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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: 1102157-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069963-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a court ordered restriction regarding the use of cell phones. It was alleged that staff person (SP1) violated the order and allowed the VA to use SP1’s personal cellphone on several occasions, planned to help the VA to get his/her own cellphone, and told another staff person (SP2), who was in training, to allow the VA to use his/her personal cellphone. Date of Incident(s): Ongoing prior to August 6, 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 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 September 15, 2023; from documentation at the facility; and through nine interviews conducted with the VA, a supervisory staff (P1), the VA’s guardian (G), and six staff persons (SP1, SP2, and P2-P5). Attempts were made via phone, text, email, and mail to contact and interview an additional staff person (P6), but P6 did not respond. The VA enjoyed his/her pet, going out into the community to shop and to the beach, and reading books. The VA’s diagnoses included schizoaffective disorder, bipolar disorder, post-traumatic stress disorder, borderline personality disorder, mild intellectual disabilities, reactive attachment disorder, and fetal alcohol syndrome. The VA’s Rights Restrictions form from May 24, 2022, provided by the facility and signed by the VA’s team stated the following information: It has been determined by [the VA’s] team that it is unsafe for [him/her] to have a cellphone or access to a phone that is not monitored by staff. [The VA] will have a cel [sic] phone and calls made from the house phone will be monitored by staff unless the person who [s/he] is calling is on the approved list of people that do not need to be monitored. The VA’s Rights Restrictions dated May 8, 2023, provided by the G and unsigned stated the following: It is unsafe for [the VA] to have a cell phone or any other electronic device that [s/he] can make unmonitored calls on or contacts with unknown/unlimited contacts. [The VA] will not have a personal cell phone and all calls will be made from the landline phone at [his/her] home. Calls will be monitored by staff unless they are on the list of contacts [the VA] created with [his/her] team. (Note: A community person (CP) was on the VA’s approved list.) [The VA] will not use any electronic device that has interact access or use social media. The G and emails between the G and P1 provided the following information: · Historically the VA agreed to certain things but did not fully understand what was communicated. The VA might “triangulate” others or exaggerate to try to get his/her way and might “stretch the truth” and “misstates timeframe.” The VA did “not normally make up stories just to get others in trouble.” · In the past, the VA shared his/her phone number and address online asking for sexual partners. As a result, strangers came to the facility to meet the VA. The VA brought them to his/her room and engaged in sexual activities without protection. The G was concerned about the risk presented to the VA, staff persons, and other residents when the VA did this. · When the VA expected a stranger who did not show at the facility s/he became frustrated. The VA might engage in self-injurious behaviors or leave the facility and sit in the road. When G gave the VA a limited capability cellphone, the carrier said that in one month, the VA used “810.4% more text messages” than the average cellphone user. The G then took away the cellphone and it was locked up at the facility. · The G filed a rights restriction through the court that said the VA was not to have “social media internet access” until s/he completed a social medial internet safety course. At the facility, the VA was to use a specialized cordless phone that did not have the ability to dial out. The VA’s calls were to be on speakerphone and monitored by staff person and unless the calls were to people on the VA’s approved list. · On August 9, 2023, during the evening, the G spoke on the phone with the VA. The VA said, “A few days ago,” an unknown staff person sent a SnapChat and text the CP for the VA. A second unknown staff person “gave [the VA] permission” to go into the staff person’s bag, get his/her cellphone, unlock it, and use it when “no one was looking.” Shortly after talking to the VA, the G emailed P1 and reiterated that the VA was “NOT to have any access to electronics involving internet including social media.” · Later that evening, P1 replied and stated that on August 7, 2023, the VA was upset that staff persons would not take him/her to the store to purchase a cellphone and “repeatedly” asked the two staff persons to send the CP a text message for him/her, which they did not do. The VA was then “allowed one phone call to [the CP] on speakerphone” from the staff person’s cellphone while s/he was monitored. P1 noted that s/he “not sure why it mattered which phone was used.” P1 said the VA was “stretching the story” to the G because s/he was upset with the staff persons. The VA, P1, P2, P3, P4, P5, and SP1, provided the following consistent information:
