|
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: 1091765-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069732-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported two staff persons (SP1-SP2) were seen with a vulnerable adult (VA), and the VA said, "No," and "Stop," while SP2 pulled up SP2’s pants up, and SP1 pulled the VA's pants up. Date of Incident(s): November 29, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (c): Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. Summary of Findings: Pertinent information was obtained during a site visit conducted on January 19, 2024; from documentation at the facility; and through seven interviews conducted by this investigator and law enforcement (LE) with facility staff supervisors (P1-P3), the VA’s case manager (CM), the VA’s guardian (G), and SP1-SP2. The VA was unable to complete an interview as s/he was limited verbally. This investigator attempted to contact P1 regarding the information s/he provided in an interview with LE, however P1 did not response to the interview request that was sent by mail. Facility documentation showed the VA spent time at the facility playing memory games, listening to music and coloring. The VA engaged in community activities such as going to the zoo, parks, Target, and grocery shopping. The VA also assisted staff persons with laundry, and household tasks in his/her bedroom. The VA’s goals included decreasing his/her behaviors to prevent future injuries. The VA was diagnosed with Autism and attention-deficit hyperactivity disorder. During the site visit this investigator observed multiple areas that had property destruction due to the VA’s behavior, and the VA had a cast on his/her arm due to an injury. It appeared the facility attempted to adapt the facility’s environment to meet the VA’s behavioral needs. The facility completed an Internal Review (IR), which provided the following information: · On December 8, 2023, P1 emailed facility administration regarding an incident that occurred on November 29, 2023. P1 stated s/he observed SP1 and SP2 with the VA, and they were on the floor of the laundry room. P1 observed SP2 pulling up his/her pants and SP1 and SP2 had the VA in a “chokehold.” · P1 said after observing the alleged incident SP1 started folding laundry, and both SP1 and SP2 acted nervous. · SP1 said s/he did not remember a specific incident in the laundry room, but said during the VA’s behaviors staff persons would walk around the facility and engaged the VA in other activities. SP1 denied harming the VA and did not remember any other staff persons having to pull their own pants up while working with the VA. SP1 said it was not unusual for the VA’s pants to fall down, and staff persons would often pull the VA’s pants back up. SP1 said P1 had contacted him/her via phone call as s/he was not comfortable at the facility due to an alleged medication error, and P1 described interpersonal concerns with P3. · SP2 said there was an incident on November 29, 2023, but SP1 and SP2 never put the VA “in a chokehold.” SP2 said SP1 was doing the laundry when the VA started having a behavior, and the VA’s cast caught SP2’s pants while assisting the VA, and SP2 had to pull up his/her pants, but they were never “down all the way.” SP2 did not have any concerns with SP1’s or SP2’s interactions with the VA. · The facility determined P1 did not follow the facility’s training of policy and procedures as P1 did not inform the facility of the alleged incident for nine days. The facility did not find any other concerns within their investigation. · There was no information within the VA’s Progress Notes which provided information related to the alleged maltreatment. LE and this investigator completed interviews, and the below information was provided: · P2 said the VA was seen at a medical appointment ten days after the incident and there were no observed injuries indicating sexual abuse occurred. · Both SP1 and SP2 denied placing the VA in a “chokehold,” and denied that any other abuse or neglect occurred during the alleged incident. SP1 and SP2 provided consistent information to that which was in the IR. · P1 said s/he observed a disturbing behavior in the laundry room between SP1, SP2, and VA, but did not observe any sexual contact between SP1 or SP2 and the VA. P1 stated that after the incident, the VA did not have any injuries around his/her head or neck. In addition, P1 stated staff persons did other illegal things, set him/her up, hacked his/her phone, email, and ultimately s/he no longer worked for the facility. · There was consistent information the VA had issues with his/her pants falling down. · There were no previous concerns with SP1’s or SP2’s work performance, or concerns related to interactions with the VA. · LE closed their investigation and charges were not forwarded to the Scott County Attorney’s Office. The G and CM did not have any concerns with care and services provided to the VA at the facility. P1, P2, P3, SP1, and SP2 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 29, 2023, SP1 and SP2 were with the VA, and the VA said, "No," and "Stop," while SP2 pulled up SP2’s pants up, and SP1 pulled the VA's pants up. P1 said s/he saw SP1 and SP2 have the VA in a chokehold, but did not have any indications of injury, and also saw SP1 pulled up the VA’s pants, while SP2 pulled up his/her own pants. After the alleged incident there were no injuries observed on the VA. Additionally, P1 had interpersonal concerns at the facility and did not report the allegation until nine days after it occurred. SP1 and SP2 denied any sexual abuse occurred, and denied the VA was placed in a chokehold. The VA was unable to provide any information related to the alleged incident. The VA was seen by a medical facility and LE said there was no injury to the VA, and there was no evidence that showed sexual abuse occurred. Given that there were credibility concerns with P1, that there was no other information to support P1’s statements, and that SP1 and SP2 each denied the incident occurred as P1 described, there was not a preponderance of the evidence as to whether SP1 or SP2 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 determined that the policies and procedures were adequate, but not followed as P1 failed to inform the facility of the alleged incident in a timely manner. The incident was not similar to past events. P1 was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
|
