time the other staff person working was in the office with the door shut. Another time when the other staff person was in the office with the door closed, the SP unlocked the security door and came into the kitchen area. The SP told the VA to lift his/her top and pull his/her pants down and then the SP “touched” the VA. The SP touched the VA a total of “two to three times” and the VA kissed the SP on the cheek. The SP told the VA something like, “You let me hug you, why can’t I touch you?” The SP planned to do laundry when the VA showered, come into the shower, and have sex with him/her. The SP told the VA if s/he was asked about what happened to deny it or s/he would “do something” to the VA. Later that day, the FM emailed the CM to inform him/her of the allegations. · On April 11, 2024, the CM read the email from the FM, called the FM, and learned what the VA told the FM. The FM and the G read the email from P1 that was sent on the same day. P1’s email reviewed concerns with the VA and a “crush”. The G went to the facility to see the VA. While there the VA said the FM wanted him/her to tell the G that s/he “kissed” a staff person who also touched his/her chest. The VA did not name the SP to the G or say anything about the SP wanting to have sex with the VA. After the G left s/he called P1 to discuss the situation. · The VA had lived in several different facilities over many years due to his/her challenging behaviors. The FM thought VA did not have many friends and primarily socialized with staff persons. The CM said the VA might “misinterpret” the relationship between him/herself and staff persons. · The CM and the FM each did not think the VA fabricated stories. The CM did not know the VA to be “a manipulator,” but the VA might “misinterpret” situations. The G did not know if the VA was an accurate reporter. P1 – P4 provided the following information: · On December 18, 2023, the VA was transferred into the facility. Prior to the VA’s intake, staff persons read the former facility’s information on the VA and learned s/he had crushes on staff persons and a history of making false sexual allegations. P1 said the VA treated staff persons like a “game” and wanted to control his/her environment. At the VA’s request, the previous facility used physical barriers between the VA and staff persons to decrease the amount of his/her physical aggression. When the VA was upset, s/he might leave the facility without supervision and/or damage staff person’s vehicles. · Staff persons were trained to give the VA space whenever s/he requested it, ignore the VA’s “drama,” be patient, and focus on the VA’s positive aspects. When the VA first arrived at the facility, staff persons attempted to do “side hugs” with the VA, but when the VA started to talk about having “crushes” on staff persons, it was changed to knuckle bumps. After that change, when the VA asked for hugs, staff persons told him/her that was not allowed. When the VA had a crush on a staff person it was likely that person would be the next person the VA physically targeted when s/he was upset. · There were always two staff persons working, including overnights. Staff persons were trained to be “interchangeable” to avoid becoming “favorites” and to maintain “tough” professional boundaries. When the VA was awake and around, one staff person was to be in visible range of the VA and the other was to be in hearing range to maintain awareness of what happened. · When the VA asked to talk with a staff person one to one, the other staff person was to remain out of sight, but be able to hear the conversation. The staff office door was to remain open so both staff persons could hear what was said in the living room area. If the staff person in the office could not hear a conversation, they were to check on the situation. · The VA might try to see from his/her side of the security door if the staff office door was open and/or another staff person was listening. From the office desk the staff person was not able to see into the living room, but s/he was able to hear what occurred. If the VA did not want to talk the staff persons were to make an excuse to leave the area, but the VA could ask to talk to a staff person at any time. P1 said the facility was “rarely silent” and had “creaky floors,” so persons could be heard walking around. · Staff persons prepared meals in the upstairs spare bedroom instead of the kitchen area. Staff persons only opened the security door if both staff person were present, the VA was not awake, or the VA was in the shower downstairs. Staff persons only went downstairs together to do laundry when the VA showered, or when the VA was out in the community. When the VA was awake, staff persons were not to be in the kitchen or downstairs alone at any time. On overnight shifts if the VA was downstairs asleep, the security door was opened while one staff person cleaned the kitchen area while the other staff person cleaned the living room nearby. · P1 – P4 thought if the security door was unlocked, opened, and closed when another staff person was in the office it would be heard through the open office door or felt through the shared wall with the kitchen. The