· The VA attempted to mislead others when s/he thought it might benefit him/her. The VA told different people different information and played individuals against each other to manipulate a situation. The VA tried to create confusion between staff persons and the G to get his/her way. Staff persons were to ask detailed question to the VA in attempt to get to the truth. · The VA gave out his/her personal information online and on the phone to unknown person that included the address of the facility. When these unknown persons came to the facility, staff persons did not know their intentions. At times, these unknown persons were resistant to leave the facility when told by staff persons. The G decided for the VA’s safety there was to be no use of cellphones, tablets, and internet, and a court order was put in place. P1 thought the VA’s restriction did not prevent the VA from using a cellphone if a staff person monitored it and gave an example of when the VA used a staff person cellphone to call the G from the veterinary’s office about the VA’s pet. · Staff persons were trained on the VA’s internet and social media restriction upon hire, annually, and there were “consistent reminders.” When the VA wanted to make a call to a person on the VA’s list of approved persons, staff persons dialed the number and the VA talked on a portable headset. Staff persons did not monitor the calls. The VA often asked staff persons to contact the CP on their personal cellphones on the VA’s behalf. P1 was advised the staff persons against doing this because then the CP would have their personal cellphone numbers in connection to the VA. Regarding SP1 violating the court order/rights restriction by allowing the VA to use SP1’s personal cellphone on several occasions: The VA said that when SP1’s adult child was in the hospital and the VA called P1 to see if s/he could go with SP1 to visit the child. P1 approved and the VA went with SP1. The VA and SP1 visited with the child for “two hours maybe” and “just talk[ed].” The VA denied s/he was given or used SP1’s phone during that time. The VA said the only staff person who allowed him/her to use a cellphone was SP2 and it was “one time.” SP2 stated that on August 6, 2023, s/he was being trained in by SP1 to work with the VA. About 3 p.m. they all went on an outing. At one point, SP1 drove, SP2 was in the passenger seat, and the VA sat behind SP1. SP1 gave the VA his/her cell phone to use until they arrived at a restaurant to get food. Then when they left the restaurant, the VA asked for SP1’s cellphone and s/he again gave it to the VA to use. SP2 believed it was “about 30 minutes” that the VA used SP1’s phone. The VA said s/he was playing games on SP1’s cellphone on the drive back, but SP2 was not able to see the phone’s screen. When SP2 asked SP1 if it was “allowed” to let the VA use his/her cellphone, SP1 said s/he “let [the VA] use it all the time and there is never anything wrong.” P3 stated that the VA told him/her about “six times” that SP1 allowed the VA to use SP1’s cell phone to text/message others and to go on social media to look up information about people. There were times when SP1 sent texts for the VA. On an unknown date, the VA told P3, “[SP1] let me Snapchat.” The VA was “not a secret keeper,” and all staff persons “were somewhat aware” that SP1 gave the VA his/her cellphone to “send pictures” and go online. P3 thought SP1 was “stuck” after s/he “allowed [the VA] to get away with so much.” If SP1 were to deny the VA the use of his/her cell phone, the VA would “get mad” and “freak out.” P3 told P1 about what the VA said, and after that, P3 still heard from other unknown staff persons that the VA continued to use SP1’s cellphone. P3 never saw the VA with SP1’s cellphone. P3 said that on an unknown date after July 23, 2023, the VA told P3 that on the day s/he went with SP1 to see SP1’s child in the hospital, SP1 let the VA use his/her cell phone. P3 talked to P2 who said s/he confirmed with P1 that it was “okay.” P2 said s/he was working a shift when SP1 took the VA with to the hospital to see SP1’s child in the hospital. SP1 said it was approved by P1 but P2 was “super confused” about it. P2 texted P1 to ask about it and P1 texted back, “Yes, because [the VA] called and asked if [s/he] could go with.” P2 thought SP1 drove the VA in his/her own car instead of the company one. P2 never directly saw the VA use SP1’s cellphone or heard about the VA using SP1’s cellphone. P4 and P5 were not aware of SP1 bringing the VA to see his/her son in the hospital or allowing the VA to use SP1’s cellphone. P4 said s/he was not aware of any instances where SP1 allowed the VA to use his/her phone. P5 heard from other staff persons that a staff person “let [the VA] access the internet or use their phone to make a call.” P5 did not recall who the staff person was who was said to have done this or of any other instances where this occurred. P5 heard from “a few different” staff persons that in May or June of 2023, SP1 allowed the VA to use his/her phone when they smoked out front. P5 denied seeing SP1 give or allow the VA to use his/her cellphone. P1 stated that s/he was not aware of staff persons allowing the VA to use a cellphone unsupervised. P1 believed that if the VA accessed a cellphone, the VA would “keep it quiet” because it was a benefit for the VA. P1 said