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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: 800997-SUD (Substance Use Disorder) Investigator(s): Neubauer-Hoffman, Deb Suspected Maltreatment Reported: It was reported that a staff person (SP) sent messages via telephone and engaged in sexual contact with a vulnerable adult (VA). Date of Incident(s): October 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 three interviews conducted with the VA, a facility manager (M), and the SP. (The SP was determined to be a non-direct care staff person.) The Chisago County Sheriff’s office did not investigate this report. The VA’s diagnoses included attention deficit hyperactivity disorder, generalized anxiety disorder, major depressive disorder, and substance use disorder. The VA’s personal goals were “getting sober” and “relapse prevention.” Information showed that the VA was initially admitted to the facility on September 8, 2025. On October 1, 2025, the VA discharged him/herself from the facility prior to completing the program. The VA returned to the facility for detoxification services (unknown date, likely October 1 or 2, 2025) and was then readmitted to the substance use disorder program on October 5, 2025. The VA discharged him/herself from the facility a second time on October 26, 2025. A facility staff person (P1) documented on October 26, 2025, another staff person (P2) told P1 that the VA was “upset and packing [his/her] belongings to leave.” P1 met with the VA in the VA’s room and the VA said s/he planned to leave the facility “in order to feel safe.” The VA said, "I'm out of here, I can't be here. I went on a date with a staff member,” and that they had a sexual relationship. The VA said the relationship had been “going on for a while, and I called [the SP] this weekend when I was struggling with a craving, and [s/he] shut me down and said [s/he] couldn't help me. Now I'm afraid that I'm going to get a probation violation for leaving here and that [s/he’s] going to get in trouble and lose [his/her] job, but I don't want that because [s/he] has kids and I care about them. I don't want to be a narc." The VA said that s/he needed to leave immediately because s/he did not want to be at the facility when the SP worked the next day. The VA refused to identify the staff person by name. The VA talked about passive threats that the SP made about “people [the SP] knows” should the VA report their relationship. The VA said that the SP carried a gun and a knife and that the knife was in the SP’s undergarment when they were on a date. The VA provided the following information: · The VA said it was “frowned upon” to date during early sobriety. The VA and SP engaged in “small talk” throughout his/his stays at the facility. Approximately 24 days into his/her first admission, the VA “got into it with my counselor” and ended up leaving the program. The VA was “vocal,” and the SP likely heard about the VA’s plan to leave. Before leaving, the VA found a note from the SP telling the VA to “take care of [him/herself], sobriety is worth it, and you are worth it.” The VA left the program, drove about 20 miles, smoked a “THC vape from a smoke shop,” and “went into a panic attack.” The VA called the facility and asked to come back. The VA returned to the facility and had to start the program over again, but on a new unit. The VA said that the SP gave him/her a hug that day but did not remember if it was when the VA was leaving or when s/he returned. · On Wednesday, October 22, 2025, the VA attended a support meeting in a nearby town. Upon arrival, the VA saw the SP, who gave the SP “a big smile” and walked over and gave the VA a hug. The VA went outside to smoke a cigarette before the meeting and the SP went outside with him/her. They talked about a nearby haunted hayride. After going back inside for the meeting, the SP did not participate in “small groups” but “stuck around” until the end of the meeting and they each said they would see each other at the facility the next day. · On Friday, October 24, 2025, the VA asked the SP if s/he could take the SP to the hayride previously talked about and the SP said, “I can’t.” The VA then gave the SP his/her telephone number and “within five minutes” the SP sent the VA an emoji of someone winking. Texting continued between the SP and VA and the SP sent the VA the SP’s “snapchat username.” The SP said they could not go to the hayride because “someone may see us” and the SP would lose his/her job. The VA suggested doing something else. Communication via their telephones continued and that same evening they met at a park in a nearby town. They drove to Stillwater in the VA’s car, walked down by the river, held hands, and kissed. They went out to eat and the VA “could tell [the SP] was nervous being in public.” After dinner they parked the VA’s car at a boat landing and “things escalated quickly” and from kissing “it became sexual in the car” with the SP