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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: 1119782-PTRF (Psychiatric Residential Treatment Facility) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that in March or April of 2025, a staff person (SP) shared details of his/her personal life with a vulnerable adult (VA), including information regarding the SP’s sexual relationships and concerns about possibly becoming a parent, the SP’s own mental health issues and self-injurious behaviors, and worries that others might see evidence of his/her self-harm on the SP’s body. Date of Incident(s): Unknown dates in March or April of 2025 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 13, 2025; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, P3, and the SP), and the VA. P1, P2, and the SP were supervisory staff persons, and P3 was an administrative staff person. The facility provided services to individuals aged 12 to 19 with significant mental and behavioral health issues with programs to support families throughout the treatment process. The VA turned 18 years old in mid-March of 2025, and since no specific dates were provided for the incidents with the SP, it was presumed for this report that the VA might have been 18 years old when the incidents occurred. The facility had a video recording system that recorded common areas of the facility, but the video recordings did not have sound. On campus, individuals received education services, therapies personalized to their needs, and recreational opportunities. Facility documentation showed that the VA was diagnosed with generalized anxiety disorder and post-traumatic stress disorder and might become upset when others made comments about his/her appearance or suggested that past events might be the VA’s fault. The VA was not subject to guardianship. The VA had a history of engaging in self-injurious behavior and knew the SP from when the SP previously worked at a facility in which the VA resided. Prior to the March/April 2025 incident being known, facility supervisory/administrative staff persons decided that the relationship between the VA and the SP was non-therapeutic because of the VA’s and SP’s previous connection, and assigned the SP to work in units at the facility that limited his/her contact with the VA. The VA was social and liked to talk. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · The VA provided consistent information in an interview with this investigator and in the facility’s Internal Review, that on a date or dates s/he could not recall in March of 2025, the SP told the VA details about the SP’s sexual experiences, including information regarding an incident during which the SP was allegedly sexually assaulted and that the SP had concerns about possibly becoming a parent. In addition, the SP told the VA that the SP sometimes engaged in self-injurious behavior, and that the SP was concerned that his/her family members might notice that s/he harmed him/herself. The VA felt that s/he was the SP’s therapist and said it seemed that s/he was counseling the SP. · P1 and P2 each stated in individual interviews with this investigator, that on July 22, 2025, the VA told them about the VA’s conversation/s with the SP in which the SP described his/her past sexual experiences and incidents of self-harm. The Ps listened to the VA’s concerns and thanked the VA for trusting them with the information, but were concerned that the SP did not maintain appropriate boundaries with the VA and thought that the SP’s actions caused the VA a significant amount of stress because the VA was extremely anxious and upset when s/he spoke with them about the SP and the information the SP shared. The VA told the Ps that s/he had been holding the information in for a long time and felt that s/he was previously unable to tell others about it. The Ps advised P3 of their concerns and relayed their conversation with the VA to P3. However, no information showed that the VA’s incidents of self-injurious behaviors increased when s/he had contact with the SP, and information was consistent that the facility took steps to limit the VA’s contact with the SP because of their previous relationship at another facility. · Information P3 provided to this investigator and in the Internal Review, showed that the facility’s leadership team decided not to discuss this incident with the VA because it would likely further upset him/her. When the leadership team contacted the SP to ask him/her about the concerns, the SP did not respond and resigned his/her employment with the facility via text later that day. · The SP told this investigator that s/he knew the VA from a facility in which s/he previously worked and in which the VA resided prior to living at the facility. The SP felt that his/her relationship with the VA was not therapeutic for him/her or the VA and said that s/he talked with facility supervisory staff persons regarding his/her the situation. Some supervisors were more supportive than others, but the SP felt that his/her concerns were generally dismissed and not taken seriously. According to the SP, s/he had a history of engaging in self-harm, and there were scars on his/her limbs that were not always covered by clothing that any reasonable person would realize occurred from incidents of self-harm that likely required medical care. The VA saw the scars and asked the SP whether the SP harmed him/herself because of the VA, but the SP reassured the VA that s/he was not the cause of any incidents of self-harm in which the SP engaged. · The SP thought that the VA attempted to interact with the SP as if