that s/he told SP1 not to take the VA to with SP1 to the hospital unless his/her shift was covered. P1 said, “I don't know that [the VA] was ever present in the hospital,” or used SP1’s cellphone while there. SP1 stated that on July 23, 2023, SP1 and P2 were working at the facility. SP1 and the VA were at the library when SP1 got a call from a hospital regarding SP1’s adult child. The VA knew and had talked with SP1’s adult child when s/he dropped SP1 off at the facility. SP1 had to go to the hospital and the VA also wanted to go. SP1 called P1 who gave approval. SP1 and the VA then drove to the hospital and were there for “probably half an hour at most,” and they spent five minutes with SP1’s adult child. The VA was with SP1 the entire time. SP1 denied giving or allowing the VA to use SP1’s cell phone during this time. SP1 denied that s/he letting the VA use his/her cellphone. SP1 said s/he did not carry his/her cell phone on his/her person when s/he was at the facility. SP1 left it in a bag and only looked at it if there was “downtime.” SP1 said his/her phone was “locked and nobody has the lock but me and how to get into it.” Regarding SP1 planning to help the VA to get his/her own cellphone. The VA stated that on an unknown date, prior to the VA’s phone rights restriction (May 24, 2022), s/he was at a store with SP1 and purchased a cellphone with the plan to hide it. SP1 called P1 and who said that since it was with the VA’s own money, the purchase was allowed. One or two weeks later, the G got the rights restriction and court order in place so the VA gave the phone to P1. The VA denied any other times when SP1 or the VA attempted to purchase a cell phone. SP2 that on August 7, 2023, around 2 p.m., SP2 and the VA were outside at the facility. The VA asked SP2 for his/her cell phone and SP2 told the VA, “No.” The VA then asked SP2 to take him/her to the store so the VA could purchase one. As they talked, SP1 came and the VA went to SP1’s car. SP1 then told SP2 to take the VA to the store and SP1 would meet them there. SP1 told SP2 that the plan was that after the VA purchased a cell phone, SP1 would take the trash and then the VA could take the phone and charger to his/her bedroom. SP2 give inconsistent information on how s/he responded. SP2 said s/he told SP1 s/he was “not comfortable” with that plan, would not participate, and planned to tell P1. SP2 also said that s/he initially told the VA and SP1, “Okay, sounds good, it sounds like a plan” and then SP2 and the VA went inside the facility. SP2 had no intentions of going through with the plan because s/he “wasn’t about to get in trouble for a second time about a stupid phone.” SP1 was scheduled to work that day, but P3 worked the shift instead. The VA told P3 s/he and SP2 were going to walk to the store and P3 offered to drive them there instead. The VA then changed his/her mind and decided s/he did not want to go. SP2 thought the VA decided otherwise since P3 driving “ruined [his/her] plan.” and the plan was not followed through on. SP2 told P1 the next day. SP1 stated that on an unknown date, s/he and the VA were at the store and the VA wanted to buy a cell phone. SP1 told the VA that due to the court order, s/he could not do so but the VA said, “They can’t take it away from me if I buy it with my own money.” At that time, SP1 let the VA purchase the phone to avoid an issue in public. SP1 then called P1 about the situation. P1 called the G and when they returned to the facility, the VA gave over the cellphone to be locked away. SP1 denied offering to assist the VA to sneak a cellphone into the facility. SP1 denied that s/he asked any staff person, including SP2, to help the VA buy a cellphone to sneak into the facility, and/or saying s/he would hide the trash. P3 stated that on an unknown date, the VA came to P3 and asked if P3 could “do us a favor” for something the VA “really wanted.” The VA told P3 that “[SP1] wanted [P3] to drive [the VA] and [SP2] to the store because [SP1] was going to buy [the VA] a cellphone so that [s/he] could have one in the house.” P3 told the VA, “No,” and then called P1 and told him/her what the VA said. P1 came to the facility and talked with the VA. P1 spoke to the VA and about what P3 said and each denied it. P2 said that one time the VA tried to buy a cell phone at a store, but the staff person who was with the VA did not allow it. P2 did not know of any staff person who planned to help the VA secretly get a cell phone. P5 heard from another staff person who s/he declined to identify, that in July or August 2023, SP1 planned to help the VA get a cellphone. P5 told P1 who said s/he was already aware. P4 said s/he was not aware of any instances of any staff person trying to help the VA get a cell phone or any plans by a staff person to sneak the VA a cellphone into the facility. Regarding SP1 telling SP2, who was in training, to allow the VA to use his/her personal cellphone. SP2 provided the following information: · On August 6, 2025, around 6:30 p.m., the VA and SP1 went outside to smoke. SP1 asked SP2 to come outside because the VA asked and SP2 came out. While outside, the VA asked SP1 to use his/her phone to text and use Facebook. SP1 said s/he was “busy” and to ask for SP2’s phone. The VA asked to use SP2’s phone to contact the CP. SP2 