|
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: 1106114-SUD (Substance Use Disorder) Investigator(s): Emily Kearns Suspected Maltreatment Reported: It was reported that a staff person (SP) and a vulnerable adult (VA) had sexual contact and conversations while the VA was receiving services at the facility and which continued after the VA was discharged from the facility, but while the SP was still employed at the facility. Date of Incident(s): Unknown dates prior to July 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); and subdivision 17, paragraph (a): 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. 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 for this investigation was obtained remotely, including documentation from the facility; and through four interviews conducted with two facility administrative staff persons (P1 and P2), a former facility staff person (P3), and the SP. The VA did not respond to phone calls or certified mail requesting an interview. The VA was not subject to guardianship and did not file any grievances during the time that s/he was receiving services. On July 24, 2025, the Department of Human Services received information that the VA said that in April and May 2025, the VA and the SP had sexual contact and “inappropriate” communication with one another while the VA was receiving services from the facility, and while the SP was employed at the facility. Sexual contact continued after the VA was discharged from the facility. The VA was feeling “taken advantage of” and felt unable to ask for help due to feeling like “sexual acts” may occur again. Facility documentation showed that the VA received services at the facility for a substance use disorder from April 1 to May 28, 2025. The SP was employed at the facility from late 2024 through June 17, 2025, but was on administrative leave from May 20, 2025, returning May 29, 2025. The VA relapsed and was later readmitted to the facility on July 10 through 28, 2025, when s/he was discharged at the request of staff persons. The VA was diagnosed with depression, anxiety, post traumatic-stress disorder, and was receiving services for alcohol and other stimulant use. The VA was not often sober “outside of a structured environment.” The VA’s plans stated that s/he enjoyed working out, playing basketball, and was motivated to “regain independence” to give back to youth populations that shared the VA’s “struggles.” P1 stated that on May 20, 2025, P1 received an anonymous letter placed under his/her office door the evening before stating that the SP and the VA were having a “personal relationship” with one another. The letter writer (LW) stated that if P1 viewed camera footage, P1 “would be able to see this unacceptable behavior happen right before [their] eyes.” P1 and other supervisory staff persons at the facility did an investigation into this. During this time, there were some “technical difficulties” with the video camera system, due to an upgrade, which temporarily took some of the cameras offline. P1 did not see any “visual evidence” of anything “inappropriate” on the video footage that s/he viewed and did not “gather tangible evidence of any inappropriate relationship” with the SP and the VA. P1, who conducted the interviews and the facility’s Internal Review provided the following information, some of which was conflicting: · According to the Internal Review, the LW came forward during the investigation, but stated that the information s/he wrote was not witnessed by him/herself and did not take it seriously, thinking it was “gossip.” A staff person on second shift had a family member that was “best friends” with the SP. On or around May 8, 2025, that staff person mentioned to the LW that the SP was “seeing” a new person whose first name was the same as the VA’s first name. It was not mentioned that it was a possible client. According to P1, another staff person’s family member was friends with the SP and heard that the SP had a new significant other between May 8 and 19, 2025, but did not know the name of the significant other. · According to P1, s/he later learned that the LW did not witness anything between the SP and the VA, despite stating that s/he did in the letter, but s/he did not want to directly report the incident due to not seeing it him/herself and instead was told about this from other staff persons and clients. No specific timeframe for the alleged “inappropriate” events were given in the letter or in follow up conversations with the LW. · According to the Internal Review, on May 19, 2025, the LW was told by P3 that s/he opened the laundry room door and saw the VA and the SP “standing face to face kissing.” The LW started paying more attention and saw the VA around “everywhere” the SP went. According to P1, nothing was seen by any staff persons interviewed, other than P3, who no longer worked there. P3 stated that s/he saw the VA and the SP in a “physical embrace” in the staff person laundry room, but that s/he did not observe any kissing between them. (Investigator’s note: Information was obtained during the course of the investigation that there were interpersonal conflicts between P3 and the SP). · According to P1, on May 20, 2025, P1 interviewed the SP and the VA and other staff persons who worked with the SP. While some staff persons on the SP’s shift might have had some awareness that “something might have been going on” with the SP and VA, no one had proof, so only “rumors” were told to P1. · According to P1 and the Internal Review, the SP denied any “inappropriate relationship” and verbalized