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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: 1093369-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: Allegation one: It was reported that a vulnerable adult (VA), who had a Rights Restriction restricting his/her access to the internet, accessed Facebook multiple times and sent explicit messages to an unknown person (U) posing as an underage child. Allegation two: It was alleged that staff persons failed to provide adequate supervision to the VA when the VA was banned from a mall after s/he “harassed” an employee in a store. Date of Incident(s): Allegation one: August 24 to September 8, 2024 Allegation two: September 29, 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 17, paragraph (a): 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 October 9, 2024; from documentation at the facility; and through seven interviews conducted with three facility staff persons (SP1, SP2, and SP3), two facility supervisory staff persons (P1 and P2), the VA, and the VA’s guardian (G). Attempts were made via phone and certified mail to contact and interview a staff person (SP4). SP4 initially responded to this investigator’s request for an interview but then provided an incorrect callback so SP4 was not interviewed. However, SP4 provided information for the facility’s Internal Review that was included below. Another staff person (SP5) declined an interview, but provided information for the facility’s Internal Review that was included below. The VA was diagnosed with depressive disorder, attention deficit hyperactivity disorder, autism spectrum disorder, expressive language disorder, and borderline intellectual functioning. The VA enjoyed watching sports, making music, and playing video games. Facility documentation showed that P1, SP1, SP2, SP3, SP4, and SP5 were trained on the VA’s plans and SP1, SP3, SP4, SP5, P1, and P2 were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Based on P2’s role at the facility s/he was not required to be trained on the VA’s plans. Relevant Rules and/or Statutes: Minnesota Statutes section 245D.07, subdivision 1a, states in part that the license holder must provide services in as specified in the person’s support plan and the support plan addendum. Allegation one: It was reported that the VA, who had a Rights Restriction restricting his/her access to the internet, accessed Facebook multiple times between August 24 and September 8, 2024, and sent explicit messages to an unknown person (U) posing as an underage child. According to the VA’s Support Plan Addendum (CSSP-A) dated July 8, 2024, the VA was restricted from having any access to the internet and electronic devices including cell phones, computers, and tablets due to “inappropriate content” accessed in the past. Additionally, the VA had zero minutes of unsupervised time at the facility. The VA had two staff from 7 a.m. to 11 p.m. and one awake overnight staff from 11 p.m. to 7 a.m. Information obtained showed that in July 2024, the VA was charged with five counts of possession of pornographic works that included minors under 14. According to the VA’s Individual Abuse Prevention Plan (IAPP), the VA had a history of talking to underage persons in a sexual manner and becoming “obsessive” about persons of the opposite gender. The VA was at risk of physical abuse from others due to those actions. If staff witnessed this behavior, they were instructed to verbally redirect the VA away from the situation and if that was ineffective, staff were to physically guide the VA to a safe location. On an unknown date earlier in 2024, the VA had all of his/her electronics seized by law enforcement due to the VA accessing child pornography so was no longer permitted to access the internet or the internet on any cell phone, tablet, laptop, or iPad at any time. The facility had an office that was located off of the kitchen. The kitchen was adjacent to the living room, and the VA’s bedroom was down a hallway from the living room. The facility office kept all staff and client files, as well as a computer. [Note: At the time of this investigation, the computer that was in the office at the time of the alleged incident had been taken by police for forensic investigation and no longer at the facility.] According to information provided by P1 and P2, the door of the facility office was kept locked at all times when staff persons were not in the office. The office previously had cameras, however, the VA cut the power cords to the cameras. According to the VA’s CSSP-A, the VA had a Rights Restriction that stated the VA was “not to access the internet on [his/her] cell phone/tablet/laptop/iPad at any time.” Additionally, the Rights Restriction stated, the VA was “not to have internet access” because s/he displayed “inappropriate behavior” when accessing the internet in the past and liked to access pornography that included underage children. An Incident Report dated September 24, 2024, provided the following information: · On September 24, 2024, at 8:10 p.m., an unknown person (U) arrived at the facility and requested to speak with the VA. SP1 and SP2 were