clarified with SP1 because the VA’s program book said the VA was not to have a cellphone. SP1 told SP2 that s/he “trust[ed]” the VA and “lets [the VA] play on [his/her] phone all the time.” SP1 also said that P1was aware and there was “never anything wrong.” The VA said s/he was “not going to do anything wrong” and only wanted to contact the CP. SP2 thought since SP1 worked with the VA for eight years and said it was okay, there was no problem with it and allowed the VA to use his/her cellphone. SP2 said that s/he felt SP1 and the VA “gang[ed] up against” him/her and s/he was “coerced” by SP1 to allow the VA to use his/her phone. · At this same time, the VA asked SP2 to look up the CP on Facebook. SP2 “pretended” to look for the CP on the platform. The VA then asked to have the phone with “text open.” SP2 said s/he was “not comfortable with that” and the VA asked SP2 to download an app called TextNow for him/her to use, which SP2 did. SP2 watched as the VA used his/her phone to message the CP and asked why s/he was not talking to him/her. SP2 did not see anything “inappropriate or bad” sent by the VA. The VA then gave SP2 his/her phone back. SP2 said “after a while” the CP did not respond, and the VA again asked for his/her phone to text the CP again. SP2 gave the VA his/her phone and the VA asked to take SP2’s phone to his/her room “for a little bit.” The VA said s/he was “not going to do anything wrong.” SP2 gave the VA his/her phone, and the VA went inside to his/her room. SP2 went inside the facility and told P2 about the incidents that day. SP2 “was freaking out” and said s/he did not know what to do. P2 suggested SP2 reach out to P1 about what happened. · SP2 said that around 7:15 p.m., s/he got his/her phone back from the VA. The VA told SP2 that s/he talked with the CP, took photos, and “sent some stuff,” but did not provide details. SP2 then told the VA, “You’re not going to use my phone again. I will be letting [P1] know.” SP2 went through his/her phone. SP2’s phone had several apps open and saw someone added in his/her Snapchat who s/he thought might be the CP. SP2 went through the apps, the phone’s camera roll, and cloud backup, but did not see any photos or sent messages from the VA and the TextNow app was also deleted. SP2 believed that the VA went through the phone and deleted the items before s/he returned the phone to SP2. The VA then spent the rest of SP2’s shift in his/her room and otherwise appeared “super happy.” SP2 reached out to P1 about the situation the next morning. P2 stated that s/he worked the evening shift when the VA used SP2’s phone. SP2 told P2 that SP1 “encouraged” SP2 to allow the VA to use his/her personal phone. SP2 was told that the VA messaged the CP and sent him/her a Snapchat. P2 texted P1 what s/he was told. SP1 provided the following information: · On August 6, 2023, in the evening, SP1, SP2, and the VA were outside in front of the facility. SP2 was training SP1 during the shift. SP2 and the VA sat by the front door talking. SP1 was also sitting outside smoking a cigarette and “wasn’t totally 100% focused” when SP1 saw SP2 dial a number and then give the VA the phone, but there was no answer. SP1 told SP2 that the VA was not to use the SP2’s phone, that SP2 needed to get it back from the VA, and SP2 could “lose your job” for it. SP2 then asked for the phone back, the VA gave it to him/her, and the VA went into the facility. The VA used SP2’s phone for about “two minutes.” Later that evening, the VA told SP1 that s/he took SP2’s phone to his/her room, knew how to unlock it, and talked with the CP “for half an hour.” · SP1 said two to four days later, s/he and the VA talked about the incident. The VA said SP2’s phone was in SP2’s backpack and the VA knew how to unlock it. The VA said s/he was told by SP2 s/he could use SP2’s phone “anytime” to take to his/her room to call the CP. SP1 called P1 and told him/her about what VA1 said and P1 later came to the facility. P1 provided the following information: · On August 7, 2023, at 11:44 a.m., SP2 texted P1 wanting to talk and later that day SP2 came to the facility and met with P1. SP2 wanted clarification on the VA’s cell phone restriction. P1 said it was a staff person’s discretion to allow the VA to make calls from their personal cell phone, but the VA was to be supervised. SP2 said that SP1 allowed the VA to use his/her cellphone to call the CP and that SP1 said it was allowed “because they were able to monitor the call. SP2 also said the VA took two selfies with SP1’s cellphone. SP2 said s/he was unable to find any photos on his/her personal phone. P1 stated that at this time, SP2 did not tell P1 that s/he let the VA use his/her phone or that SP1 told SP2 that it was okay to do so. P1 was said s/he was not aware the VA has SP2’s phone in his/her room. · P1 then talked to SP1 acknowledged that s/he called the CP with the VA on his/her personal cellphone but denied that the VA took any photos. P1 said that because the call was monitored by SP1, s/he did not feel it was a violation of the court order because the VA was able to contact the CP while supervised on the landline phone. SP1 said SP2 allowed the VA to use his/her phone to take photos. P3 talked to the VA who provided information regarding the VA using SP2’s cell phone that was