frustration as this was now the second allegation in the time s/he had been there, with the previous allegation being unfounded. The SP was immediately put on leave pending the outcome of the investigation. · According to P1, the VA denied any physical contact or any “inappropriate relationship” with the SP, or any staff persons. The VA stated that s/he had not been in the staff person laundry room but had only stood in the doorway of it to get a Tide Pod. The Internal Review stated that the VA denied being in any staff person’s car, receiving extra support from any staff person, and denied meeting with any staff person in the VA’s bedroom or anywhere else at the facility. The SP denied knowing of any clients in any staff person’s vehicles and added that P3 sometimes used the SP’s car. · The Internal Review stated that P3 said that there was “suspicion” and “rumors” going around about the SP and the VA. The VA “followed” the SP around and P3 heard “rumors” on May 19, 2025, that the SP had “invited [persons]” into his/her car. P3 was “uncomfortable” and was could not “focus” on his/her job with the distractions. The SP told P3 that s/he “liked [the VA] a lot.” On May 19, 2025, the SP was driving P3 home and told P3, “I don’t give a fuck, I really like [the VA]. I have good feelings about [him/her].” P3 told the SP that s/he was going to lose his/her job. · P1 stated that the SP was unaware that cameras were not working at the facility during this time. · P1 stated that the facility was a “no touch” facility, aside from “fist-bumping” someone during a “big event” like a sober-date celebration. Hugs and physical touch were not allowed, and the facility had expectations that staff persons would not disclose anything personal, including phone numbers to a client or communicate with them on social media. Conversations with clients were to be about the client, and staff were to be “there for” clients without being their friend. Staff persons were to report to a direct supervisor if a client or another staff persons were crossing boundaries. · P1 stated that staff persons were not have any contact with a former client for two years from the client’s discharge date. P3 provided the following information: · P3 was employed by the facility from May 4, 2025, to the middle of August 2025 and knew the SP for several years prior. When P3 first started working at the facility, the SP approached P3 and said that s/he was “seeing” a client at the facility and told P3 not to “say nothing to nobody.” P3 did not know the rules yet, but P3 told the SP that s/he would get caught and that this would be the second client that this happened with, after the SP previously sent another client pictures. According to P3, the SP was “talking to” another client at the facility before P3 worked there. P3 only heard the other client and the SP talking on speakerphone and the other client asked the SP when s/he was going to visit him/her at the facility. · The facility was a “no touch” facility and staff persons weren’t allowed to have personal relationships for at least a year after a client had been discharged. Staff persons were not allowed to physically intervene to “break up fights” between clients and had to use words to try to deescalate. · The SP was one staff person that P3 saw have physical contact with a client while P3 and the SP were working. P3 entered the staff person laundry room once and saw the SP grab the VA’s face and say to the VA, “I care a lot about you don’t do nothing stupid.” P3 left the room and let the LW know. · Another time, P3 and another staff person were dealing with an incident where all staff persons needed to help. Staff persons had headsets and walkie-talkies to communicate. During the incident, P3 and the other staff person were unable to get in contact with the SP over the walkie-talkies for over 30 minutes. They looked “everywhere.” At some point, the SP and the VA just “popped up” from around a corner. Later that evening, P3 was upset with the SP and went into an office to work on paperwork when another unknown staff person said that they saw the SP “hugging” a client. The client was not the VA. P3 told the LW about this incident. The Internal Review stated that during the investigation, it was discovered that some staff persons’ answers to questions asked during the interviews were found to be “non-credible” related to “interpersonal team dynamics and concern for unfounded targeting of the [SP].” The SP received coaching and returned to work with additional coaching and after signing a Performance Improvement Plan in late May 2025 after the VA was discharged from the facility. On June 16, 2025, P3 turned over a picture sent to P3 from the SP that was said to be of the SP and the VA in the SP’s vehicle. The picture was sent to P3 on June 7, 2025, and was alleged to have been taken on a trip to Duluth, Minnesota. The SP was then terminated after this incident for violating his/her Performance Improvement Plan. The facility provided this investigator with the screenshot of the image which the facility said was of the VA and the SP. The SP provided the following information: · In the time that the SP worked at the facility, there had been several allegations made against the SP, which s/he denied, and one of which involved a client being in the SP’s personal car. The SP parked in view of facility camera’s so that administrative staff persons could see who was in or not in his/her car. Facility administrative staff knew that the SP shared his/her car with P3. The SP and P3 had a falling out and were no longer friends.