office door could not be seen from the security door as it opened into the office space, not into the hallway. If a staff person was in the bathroom with a fan on, or if a staff person was in the office and the VA was playing music, the staff person would not be able hear a conversation taking place in the living room. (During the site visit, the DHS investigator observed and recorded that the security door made an audible sound when it was unlocked, opened, closed, and locked again). · Staff persons had no previous concerns about how the SP and VA interacted. The VA requested frequent one to one talks with the SP during the time when s/he was the VA’s “favorite” staff person before the VA moved on to favoring another staff person. P2 worked with the SP “a lot.” P2 was not aware of any times the SP went downstairs alone when they worked together, nor of any times when the SP was the only staff person on the other side of the security door. Facility documentation showed that the staff persons interviewed for this investigation were trained on the VA’s care plans and on the Reporting of Maltreatment of Vulnerable Adults Act. During the course of the investigation additional information was obtained that on July 4, 2024, around 2 p.m., the EMT responded to a 9-1-1 call from the facility about the VA as the VA left the facility, went to a pond, and said s/he planned to drown him/herself. The EMT arrived at the pond and saw the VA lying in some grass. At that time, the SP was with the VA. The VA agreed to be taken to a hospital and got in the ambulance. On the way there, the VA said that within the last couple months, the SP touched his/her genitals. The VA was taken to the hospital for a mental health evaluation. Brooklyn Park Law Enforcement also investigated the alleged sexual abuse of the VA by the SP. As there was no evidence to corroborate the allegations, the case was closed and not submitted for charges. Conclusion: The VA said that on two unknown dates in February 2024, the SP had sexual contact with the VA and propositioned the VA for sex. According to the VA, the first occasion happened when the SP and P2 were working, and P2 was in the staff office with the door closed. The VA said the SP “sneaked” into the gated kitchen area, told the VA to take his/her clothes off, and the VA complied; then the SP touched the VA’s chest and genitals, kissed the VA, told the VA to put his/her mouth on the VA’s genitals but the VA refused, said s/he wanted to have “sex” with the VA and described a plan to have a sexual encounter with the VA in the lower level bathroom. However, the SP denied each allegation. Furthermore, information from P1 – P4 was consistent that except when the VA had music on, a staff person in the staff office would likely hear a person opening and closing the security door, and would also hear conversations taking place in the living room; and P2 said s/he was not aware of any time the SP went to the other side of the security door without another staff person present. According to the VA, the second occasion happened “a couple days later” when the SP and P2 were working. When P2 was not around the SP opened the security door; went into the kitchen; asked the VA to take his/her clothes off, and the VA complied; then the SP touched the VA’s chest and genitals for ten minutes before returning to the living room side of the security door. However, the SP denied each allegation. Furthermore, information from P1 – P4 was consistent that there were always two staff persons assigned to work with the VA, and each was to remain within sight and/or hearing of the VA. The VA said that approximately five days later, the SP and P3 were working. When P3 was in the staff office, the SP tried to touch the VA through the security door. The VA told the SP to stop and the SP stopped, and later that evening the VA told P4 about the SP’s alleged sexual contact and sexual advances. There was conflicting information about the VA’s credibility. Although neither the CM nor the FM had known the VA to be “a manipulator,” each said s/he might “misinterpret” situations. In addition, P1 – P4 each said that information from the VA’s previous residential facility showed the VA had a history of treating staff persons like a “game” and making false sexual allegations. Meanwhile, the SP’s credibility was augmented because s/he documented on April 9, 2024, that the VA threatened to have the SP fired; and the SP proactively reached out to P1 to discuss the situation involving the VA. Further, neither P1, P2, P3, nor P3 had any previous concerns about the VA’s and the SP’s interactions. Therefore, there was not a preponderance of evidence whether the SP had 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 the facility’s policies were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that one staff person failed to report suspected maltreatment as required. A letter from DHS was sent to the individual regarding his/her failure to report the suspected maltreatment and potential consequences for future such failures. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal.
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