outside when the U arrived, and the U told SP1 and SP2 that the VA was “trying to lure young [girls/boys]” and asked to speak to the VA. SP1 and SP2 told the U to leave. The U threatened to call 911, returned to his/her vehicle, and left the facility property. The VA had “very limited interaction” with the U. “A short time later” law enforcement arrived at the facility. · Law enforcement officers told an unknown facility staff person that the U and his/her “associates,” “regularly drive around the country to lure and confront potential predators.” The U had Facebook messages between the VA and an “alleged young [child]” ranging between August 24 and September 8, 2024. · Law enforcement spoke with the VA, who denied sending the messages, however, stated that s/he used the facility office computer “about five times.” Law enforcement searched the facility’s computer history and found “several” visits to Facebook that “correlated closely” in time with the timestamp on the Facebook chats provided by the U. When Facebook was pulled up on the facility’s computer, the VA’s “known profiles” came up as login suggestions. The password to the profiles were not saved to the computer. Law enforcement took photos of the computer history and downloaded files. The following Facebook messages were sent from the facility’s IP address from August 24 to September 8, 2024, and facility documentation included staff schedules for those dates showed the following: · On August 24, 2024, one message was sent during the overnight shift when SP3 was working. · On August 25, 2024, two messages were sent during the overnight shift when SP3 was working · On August 26, 2024, one message was sent during the overnight shift when SP4 was working. · On August 31, 2024, one message was sent during the overnight shift when SP1 was working. Later that day, another message was sent when SP1 and SP5 were working. · On September 1, 2024, three messages were sent during the overnight shift when SP5 was working. · On September 8, 2024, two messages were sent during the overnight shift when SP3 was working. The VA provided the following information: · On a date unknown to the VA, law enforcement arrived at the facility and questioned the VA about Facebook messages that were sent from the facility’s IP address. The VA stated that his/her name was not on the Facebook messages and that someone may have “cloned” the facility’s IP address to make it appear as though the messages were being sent by the VA. · The VA denied sending any Facebook messages or going on Facebook. The VA stated that s/he never used the facility computer to go on Facebook, and only ever used the facility computer to print things. The VA stated that s/he was not permitted to use any electronic devices with internet connectivity other than his/her television. P1 provided the following information: · The VA had a court order restricting his/her access to the internet. The VA was also not permitted to have a cell phone, tablet, computer or any device other than a television that had internet access. The VA was also not permitted to be in the facility office. · P1 stated that on several occasions, the VA sent messages on Facebook that were traced back to the facility’s IP address. P1 believed staff persons did not give the VA permission to use the staff computer, but that the VA snuck into the staff office when staff persons were not paying attention. The VA denied to P1 that s/he accessed Facebook. P2 provided the following information: · On September 24, 2024, law enforcement told P2 the times and dates that the VA accessed the internet and sent Facebook messages to the U. P2 reviewed the messages obtained by law enforcement and saw the VA’s name on the messages which contained sexual content. P2 could not remember the exact dates but stated that the dates ranged from August 24 to September 8, 2024. The VA’s Facebook login information was saved on the facility’s computer and on the VA’s television, but the messages were sent from the facility’s IP address which was the facility’s computer. · P2 stated that SP3 worked most of the overnight shifts when the Facebook messages were sent. P2 did not recall who else worked during the times the Facebook messages were sent. SP1 provided the following information: · SP1 was aware of the VA’s internet restrictions and stated that the VA was not allowed to have “anything connected to the internet.” The VA had 2:1 staffing during the day and 1:1 staffing at night. The VA had a TV with video games and a landline phone, but no other electronics. · SP1 denied allowing the VA to use the facility computer during SP1’s shifts. SP1 stated that other staff allowed the VA to use the facility computer and sat next to the VA supervising when s/he did so. SP1 stated that s/he believed the VA waited for staff to be in the bathroom or doing another task and snuck into the facility office to use the computer. SP3 provided the following information: · SP3 worked the overnight shift with the VA. SP3 stated that on a typical shift, s/he cooked for the VA and watched TV or listened to music with the VA. · Staff persons were required to