· After these incidents were investigated by the facility, the SP was suspended for a period of time and came back to work after signing a “contract” with the facility. The SP said that the facility’s investigation “proved” that the SP “didn’t do anything wrong” by letting the SP come back to work. The contract was to “protect” the SP. · The facility trained staff persons to set boundaries, which included keeping a “personal distance” and telling people, “No.” It included “not favoring people.” The SP’s position involved helping the clients by listening to them, passing along notes, doing attendance, monitoring their visitations, and breaking up fights between clients. The SP stated that staff persons could not “date” or have “physical contact” with clients, including contacting them on social media and “thought” that the rules continued for two years but was not sure if it applied since s/he was no longer employed currently by the facility. · The SP was currently in a relationship with the VA, whom s/he met as a former client of the facility. The SP did not know if the two year no contact rule applied since the VA was no longer receiving services at the facility and since the SP no longer worked there. · The SP and the VA “began talking” one or two weeks ago when the VA left the facility for the second time and called the SP. The SP gave the VA his/her phone number “a couple weeks” prior to the VA on Facebook Messenger after the VA came up as a friend suggestion. The SP provided the VA his/her phone number via Facebook Messenger and stated that it was “probably before July 4, [2025],” and it was when the VA was still at the facility. The SP stated that it was when the SP was on leave from the facility. (Investigator’s note: The SP was on leave from the facility from May 20 to 28, 2025 and the VA was discharged for the first time from the facility on May 28, 2025.) The SP denied anything sexual occurring when s/he still worked at the facility, stating, “There is no way I would do that; Honest to God.” · The SP “struggle[d] with impulse control,” but denied that a relationship began before the VA’s discharge from the facility. However, the VA would call the SP from the facility to “talk.” The VA had heard about the “rumors” about the VA and the SP and they “kinda thought it was funny” but it was getting “irritating.” The VA “graduated” from the program and they “lost contact” but then the VA relapsed and returned to the facility. Once the VA was “kicked out” of the facility during the second stay, the SP drove the VA down to another facility near the Twin Cities. Currently, they were still talking and in a “relationship” as of about a week ago, however the VA was currently in the hospital. · The SP denied any “inappropriate physical or sexual touching,” and denied kissing the VA in the staff person laundry room. The SP stated that on one occurrence, the VA and another client were in the staff person laundry room because the client laundry room’s machines were full. The SP stated that the other client was with them during this time. · P3 had a reason to maybe get the SP “in trouble” because they were “fighting,” and the SP had previously had staff persons “making stuff up due to jealousy.” · The SP was in Duluth with the VA on the weekend before July 4, 2025, which was “right before [the VA] relapsed,” and that s/he “felt like a dumbass” and did not want to get the VA in trouble. There was no kissing or sexual contact with the VA and SP during the Duluth trip. P2 provided the following information: · The SP no longer worked at the facility due to “boundaries violations.” P2 provided this investigator a new phone number for the VA which was discovered to belong to the SP. (Investigator’s note: when this investigator called the number for the VA, the SP answered and indicated that s/he was the VA’s significant other). · On July 23, 2025, the VA asked P2 if the SP could get on the VA’s visitor list. The VA was “adamant” that the SP had been “cleared” during a previous investigation and that the SP should be allowed to visit the VA at the facility. On July 24, 2025, it was decided by administrative staff persons that the SP should not be allowed back on facility property. The facility’s Personal Relationships Staff and Clients policy stated that personal relationships with clients and staff persons were “strictly prohibited” which included, “messaging on social media platforms,” “friendly interactions outside of work duties,” “dating,” and “contact or communication between a staff person and client outside of the client’s treatment plan that the staff persons conceals” from other staff persons. The policy also stated that personal relationships between facility staff persons and a client was “strictly prohibited” for a minimum of two years after termination of services. Staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policy on personal relationships with staff persons and clients. Conclusion: Information showed that the VA received services at the facility for a substance use disorder from April 1, 2025, to May 28, 2025, and relapsed, returning to the facility on July 10 through 28, 2025. The SP was employed by the facility from late 2024 through June 17, 2025, but was on administrative leave from May 20, 2025, returning May 29, 2025. According to P1, P1 received an anonymous letter in his/her office written by the LW that stated that the SP and VA were having a “personal relationship.” The LW later stated that s/he was told by P3 that s/he saw the VA and SP “kissing” but the LW did not witness anything between the VA and SP, and did not give a timeframe for the alleged “inappropriate” events with the SP and VA. P3 denied seeing the VA and SP kiss, but stated s/he saw them in a “physical embrace.” According to P3, the SP told P3 that s/he was “seeing” a client at the facility. The facility’s Internal Review stated that some staff persons’ answers during the interviews were found to be “non-credible” related to “interpersonal team dynamics and concern for unfounded targeting of the [SP].” The SP and VA denied any “inappropriate relationship” with one another. However, on July 24, 2025, DHS received information that the VA said that the VA and the SP had sexual contact while the VA was receiving services from the facility and after the VA was discharged but the VA did not respond to interview request attempts so did not provide information for the investigation to this investigator. Although the SP admitted to spending time with the VA and sent P3 an image via text message of the SP and the VA on June 10, 2025, and that the SP and VA exchanged social media and phone contact information when the VA was not a client at the facility, given that according to P1, the SP and VA denied any “inappropriate relationship” with one another, that there was conflicting information from the LW and P3 about the VA and the SP “kissing”, and that the VA did not provide information to this investigator, there was not a preponderance of the evidence whether the SP had sexual contact with the VA or failed to provide the VA with reasonable and necessary care and services. It was not determined whether sexual abuse or neglect 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 and 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). Action Taken by Facility: The facility’s Internal Review showed that policies and procedures were adequate, but not followed. Staff persons were retrained on boundaries with clients and on mandatory maltreatment reporting. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
|
