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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: 1070419-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Neubauer-Hoffman, Deb 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) engaged in sexual contact with a vulnerable adult (VA). Date of Incident(s): May 4, 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 (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 for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through five interviews conducted with a law enforcement officer (LEO), the VA, a staff person (P), and two family members (FM1 and FM2). The SP did not respond via telephone, email, and certified mail to request the SP participate in an interview. The VA resided at the facility for approximately seven weeks at the time of the incident. The VA was outgoing and enjoyed social events, cooking and baking, and being outside in the yard working on flowers or bird watching. The VA’s diagnoses included post-traumatic stress disorder, borderline personality disorder, intellectual disabilities, bipolar disorder, anxiety disorder, depression, and fetal alcohol syndrome. The VA was not subject to guardianship. The VA’s plans showed the following information: · A Self-Management Assessment stated that the VA was “impulsive” and “did not think before acting when upset.” The VA did not recognize dangerous social or environmental situations. Staff persons remained in proximity while in the community to provide verbal support when needed. In addition, the VA used “poor judgement” regarding the opposite sex and sexual relations and “may not report” if sexual abuse occurred. However, “if [she] did report, [the VA] has a history of exaggerating facts, timelines or falsely reporting.” The VA had a history of “inconsistent information regarding possible rape.” · A Support Plan Addendum for Intensive Services showed that the VA was not allowed unsupervised time in the facility or in the community. The VA provided the following information during interviews with law enforcement and/or this investigator: · On May 4, 2025, the VA was wearing shorts and a tank top. The VA asked the P if she could go along with the P who was transporting one of the clients to their parental home. The VA was told “no” and she “got kinda scared” and had “a funny feeling” about remaining at the facility with the SP. The SP said the VA would be fine if the P left the facility. · Shortly after the P and two clients (C1 and C2) left, the SP and the VA “went downstairs” because the SP said s/he wanted the VA’s assistance with doing another client’s (C3’s) laundry. Once in the laundry room, the SP “fondled” the VA’s breasts over her clothing, kissed the VA’s neck, and “made [the VA] give blow jobs.” The VA estimated they were in the laundry room for “a good 20-30 minutes.” The VA said C3 was the only other person at the facility, and C3 was nonverbal and upstairs in his/her bedroom. · The SP said s/he needed to bring C3’s laundry to his/her room. Once upstairs, the VA went to her bedroom door and the SP pushed her inside and the SP told her to wait in her room. The SP went into the VA’s room and told her to pull down her shorts and underwear and bent the VA over on the bed where the SP “put his penis inside me” from “behind.” The SP said, “Oh shoot I am coming” and ejaculated into the garbage can next to the VA’s bed. The SP was in the VA’s room for approximately 10 minutes. The SP told the VA that she could get dressed, told the VA not to tell anyone, and then left the VA’s room. · The VA grabbed a phone and took it to her bedroom where she called a friend from church, FM1 and FM2, and 9-1-1. FM1 and FM2 came to the facility and were “upset and mad” and they said they “didn’t believe [the VA].” The VA’s family members (FM1 and FM2) provided the following information: · FM1 said that around noon on May 4, 2025, the VA called FM1 and FM2 and said, “Something happened at [the facility]” and she was “raped.” The VA was “very upset.” The VA also said that the SP complimented the VA’s “nice legs and sexy body.” FM1 took the VA to an emergency room for a sexual assault exam. In the past, the VA “cried wolf” and had a history of claiming things that were “not true or exaggerated.” · FM2 provided similar information as FM1. In addition, FM2 said that when they arrived at the facility, the SP opened the front door and had a “normal affect.” FM2 said that s/he was there to see the VA and the SP said the VA was in her bedroom. FM2 observed the VA in her bedroom crying and said the incidents occurred in the laundry room and the VA’s bedroom. The VA said that sexual intercourse occurred in her bedroom and the SP ejaculated in the VA’s garbage can. The VA told FM1 and FM2 that the SP’s “DNA” (deoxyribonucleic acid) was in the VA’s garbage can. A second staff person (P) arrived at the facility while FM1 and FM2 were in the VA’s bedroom. The LEO provided the following information in a telephone conversation and/or a written report: · The LEO obtained a statement from the VA that was similar to what the VA told this investigator approximately one month after the incident. · The SP was not a regularly scheduled staff person at the facility and helped out because the facility was short staffed. · On May 4, 2025, the LEO spoke to the SP via telephone and the SP agreed to meet with the LEO on May 7, 2025, to provide a statement and a DNA buccal swab. The LEO said s/he would call the SP again on May 6 or 7, 2025. Multiple attempts to reach the SP via telephone, going to his last address, and contacting his emergency contact person were unsuccessful. In addition, the LEO had information that the SP left the country. · Swabs from the VA’s collar bone and nipples showed “a mixture” of DNA originating from “two individuals,” and one of the individuals was “an unidentified male.” · The VA’s vaginal swab was processed for DNA, however, without a DNA sample from the SP, it was not possible to determine if it belonged to the SP. No sperm cells were identified with the vaginal swab; however, there “may be trace male DNA” and the LEO noted that the VA stated the SP ejaculated in the garbage can, not inside her.” · If the SP was located, law enforcement planned to pursue charges and get DNA samples. The P provided the following information: · On the morning of May 4, 2025, the P transported the VA to church and while in the car, the VA told the P that she did not like the SP because he was not giving the VA “attention.” · The VA had no unsupervised time in the community so the P remained with the VA at church and afterwards they returned to the facility. The P planned to leave the facility again with unidentified clients and told the VA that s/he could not take her along. The VA seemed “okay” with remaining at the facility with the SP. The SP was cleaning and doing laundry when the P left. · The P was gone about one hour and when s/he returned, the VA was in her bedroom with FM1 and FM2. The P asked the SP what was going on and he “did not know what was happening.” The P called his/her supervisor who said the VA said that the SP and VA “had sex” while the P was gone. Facility information showed that staff persons, including the SP, were trained regarding the VA’s program plans, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information showed that on May 4, 2025, the SP was working at the facility when the P and other clients left, leaving the VA, the SP and one other client at the facility. The VA stated that while the P was gone, the SP engaged in sexual contact with the VA the laundry room and the VA’s bedroom. Although there were no direct witnesses to what happened, and the VA had a history of exaggerating facts and providing “inconsistent information regarding rape,” factors that supported the VA’s account included: · Swabs of the VA’s body that showed “a mixture” of DNA originating from “two individuals” on the VA’s collarbone and nipples, and one of the individuals was “an unidentified male.” In addition, the VA’s vaginal swab showed there “may be trace male DNA.” · The VA had no unsupervised time in the community where she could have obtained male DNA on her collarbone or nipples. · The SP failed to show up for a meeting with the LEO scheduled for May 7, 2025, and the LEO had information that the SP left the country. The SP did not respond to multiple attempts to contact or locate him. Given the evidence of male DNA on the VA’s body specifically on her breasts and neck where she said the SP touched and kissed her, that the VA had no unsupervised time in the community, that the SP failed to follow through with a meeting with the LEO and that LEO planned to pursue charges if the SP was located, there was a preponderance of the evidence that the SP had sexual contact with the VA. It was determined that 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. 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. The SP was trained regarding the VA’s program plans, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated abuse for which the SP was responsible was not recurring because it was a single incident; however, was serious maltreatment because the SP had sexual contact with the VA. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and were followed because as soon as they heard about the incident the SP was immediately removed from the schedule. Subsequently, the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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