be always within visual range of the VA, unless s/he was in his/her bedroom. SP3 added that staff persons were not allowed to sleep on the overnight shift and denied doing so. · The VA never asked SP3 to use the computer during SP3’s shifts and SP3 never permitted the VA to use the facility computer during his/her shifts. SP3 stated that the VA brought the living room television into his/her bedroom and locked the door. SP3 stated that it was “impossible” that the VA accessed the facility computer to send Facebook messages while SP3 was working because the only time SP3 was not in visual range of the VA was when the VA was in his/her bedroom, at which time SP3 was in the staff office. When SP3 was not in the office, s/he kept the door locked. SP3 thought that the VA accessed the internet through the TV while in his/her bedroom and had previously used the TV to access Facebook. (Note: The VA’s television would have had a different IP address from the facility’s computer.) · SP3 was unaware if other staff persons allowed the VA to access the facility computer, because s/he did not work with other staff persons. SP4 provided the following information for the facility’s Internal Review: · The VA used the facility computer one time when SP4 was working, and the VA had prior approval from a house manager to use it to fill out a job application. The VA was not allowed in the staff office, but that other staff told SP4 that the VA went in the staff office anyway. The VA asked SP4 if s/he could use SP4’s personal cell phone to “look up things,” and SP4 did not allow the VA to do so. · The VA made comments such as, “If I am treated like a child then why can I not sleep with one?” SP4 stated that s/he was aware of the VA’s rights restrictions and had been trained on the VA’s plans. SP5 provided the following information as part of the facility’s Internal Review: · The VA used the facility computer during SP5’s shift to download music, print things, and complete his/her grocery list. While the VA worked on his/her grocery list, s/he attempted to open other tabs on the browser. · SP5 was aware the VA was not supposed to be in the staff office but said that “every staff allows it.” SP5 thought there was “confusion” among staff regarding the VA’s internet restrictions. The G provided the following information: · The VA was only allowed to use the internet and the facility computer to order his/her groceries. The G and the facility arranged for the VA to be able to do so because when staff persons ordered groceries for the VA, the VA refused to eat the food that was ordered. · The VA had a history of criminal charges due to possession of child pornography. The VA had an internet rights restriction and was restricted from going to certain locations in the community where children were present. · On an unknown date, the G spoke with the VA about the messages. The VA did not understand that s/he could not “be friends” with children online. It was “hard to explain” that to the VA because the G thought the VA’s intentions were “just to make friends.” · The G stated that the VA was incarcerated early in 2024 and the jail was not equipped to handle his/her behaviors. The jail released the VA back to the care of the facility. The G believed the facility was doing “whatever they could” for the VA, but because it was a criminal matter, there was little they could do to get involved. Conclusion for Allegation One: A. Maltreatment: The VA had a history of accessing child pornography and had a Rights Restriction and court order prohibiting him/her from accessing the internet or using electronic devices that accessed the internet On six dates the VA’s internet protocol was not followed, which was a violation of Minnesota Statutes section 245D.07, subdivision 1a. The VA accessed Facebook and sent Facebook messages that were sexual to someone posing as a minor. P1 and P2 confirmed that the messages were sent from the facility’s computer IP address, and that the VA sent the messages. Information from P2 and SP3 showed that the VA had access to the internet on his/her TV that the VA previously used to access Facebook, as his/her login credentials were saved there. Although all staff persons denied allowing the VA to access the facility computer or any other electronic devices to access Facebook, and the VA denied using the facility computer to access Facebook and/or send messages, each staff person and the VA had reason to minimize their actions for fear of repercussions. Given the VA’s vulnerabilities and restrictions as outlined in his/her support plan and support plan addendum, that the VA was able to access and use the facility computer on multiple occasions, and that there was a failure to follow the VA’s specific protocols that addressed his/her vulnerabilities which led to possible legal consequences, there was a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care and supervision to maintain his/her physical 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. SP1, SP3, SP4 and SP5 received training on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Information showed that based on the