|
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: 1097509-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kim Huettl Anderson kimberly.huett.anderson@state.mn.us Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA) was missing $16,868 that was unaccounted for with receipts for expenditures. Allegation Two: It was reported that a staff person (SP1) forced the VA to perform sexual acts on SP1 and threatened to harm the VA if the VA ever told anyone. Allegation Three: It was reported that the VA left the facility without a staff person’s (SP3) knowledge and that during the time the VA left the facility, the VA stole a vehicle, consumed alcohol, and got a tattoo. Date of Incidents: Allegation One: Prior to May 9, 2023 Allegation Two: Unknown Allegation Three: May 9, 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 (b), clause (2); and subdivision 2, paragraph (c); and subdivision 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): 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. 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 June 12, 2023; from documentation at the facility and law enforcement records; and through six interviews conducted with the VA, the VA’s guardian (G), facility management persons (P1), and facility staff persons (P2, SP1, and SP2). Attempts were made via telephone and US mail to contact and interview a community person (CP) who worked with the VA outside of the facility and SP3, but the attempts were unsuccessful. The facility was a two-story home in a rural area. The first level consisted of a kitchen, living room, and staff office. The second level consisted of bedrooms, including the VA’s bedroom, and a living area. There was a deck off of the second level with stairs leading to the ground. The facility parked a vehicle in a grassy area next to a detached garage. The VA’s Coordinated Services and Supports Plan stated that the VA enjoyed playing video games, watching movies, swimming, and spending time outdoors. The VA’s Self-Management Assessment of Risks stated that the VA was diagnosed with disruptive mood dysregulation disorder, generalized anxiety disorder, post-traumatic stress disorder, intermittent explosive disorder, and reactive attachment disorder. The facility’s personnel files showed that SP1, SP2, SP3, and P1 were each trained on the facility’s orientation, the VA’s plans and needs, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Allegation One: It was reported that the VA was missing $16,868 that was unaccounted for with receipts for expenditures. The VA’s Individual Abuse Prevention Plan stated that the VA was unable to manage his/her own finances. The facility did not oversee the VA’s finances, the VA’s finances were managed by a rep-payee from an outside organization. A law enforcement report stated that the VA told the CP that the VA thought s/he was had been financially exploited by SP1 because SP1 kept the VA’s gift cards and other property at SP1’s residence and there were several expenditures documented on the VA’s financial documents that did not have receipts to explain how the money was spent. The CP believed that the VA had $16,868.21 that was unaccounted for. The G stated that the VA was not missing any money. The VA had a trust fund and the trustee asked the G to simplify the terms of the trust and only required a summary of how the VA spent his/her money so receipts for expenditures were not necessary. The CP was not aware of the terms of the trust and that receipts were not required. The G was in possession of all the receipts for expenditures and filed receipts as required and all of the VA’s money was accounted for. The VA’s interview was done in conjunction with a law enforcement officer (LEO). The VA said that s/he was not missing any money and that s/he did not think any of the staff persons took his/her money. Conclusion for Allegation One: Although the CP said that the VA was missing $16,868.21 that unaccounted for with receipts for expenditures, the VA said s/he was not missing any money and the G stated that s/he had the receipts for expenditures and that the money was accounted for. Therefore, there was a preponderance of the evidence that staff persons did not willfully use or withhold the VA’s funds or property. It was determined that financial exploitation did not occur (In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Allegation Two: It was reported that SP1 forced the VA to perform sexual acts on SP1 and threatened to harm the VA if the VA ever told anyone. The VA’s Individual Abuse Prevention Plan stated that the VA was not able to distinguish between abusive and non-abusive sexual exchanges. The CP stated that the VA told him/her that on an unknown date, SP1 “sexually abused” the VA and threatened to harm the VA if the VA told anyone. The VA said that on more than one occasion, SP2 “forced” the VA to have sexual contact with SP2 in the VA’s bedroom and then threatened the VA by holding a “switch knife” against the VA’s back and neck if the VA told anyone. SP3 never cut or harmed the VA. The VA stated that s/he did not have sexual contact with SP1. The facility’s Investigative Summary stated that on April 13, 2024, an unknown staff person told P1 that SP2 was sleeping on the couch under a blanket with the VA. During the course of the facility’s investigation, P1 learned that it was not SP1 but SP2 who was sleeping on the couch with the VA. SP1 denied that s/he was sleeping on the couch with the VA. P1 stated that s an unknown staff person told P1 that the VA was sleeping on the couch with SP1 and sharing a blanket (Note: It was originally reported that it was SP2). P1 spoke to SP1 about the incident but SP1 denied that s/he was sleeping on the couch and/or sharing a blanket with the VA. SP2 then turned in his/her resignation and no longer responded to P1. P1 did not talk to the VA about the incident because the VA was refusing to speak to anyone at the facility. P1 did not have any information