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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: 1116805-H_CRS (Home and Community-Based Services-Community Residential Setting) 1068675-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-6553 Suspected Maltreatment Reported: It was reported a staff person (SP) "inserted two fingers" into a vulnerable adults (VA) genital area while assisting the VA with a catheter issue. Date of Incident(s): November 6, 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 November 19, 2024; from documentation at the facility, law enforcement records, and medical records; and through seven interviews conducted with the VA, facility staff persons (P1-P2), a facility supervisor (P3), the VA’s case manager (CM), the VA’s guardian (G), and the SP. Facility documentation showed the VA’s strengths included helping others, and having a sense of humor. The VA enjoyed completing crafts, going on walks, and cooking. The VA wanted stable mental health and to have a safe and supportive environment. The VA was diagnosed with bipolar disorder, somatic symptoms disorder, depression, anxiety, post-traumatic stress disorder, multiple physical health diagnoses, and had a urinary catheter. The VA had a behavioral history of seeking medical care. The VA’s Community Support Plan provided the following information: · The VA was physically able to manage his/her personal hygiene unless his/her mental health issues were causing him/her difficulty. The VA was able to manage his/her “toileting needs, mobility, and positioning needs” independently. · The VA was easily agitated and frustrated, and had difficulty regulating his/her emotions. The VA experienced "command hallucinations” some of which encouraged the VA to self-harm, and had experienced significant trauma and abuse in his/her life. The VA’s Support Plan (Addendum) provided the following information: · The VA had 2:1 staffing from 7 a.m. to 11 p.m., and 1:1 awake overnight staffing. The VA did not have any home or community alone time, and must be within sight and sound of at least one staff person at all times, with the exception that during 1:1 supervision there might be times where staff persons were not within sight and sound of the VA in order to complete job-related tasks or use the restroom. · The VA had a history of self-injurious behaviors and suicidal ideation. When the VA was dysregulated, staff persons talked with the VA and the VA used coping skills to self-sooth. When the VA was experiencing suicidal ideation, staff persons only left the VA alone to use the. The VA had multiple rights restrictions related to his/her self-injurious behaviors. · The VA historically engaged in behaviors of seeking medical attention during evening hours as a coping skill, and frequently made “false medical claims” that s/he required emergency medical care for what were in fact non-emergency situations. A plan was created by the VA’s team and hospital personnel to encourage the VA to use coping skills instead of emergency services. Additionally, as a result of past behavior, the VA’s team approved a rights restriction related to access to a telephone. The restriction stated staff persons would contact 9-1-1 on behalf of the VA if emergency services were required. · The VA also had a rights restriction regarding locking his/her bedroom or unit door. Staff persons completed a sweep of the bathroom prior to the VA going in, and removed all items from the bathroom that could be ingested. A staff person remained in the bathroom with the VA if necessary to ensure the VA’s safety. A staff person also remained in the bathroom with the VA if his/her mental health was not stable. · There were multiple examples of the VA providing inaccurate statements such as a family member calling the VA names, and that another family member had “faked” his/her death. The VA’s Individual Abuse Prevention Plan stated the VA was susceptible to sexual abuse. The VA was at risk of cooperating in an abusive relationship and might not recognize that the relationship was unhealthy and unsafe. The VA Self-Management Assessment included consistent information to that of his/her other client specific plans, but also stated the VA had a history of “false reporting.” The facility’s Incident and Emergency Report(s) from November 6, 2024, stated that around 8 p.m., the VA informed staff persons the ballon part of his/her catheter seemed low, and the VA tried to adjust it. An on-call supervisor was contacted and provided guidance, including having the SP “look at the catheter,” if the VA was willing. The VA agreed, and the SP “evaluated” the catheter, and the catheter “looked normal.” Afterward, the VA attempted to use the bathroom, and the catheter came out. The VA was transported to an emergency room for medical assistance at 9 p.m. The doctor “reported that it was abnormal for a catheter to come out so many times.” A medical facility’s After Care Summary from November 6, 2024, showed the VA was diagnosed with mechanical malfunction of his/her urethral catheter. The VA’s Daily Log Notes and Health Progress Notes provided the following information: · On November 6, 2024, at 9 p.m., the SP noted the VA’s catheter “came out,” and the VA was seen at an emergency room. Prior to going to the emergency room, the VA was in the bathroom and the ballon part of the catheter was coming out. The VA attempted to push it back in, but was unsuccessful. An on-call supervisor suggested the use of Vaseline, but it was documented, “it was stuck and wouldn't move.” A plan was created for the VA to go to Urgent Care in the morning, but the VA continued to be in discomfort, and an on-call supervisor suggested the SP look at the catheter to see if everything looked normal. The SP observed the catheter, and believed “everything looked normal.” Afterwards the VA tried to go to the bathroom, and was “straining” while going to the bathroom. The VA then showed the SP the ballon had “came out.” The VA was seen at the emergency room to get the catheter replaced. · On November 6, 2024, P1 documented information related to the incident, including his/her observations, which were consistent with the information documented by the SP. There was no information within P1’s documentation which showed the SP’s behavior or interaction with the VA was abnormal or non-therapeutic, or that P1 observed any abnormal behavior or emotional distress from the VA after the VA and SP were in the bathroom. P1 did not document any concerns the VA expressed while being transported to the emergency room, or during the remainder of the day. · On November 8, 2024, there were multiple entries regarding the VA and an alleged incident on November 6, 2024. o On November 8, 2024, the VA told P4 and P5 that on November 6, 2024, while checking the catheter the SP put his/her fingers into the VA’s genitals. The VA felt “violated,” and “was not comfortable” with the SP checking his/her genital area. o During a phone conversation with family members the VA stated that the SP put two fingers in his/her genitals, moved the fingers around, and the SP’s nail scratched the VA. The VA said s/he “screamed” during the incident. o The VA went to the bathroom and informed staff persons the catheter was out. An on-call supervisor was contacted, as well as a nurse hotline, and it was recommended the VA be seen at a medical facility. While at the medical facility the VA stated s/he was sexually assaulted on November 6, 2024. Law enforcement was contacted and took a statement from the VA. Information from LE Records was consistent with the information from the facility’s Internal Review, as well as from information from the interviews this investigator completed with the VA, the G, the CM, P1-P3, and the SP. LE records documented that: · Medical personnel advised a sexual assault exam would not be medically beneficial due to the duration between the alleged incident and the exam, and because the VA had showered since the alleged incident.