facility computer’s IP address, that the VA accessed the internet via the facility computer six dates between August 24 and September 8, 2024, when SP1, SP3, SP4, and/or SP5 were working. SP1 and SP3 each stated that they did not allow the VA to access the facility computer. SP4 said s/he allowed the VA to use the facility computer on one occasion with prior approval from the house manager. SP5 said s/he allowed the VA to use the facility computer to download music, print things, and complete his/her grocery list. However, information obtained showed that when the VA sent the Facebook messages on the six different dates, SP1 worked one date, SP3 worked three dates, SP4 worked one date, and SP5 worked two dates during the time the VA sent the messages. Given that SP1, SP3, SP4, and SP5 denied letting the VA use the facility computer to access Facebook; that the VA denied accessing Facebook from the facility computer; that P1 believed staff persons did not give the VA permission to use the staff computer, but that the VA snuck into the staff office when staff persons were not paying attention, information regarding the circumstances surrounding the VA’s access to and use of the computer was not able to be determined. Therefore, there was not a preponderance of the evidence whether SP1’s, SP3’s, SP4’s, and/or SP5’s actions were therapeutic conduct or whether they were responsible for the maltreatment of the VA. The responsibility for the maltreatment of the VA was inconclusive. Allegation two: It was alleged that staff persons failed to provide adequate supervision to the VA when the VA was banned from a mall after s/he “harassed” an employee in a store. According to the VA’s Support Plan Addendum (CSSP-A) dated July 8, 2024, “staff will accompany [the VA] at all times while in the community, see staff presence of staff section,” which stated that the VA had zero minutes of unsupervised time in the community. (Note: There was no additional information provided regarding how staff persons were to supervise the VA when in the community.) According to an Incident Report dated September 29, 2024, “[The VA] was at [a store] speaking with a sales associate in the store. [The VA] asked the sales associate if [s/he] wanted to be friends. [The VA] was informed that [the sales associate] did not become friends with customers. [The VA] questioned the sales associate why [s/he] did not want to be friends with [the VA]. During this conversation, the store manager contacted mall security.” After mall security arrived, the VA was informed that s/he needed to leave the premises and was also banned from the mall for 6 months. The VA provided the following information: · On an unknown date, two staff persons, whose names the VA could not remember took the VA to the mall. While at the mall, the VA went into a store and asked an employee at the store if s/he wanted to be friends. The employee declined the VA’s offer and stated that s/he was not friends with customers. The VA stated that both staff persons were inside the store with him/her when s/he spoke with the employee. · The VA stated that after the interaction with the employee, mall security arrived to the store and told the VA that s/he was banned from the mall for six months. The VA was “not sure what happened” because s/he felt like the conversation s/he had with the employee was “appropriate.” SP1 provided the following information: · When SP1 started working with the VA, SP1 was told by “several people, managers and stuff,” whose names SP1 could not remember, that staff persons did not have to follow the VA into “smaller stores,” but in larger stores “like Walmart” they were required to walk next to the VA. When the VA went into smaller stores, SP1 waited outside the store for the VA. · On September 29, 2024, in the afternoon, SP1 and SP2 were working and took the VA to the mall. SP1 went into a store at the mall with the VA and SP1 sat in the corner of the store in a chair. SP1 was able to hear the VA’s interactions with persons inside the store and stated that s/he did not hear the VA say anything that s/he found “concerning.” SP2 stayed outside the store at this time. · SP1 and the VA then left the store and went to another store along with SP2. While SP2 and the VA were in the second store, SP1 went to the bathroom. While SP1 was in the bathroom, SP2 texted stating that s/he and the VA went back to the first store. After SP1 left the bathroom, s/he went to the first store and saw the VA and SP2 speaking with mall security. Mall security did not provide information to SP1 about what occurred, however, the manager of the store told SP1 that the VA hung out in the store “a lot” and “made people uncomfortable.” SP1 and SP2 followed as the VA was escorted out of the mall and was banned from going back to the mall for six months. · SP1 was trained to distract the VA and change the subject when the VA engaged in inappropriate conversations or exhibited dangerous behaviors. SP2 provided the following information: · On September 29, 2024, in the afternoon SP1 and SP2 worked and took the VA to the mall. SP1 and the VA went into a store while SP2 