that SP2 slept on the couch with the VA or threatened to hurt the VA if s/he told anyone that they had sexual contact. The G stated that s/he was made aware of the allegation. The G talked to or spent time with the VA approximately three times a week and the VA never mentioned anything to the G about feeling threatened by a staff person or being forced to perform sexual acts. Due to the VA’s physical size and history of not providing accurate information, the G did not believe that the VA would allow anyone to touch him/her without his/her consent and did not think that the VA would be threatened by any staff person. SP1 stated that s/he thought s/he was “too friendly” with the VA because s/he gave the VA hugs when the VA had a bad day and on one occasion, held the VA’s hands to prevent the VA from hitting SP1. SP1 thought that the VA had the “wrong impression” that s/he was in a “relationship” with SP1. When SP1 explained to the VA that s/he was the VA’s staff person and that they were not in a relationship, the VA got “mad” and said that s/he was going to tell people that SP1 was “sleeping” with the VA. SP1 stated that s/he “never” slept on the couch and/or shared a blanket with the VA, “never” had a sexual relationship with the VA, and “never” threatened to hurt the VA. SP2 stated that s/he never had a sexual relationship with the VA and never threatened to hurt the VA. SP2 stated that s/he never slept on the couch with the VA and/or never shared a blanket with the VA. The VA had a history of providing inaccurate information and “manipulating” a situation to the VA’s advantage. Conclusion for Allegation Two: Although the VA told the CP that SP1 “sexually abused” the VA and threatened to harm the VA if the VA told anyone, the VA told this investigator and the LEO that SP2 was the one who s/he had sexual contact with and who threatened to harm the VA. Given that the VA provided inconsistent information, that the VA had a history of providing inaccurate information, and that SP1 and SP2 each denied having a sexual relationship with the VA and/or threatening the VA, there was not a preponderance of the evidence whether the VA had sexual contact with and/or were threatened by SP1 and SP2. It was not determined whether sexual or emotional 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. 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). Allegation Three: It was reported that the VA left the facility without SP3’s knowledge and that during the time the VA left the facility, the VA stole a vehicle, consumed alcohol, and got a tattoo. The VA’s Self-Management Assessment of Risks stated that the VA was allowed to remain in his/her bedroom unsupervised for eight hours a day, but staff persons were present in the home at all times. The VA was allowed one hour of unsupervised time in the community places such as a shopping center, movie theater, and restaurant. The VA had a history of stealing the facility’s vehicle and not providing an accurate recollection of information. Staff persons were to keep the facility’s vehicle’s keys in a locked area and the VA was never allowed to be left alone in a running vehicle. Information obtained showed that the VA did not have a driver’s license. The VA’s Individual Abuse Prevention Plan stated that the VA was not able to understand the need for personal safety in the community. Facility staff persons were to be within hearing range of the VA while at home and within visual range while in the community. The facility’s Occurrence/Injury Report and Incident Report and Internal Review stated that the VA took a truck owned by the facility and “ran away” from the facility. On May 9, 2023, at approximately 4 p.m., SP2 noticed that the facility’s truck was missing and then realized that the VA was not in his/her bedroom. SP2 contacted the LEO to report the VA and the truck missing. At approximately 9 p.m., the G contacted the facility stating that the VA called the G and said that s/he was in Grand Forks, North Dakota at a family member’s house. The VA told this investigator and the LEO that the day before s/he left when SP2 was working, the VA “snuck” into the facility’s office to get the keys to the facility’s truck. The VA then “ran away” in the “middle” of the night when SP3 was working. SP3 did not know the VA left because SP3 was downstairs and could not hear the VA who left through the upstairs deck. The VA stated that s/he took the truck and drove to North Dakota. The VA stated that P1 told him/her that SP2 did not notice the VA was gone until 4 p.m. The VA “normally” came out of his/her bedroom around 9:30 a.m. to take his/her medications and eat breakfast. The VA said s/he did not typically spend the day in his/her bedroom because s/he was required to interact with his/her peers and staff persons to earn an outing at the end of each week. The VA stated that had been planning to “ran away” from the facility because s/he thought s/he was being “mistreated” because s/he did not get the things that s/he wanted. The G stated that when the CP became involved in the VA’s life, the CP thought that the VA should be independent and started talking to the VA about living on his/her own. The CP started the process to remove the VA’s need for a guardian. The G believed that this process “scared” the VA because the VA had lived in placements most of his/her life so the VA “self-sabotaged” him/herself by stealing the facility’s truck and driving to North Dakota. P1 provided information that was consistent with the information in the Occurrence/Injury Report and Incident Report and Internal Review and the following additional information: · According to P1, on May 8, 2023, SP2 worked with the VA during the day shift and SP3 worked the overnight. On May 9, 2023, at approximately 9 a.m., SP2 arrived at the facility to again work the day shift. · On May 8, 2023, the VA took the facility’s truck keys from the facility’s staff office, and on May 9, 2023, the VA took the facility’s truck