· The VA said that on November 6, 2024, prior to the alleged incident s/he was having issues with his/her catheter and the SP was instructed by an on-call supervisor to check the catheter. The VA said s/he the SP were in the bathroom, and the SP put on gloves, but instead of checking the catheter the SP inserted two fingers into the VA’s genitals. The VA said that during the incident s/he “scream[ed],” and said the SP was “violating” the VA. The VA estimated the interaction lasted approximately 20 minutes. · P1 said there was an on-going issue with the VA’s catheter on November 6, 2024, and believed prior to the catheter coming loose, the VA was “acting and walking differently.” The VA requested the SP come into the bathroom with him/her due to the issue with the catheter. During the alleged incident P1 was outside the bathroom door, which was “cracked open,” and could hear what the VA and the SP were saying. P1 said it did not appear the SP made physical contact with the VA, and believed the SP had only completed a visual check of the catheter. P1 overheard the conversation between the VA and the SP while they were the bathroom, which included the VA and SP “joking” and acknowledging it was “uncomfortable” for a person to observe another’s genitals. P1 did not hear any statement about the VA being “violated,” and did not hear the VA scream. P1 did not observe any concerning interactions between the VA and the SP during the remainder of the evening. · P2 said s/he was present at the facility during the alleged incident, but was not working directly with the VA. P2 was aware the VA and the SP were in the bathroom on November 6, 2024, but was not informed of the alleged incident until on November 8, 2024. P2 did not observe any abnormal interactions between the VA and the SP after they came out of the bathroom, or the remainder of the evening. P2 “confidently” believed that the SP did not sexually abuse the VA. · P3 was not present for the incident, but had worked with the SP. P3 did not have concerns about the SP’s prior interactions with the VA or other vulnerable adults. P3 stated the VA was not an accurate reporter of information, and sought medical attention by engaging in negative behaviors. · The CM said the VA did not reliably provide accurate information, and had a history of seeking a reason to go to medical facilities. The CM provided multiple examples of inaccurate information the VA had provided, but added the VA had not previously alleged sexual abuse by staff persons. The CM said the VA would not understand the ramifications of providing inaccurate information of sexual abuse. · The G said the VA did not provide accurate information “all the time,” and provided examples of inaccurate information the VA had provided in the past. The G said the VA would seek medical attention, and appeared to be intentionally causing issues with his/her catheter in order to go to the emergency room. · The SP said on November 6, 2024, s/he visually checked the catheter after the VA verbally agreed, but denied inserting his/her fingers into the VA’s genitals. The SP said the VA asked him/her to touch the VA’s genitals where the catheter was located, but the SP declined, and did not physically touch the VA while checking the catheter. The SP said P1 was outside of the bathroom while the SP checked the VA’s catheter, and the VA and the SP talked about the situation being uncomfortable, but the SP completed the assessment without any further issues. The SP said s/he and the VA joked and laughed about it afterward. · There were no prior concerns with the SP’s employment, nor with the care and services s/he had provided at the facility. · Based on the information LE obtained, the case did not warrant criminal charges and was inactive pending any additional Information. P1, P2, P3, and the SP were each trained on the VA’s plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: It was reported that on November 6, 2024, the VA was having issues with his/her catheter, and the SP inserted two fingers into the VA’s genitals while assisting the VA in the bathroom. The VA told LE and this investigator that s/he and the SP went into the bathroom so the SP could check the VA’s catheter, and while in the bathroom the SP inserted two fingers into the VA’s genitals. The VA said that during the incident s/he “screamed” and said the SP was “violating” the VA. The SP acknowledged visually observing the VA’s catheter in the bathroom on November 6, 2024, and said the VA asked him/her to touch his/her genitals where the catheter was located. However, the SP denied any physical contact with the VA’s genitals. The SP said while they were in the bathroom, s/he and the VA talked about the situation being uncomfortable. P1 said s/he was outside the bathroom during the alleged incident with the door cracked open, and heard the conversation between the VA and the SP. P1 did not hear the VA scream or make any comments about being violated. Rather, P1 heard the VA and the SP “joking” and acknowledging the situation was “uncomfortable.” For the remainder of the shift on November 6, 2024, P1 and P2 each said there were no other concerns. Given the inconsistency between the VA’s account of the incident compared with the SP’s and P1’s, that the VA had a known history of providing inaccurate information, and that the SP denied the allegation, there was not a preponderance of the evidence as to whether the SP engaged in sexual contact or penetration 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 adequate, but not followed. The VA had a history of being involved in similar allegations. The facility took corrective action to ensure two staff persons were present in the bathroom with the VA if s/he had a catheter, or displayed unsafe behaviors. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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