stayed outside the entrance to the store. SP2 stated that s/he could see the VA inside the store. SP1 and the VA were in the store for “quite some time” and when they left the store, the three went to another store. At some point, they returned to the first store. SP2 again stayed outside the entrance to the store and SP1 went into the store with the VA. At that time, mall security approached from the mall and said the VA was getting kicked out of the mall but would not provide details as to why. SP2 thought there was an ongoing issue with the VA at the store, because s/he went to that specific store every time s/he went to the mall. While mall security was speaking to the VA, the manager of the store told SP2 that s/he warned the VA about his/her behavior in the past. SP2 said that s/he did not hear the VA make any inappropriate comments to people at the mall. · SP2 stated that s/he received “a lot” of training before working with the VA and that the VA had two staff persons during the day who were required to “always have eyes on” the VA. SP2 also stated that the VA had an “interest in minors” and staff persons were trained to watch the VA closely if they were in a place with children to ensure the VA did not do “inappropriate” things. P1 stated that s/he was not working on September 29, 2024, but remembered seeing something in a staff group chat about the VA getting kicked out of the mall. P1 heard that the VA had asked a store employee on a date, who declined but the VA “kept pressing the issue.” The store employee called security, and the VA was removed. P1 stated that when s/he spoke to SP1 and SP2 about the incident, they each stated that they were both in the store and could see the VA, but that at one point SP1 was in the bathroom. P1 reminded SP1 and SP2 that being within visual range of the VA was not sufficient, and that they were required to be right next to the VA in the community to intervene in situations as necessary. [Note: There was no information in the VA’s plans about specific ways staff persons were to supervise the VA in the community.] P2 stated that SP1 and SP2 provided “different information at different times.” At first, they said they were both outside the store, but later said SP1 was inside the store out of “hearing distance” of the VA while SP2 waited outside the store. P2 called the store and spoke to a manager who stated that no staff persons were ever in the store with the VA on September 29, 2024. The G stated that on an unknown date after the incident at the mall, the G went to the facility to speak with the VA about the incident. The VA initially told the G that SP1 and SP2 were next to him/her in the store, but later told the G that SP1 and SP2 were “a clothing rack over.” The VA told the G that s/he approached a worker at a store at the mall and asked if s/he wanted to hang out. The worker told the VA that s/he did not want to be friends, and then security was called. Conclusion for Allegation Two: The VA had no unsupervised time and during daytime hours had 2:1 staffing including when s/he was in the community. The VA’s CSSP-A stated, “staff will accompany [the VA] at all times while in the community, see staff presence of staff section,” which stated that the VA had zero minutes of unsupervised time in the community. There was no additional information regarding how staff were to supervise the VA while in the community. Information was consistent that on September 29, 2024, SP1 and SP2 took the VA to a mall and while in a store, the VA said something to an employee, the store manager called mall security, and the VA was subsequently banned from the mall. Information regarding where SP1 and SP2 were when the VA was in the store varied including, that they were both inside the store, that they were both outside the store, and that only SP1 was in the store. Given that the VA’s plans required 2:1 staffing during the day, SP1 and SP2 were both working when they took the VA to the mall, and that both SP1 and SP2 were in and/or near the store with the VA, there was not a preponderance of the evidence whether SP1 and/or SP2 failed to supply a vulnerable adult with care or services, including supervision. 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: The facility completed an internal review and determined that policies and procedures were adequate but not followed, the events were similar to past events with the persons, staff, or services involved, there was a need for additional staff training and there was a need for corrective action to be taken by the license holder to protect the health and safety of the person served. All staff persons received re-training on the VA’s rights restrictions. The VA’s support team developed a list of approved locations the VA can go to minimize interactions with minor children. Internet capabilities were removed from the VA’s television. Action Taken by Department of Human Services, Office of Inspector General: Given that the facility took immediate corrective action a Correction Order was not issued for the violation outlined in this report.
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