and drove to North Dakota to a family member’s home. · On May 9, around 4 p.m., SP2 noticed that the truck was missing from the yard. SP2 contacted P1 and said the truck was missing and that VA had not been responding to SP2. P1 told SP2 to open the VA’s bedroom door to check on the VA. When SP2 opened the door, the VA was not in his/her bedroom. SP2 told P1 that s/he knocked on the VA’s door multiple times throughout the day but was not alarmed that the VA did not answer because it was not unusual behavior for the VA who had a history of being “non-responsive” when staff persons knocked on his/her bedroom door. P1 said it was normal for the VA to not respond when staff knocked on his/her door so there was no immediate need to be concerned when the VA did not answer. · The keys to the truck were stored in a lock box and after the incident, the VA told P1 that s/he broke the lock box to take the keys. No one at the facility noticed that the lock box was broken until it was discovered that the VA and the facility’s truck were missing. · According to P1, s/he was not surprised that SP3 did not hear the VA leave during the night because the door that the VA left through, and the truck were on the opposite side of the house where SP3 was working. The VA told P1 that s/he was “very quiet” when s/he left the facility and that s/he kept the lights off on the truck as s/he drove through a ditch to get to the road. · When the VA returned to the facility, there were no signs of physical injury or harm to the VA. SP2 provided the following information: · On May 9, 2023, at 9 a.m., SP2 arrived at the facility. When SP2 drove into the facility’s driveway, s/he did not notice that the facility’s truck was gone. Occasionally another facility borrowed the truck, but SP2 was “usually” told when it was being borrowed. When SP2 arrived, SP3 left. · Unless the VA was feeling “depressed,” the VA “typically” came out of his/her bedroom make his/her own breakfast and lunch and spend time with SP2 during the day. When the VA did not come out of his/her bedroom on the day of the incident, SP2 knocked on the VA’s bedroom door two separate times but the VA did not answer. SP2 was not alarmed because it was common for the VA to not respond to SP2 when s/he knocked on the door. · Between 2 and 3 p.m., SP2 knocked on the VA’s door a third time and when the VA did not answer, SP2 used his/her key to open the VA’s bedroom door. The VA was not in his/her bedroom and SP2 noticed that some of the VA’s possessions were gone. SP2 notified P1 and then looked for and saw that the facility’s truck was missing. · According to SP2, the facility’s policy was to keep the office door locked at all times. SP2 kept the facility’s office door locked and the keys on his/her person, but on May 8, 2023, s/he “accidently” left the office door open a “few” times throughout the day. SP2 did not notice that the lock box containing the facility’s vehicle keys was broken until after the incident because the lock box was broken from the back and only contained the truck keys, and s/he had not needed to use the keys. Conclusion for Allegation Three: Information showed that on May 8, 2023, SP2 was working when the VA accessed the office, broke into the facility’s lock box, and took the keys to the facility’s truck. On May 9, 2023, at an unknown time in the “middle of the night,” SP3 was working when the VA left the facility without SP3’s knowledge and drove to North Dakota. At 9 a.m., SP2 arrived at the facility. At that time, SP2 did not notice that the VA or the truck was gone until approximately 4 p.m. SP3 did not provide information for the investigation. The VA’s Self-Management Assessment of Risks stated that the VA was allowed to be in his/her bedroom for eight hours. From the time SP2 arrived at the facility to the time s/he discovered the VA was gone was seven hours. SP2 stated that s/he knocked on the VA’s door at other points during those seven hours, but the VA did not respond which according to SP2 and P1 was not unusual for the VA. The VA also stated that SP3 did not know the VA left because SP3 was downstairs and could not hear the VA who left through the upstairs deck. SP3 did not provide information for this report, so it was unknown what time, SP3 last had contact with the VA. The VA snuck into the office while SP2 was working, broke into the lock box, and took the truck keys. There was no information provided that SP2 or SP3 were going to use the truck at any point so should have realized that the keys were gone. In addition, SP2 said that the lock box was broken from the back, so s/he did not see or notice that it was broken which was reasonable. Although the VA was able to obtain the keys and leave the facility without staff knowing, given the lack of details including time and what staff persons were doing when the VA took the keys and when the VA left, details about the incident were not able to be determined including what SP2 and/or SP3 were doing at each time so it was possible that they were engaged in work related and/or therapeutic activities. Therefore, there was a not preponderance of the evidence whether there was a failure to supply the VA with care and services that were reasonable and necessary to maintain the VA’s physical and mental health and safety. It was not determined whether 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). Action Taken by Facility: Allegation One: The facility completed an internal review and determined that their policies and procedures were adequate and followed. Allegation Two: The facility completed an internal review and determined that their policies and procedures were adequate and followed. Allegation Three: The facility conducted an internal review and determined that their polices and procedures were adequate and followed, but that there was a need for additional staff training to ensure that the keys to the vehicle were locked and secure. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