the VA was a staff person and behaved like s/he was the SP’s therapist. The SP redirected the VA but thought that the VA listened outside the staff person office when the SP discussed aspects of his/her personal life with staff persons who were also his/her friends in the community, which was how the VA obtained information regarding his/her sexual relationships and concerns about the possibility that s/he might become a parent. The SP denied that s/he intentionally shared information regarding his/her personal life with the VA. The facility’s Boundaries, Red Flag Behavior, and Professionalism information provided to staff persons showed that each staff person was responsible for creating an environment in which all felt safe. Staff persons were to recognize professional behavior and the benefits of professional boundaries. The facility established boundaries to ensure that relationships between staff persons and individuals remained professional and recognized that when topics or discussions outside boundaries were allowed into relationships, it might become confusing for the persons involved. If there were poor or inconsistent boundaries, therapeutic relationships might be compromised and ineffective. Mental boundary violations included dismissing/criticizing feelings, asking personal questions not appropriate for the relationship, telling others how to feel/giving unsolicited advice, emotionally dumping or oversharing, repeating confidential information, and/or making demands rather than requests. Consequences of poor boundaries included isolation, confusion, emotional lability, self-harm behaviors, disengagement, depression, emotional turmoil, or cognitive distortion. Staff persons were not to share personal information or personal struggles in hopes of relating to the individuals. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: Information was consistent from the VA, P1, P2, and the facility’s Internal Review, that in March or April of 2025, the SP shared details of his/her personal life with the VA. The VA was upset, was initially unable to share the information with others, and felt that s/he was the SP’s therapist or counselor. P1 and P2 each stated that on July 22, 2025, the VA told them about conversations between him/herself and the SP during which the SP told the VA details of his/her personal life that were outside the boundaries of information that staff persons were permitted to share with individuals at the facility. The Ps were concerned and discussed the matter with P3, and administrative staff persons contacted the SP to ask him/her about it, but the SP did not respond and resigned his/her position at the facility. The SP said that his/her relationship with the VA was not therapeutic for them, and s/he talked with supervisory staff persons about it prior to the incident. The SP had visible scars that others might recognize as the result of self-harm that likely required medical care. The VA noticed the scars and asked the SP whether s/he harmed him/herself because of the VA, but the SP reassured the VA that s/he was not the cause of any incidents. However, it was possible that the VA viewed him/herself as a staff person and attempted to act as the SP’s therapist. The SP thought that the VA overheard the SP’s conversations with staff persons when s/he discussed his/her personal life, which explained how the VA knew detailed information about the SP, but the SP denied that s/he intentionally shared information about him/herself with the VA. Facility information regarding boundaries showed that staff persons were responsible for creating safe environments. When boundaries were not observed, it might become confusing for those involved. When there were poor or inconsistent boundaries, relationships might be compromised and ineffective. Mental boundary violations included emotionally dumping or oversharing, and consequences of poor boundaries included isolation, confusion, emotional lability, self-harm behaviors, disengagement, depression, emotional turmoil, or cognitive distortion. Staff persons were not to share personal information or personal struggles with individuals. The VA had information regarding the SP’s personal life, and it was possible that the SP shared some details of his/her actions outside the facility with the VA, which was inconsistent with facility policies and procedures, and not consistent with the role of a professional caregiver in a DHS licensed facility. However, the VA had significant mental health concerns that were being treated at the facility, it was unclear whether the VA obtained the information from the SP or overheard it when the SP talked with staff persons, and no information specifically connected the VA’s knowledge of the SP’s personal life to the VA’s self-harming behaviors. Given this, and that the SP denied that s/he intentionally shared personal information with the VA, there was not a preponderance of the evidence whether the SP engaged in conduct that caused or could reasonably be expected to cause emotional distress to the VA. It was not determined whether abuse occurred (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). Action Taken by Facility: The facility completed an Internal Review which determined that their policies and procedures were adequate, but were not followed when the SP shared personal information with the VA. The incident was similar to previous incidents with the SP regarding boundary concerns at the facility. At the time this report was written, the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken
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