consistent with the information provided by SP2. P2 later told P3 that SP2 “didn’t know it wasn’t allowed,” and “just kind of went with it” because SP1 had allowed it. P4 and P5 were not aware of SP2 allowing the VA to use his/her personal cellphone in his/her bedroom. The VA said that on an unknown date in August 2023, the VA and SP2 were outside. SP2 made a phone call for the VA and allowed the VA to listen. The VA then asked and SP2 gave him/her the phone. SP2 showed the VA the phone’s password and the VA then used the phone in his/her room for “like three hours.” The VA contacted the CP and sent him/her texts, Snapchats, and pictures of the VA’s chest. When the VA gave SP2 his/her phone back, SP2 said that if the VA wanted to use it again to take it out of SP2’s bag. Facility documentation showed that SP1 and SP2 were trained on the Reporting of Maltreatment of Vulnerable Adults Act, Boundaries, and the VA’s plan. Facility documentation showed that SP1 was trained on the VA’s plan. The facility did not provide documentation that SP2 was trained on the VA’s plans which was a violation of Minnesota Statutes, section 245D.095, subdivision 5, which states in part that the license holder must maintain a personnel record for each employee to document and verify staff orientation and training. Conclusion: Regarding SP1 violating the order and allowed the VA to use SP1’s personal cellphone on several occasions.: Information was inconsistent whether SP1 allowed the VA to use his/her phone in violation of the VA’s rights restriction. The VA and SP1 each denied this occurred but SP2 and P3 provided consistent information that the VA told each separately that SP1 allowed him/her to use SP1’s phone. Although the VA calling the CP was not a violation of his/her rights restriction even if it was unsupervised, allowing the VA access to the internet unsupervised was a violation. However, without additional information or details regarding incidents, such as dates, times, and/or who the VA called and/or communicated with, there was not a preponderance of evidence whether SP1 allowed the VA unsupervised access to or use of a cell phone in violation of the VA’s rights restriction. 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.) Regarding the allegation of SP1 planned to help the VA in getting his/her own cellphone in violation of the court order: Information was inconsistent regarding SP1 helping the VA obtain a cellphone. The VA stated it occurred prior to his/her rights restriction; SP2 stated that on August 7, 2023, SP1 told SP2 to bring the VA to the store where SP2 would get a cell phone with the VA; and SP1 stated that s/he one time s/he allowed the VA to purchase a cell phone but it was taken away upon their return to the facility.
Given that there was no information to diminish SP2’s credibility, it was concerning that SP1 asked SP2 to bring the VA to the store to get a phone and for SP1 to have allowed the VA to purchase a phone when the VA has rights restrictions in place. This was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. However, there was no information provided that at any time, the VA had a hidden cell phone. Therefore, there was not a preponderance of evidence whether there was a failure to supply the VA with necessary care or services. 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.) Regarding SP1 telling SP2, who was in training, to allow the VA to use his/her personal cellphone. Information was consistent that on August 7, 2023, the VA asked and was given SP2’s phone and used it unsupervised which was a violation of the VA’s rights restriction. Although the VA contacted the CP who was on the VA’s list of approved persons who did not require staff supervision, the VA had access to the internet while using SP2’s phone. Information regarding how the VA obtained the phone varied. The VA and SP1 said SP2 allowed the VA to use his/her phone to call the CP and then later take the phone to the VA’s bedroom. However, SP2 stated SP1 instructed SP1 to call the CP and then allow the VA to take the phone to the VA’s bedroom. Regardless of how the VA obtained the phone, SP2 was aware of the VA’s rights restriction. Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (4), states, "A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care." Given that SP2 was in training at the time and was to be supervised by SP1 and P2 at the time of the incident, and there was no injury or harm to the VA it was determined that SP2 allowing the VA to use his/her cell phone constituted an error in the provision of therapeutic conduct. This error in the provision of therapeutic conduct to the VA by SP2 was not maltreatment. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate, but not followed. All staff person were to be trained on the boundaries and rights restriction. SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP2 was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which s/he was responsible met the criteria to be determined an error. SP2 was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which s/he is responsible might not be considered an error. On July 23, 2025, the license holder was issued a Correction Order for the violation outlined in this report.
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