performing oral sex on the VA. The VA drove the SP back to his/her car at the park. The VA had a weekend leave of absence to clean out a storage shed and planned to stay at a relative’s home. The VA texted the SP to let him/her know s/he arrived safely. · On Saturday, October 25, 2026, the VA cleaned out the storage shed and found some marijuana and a meth pipe. An unidentified person who was with the VA destroyed the items but finding them “threw [the VA] into an emotional wreck.” The VA sent messages to the SP who said s/he was busy with his/her kids. The VA texted and called the SP “a few times” but received no response. After spending the previously day texting and then having their dinner date, the VA started “to worry about things.” The VA eventually received a message again saying the SP was busy with his/her kids. · On Sunday, October 26, 2025, the VA sent a message asking the SP if s/he wanted to go to church with the VA. The SP responded that they “needed to slow down.” The VA believed the SP “was having remorse.” The VA contacted the SP again after church and the SP replied that s/he did not want to talk to the VA anymore. The SP said the VA was “obsessive” and “a psycho.” The VA decided to leave the facility that day. P1 heard the VA “freaking out” and the VA told P1 that s/he had to leave because the VA did not want to see the SP again. The VA denied that the SP threatened the VA, but told P1 the SP “carried a knife” in his/her undergarment and “who’s to say [the SP] doesn’t have a gun?” The SP provided the following information: · The first time the VA discharged him/herself from the facility, the SP wrote the VA a note of encouragement. As the VA packed his/her car, the SP was outside walking on his/her lunchbreak and the VA thanked the SP for the note. The SP did not “recall” if s/he gave the VA a hug. The VA returned to the facility a few days later. Subsequently when the VA saw the SP working outside of the VA’s assigned unit, the VA “would hang out and we talked in passing.” · The VA “showed up” at a community support meeting that the SP attended. The VA approached the SP and they talked. The SP said s/he was trained that in those circumstances, s/he was supposed to “be anonymous and have no contact.” The SP provided no further information regarding that evening. · On Friday, October 24, 2025, the VA approached the SP in a hallway and asked if they could go on a hayride and the SP said, “No, we can’t do that.” The VA was “persistent” and asked if they could go somewhere else and gave the SP his/her number. The SP put the VA’s number into his/her phone. Shortly after that, the SP sent the VA a “smiley face” or “something like that” even though s/he knew “I should not have” because “that is not allowed.” The VA and the SP texted back and forth, and the VA asked the SP to meet him/her. After the SP was off work that day, they met at a park in a nearby town. The VA drove the SP to Stillwater where they went out to eat, kissed, and held hands. The SP denied any sexual contact between him/herself and the VA. The SP knew the VA had a weekend pass to go to the VA’s hometown. Because it was later in the evening, the SP told the VA to let the SP know when the VA arrived there. · On Saturday, October 25, 2025, they communicated via telephone. The SP told the VA that s/he had plans with his/her kids “yet [the VA] still messaged me several times and tried calling me.” The VA was contacting the SP “way too much and I was not liking it.” · On Sunday, October 26, 2025, the VA called and sent messages, and the SP told the VA that the VA “needed to slow down.” The VA continued to contact the SP and when the SP told the VA “not to,” the VA “went off the rails and was pretty upset” and told the SP that s/he was “messing with [the VA’s] emotions.” The VA said that s/he needed to leave the facility to avoid the SP. The VA screamed profanities at the SP and said if the SP did not tell the facility why the VA left, the VA would. The SP “blocked” the VA’s ability to contact the SP. · The SP said that s/he had a little Swiss army knife used for work that s/he kept in his/her pocket. The SP was not aware of the VA ever seeing his/her knife. · The SP said his/her training stated s/he was “not to have outside contact with clients,” and that s/he “should not have done any of it.” A Summary of Care Note stated that the VA “chose to discharge prematurely and abruptly” due to “conflict with staff member.” The VA was determined to be “very high risk of continued use currently” because “triggers” for the VA were “stress, financial stress, low self-worth, depression, anxiety, anger, and feeling overwhelmed.” After the VA left the facility on October 26, 2025, s/he was scheduled for admission to an intensive outpatient facility on October 28, 2025. The facility’s Professional-Patient Boundaries Policy stated that workforce members are expected to practice good judgment and demonstrate high ethical standards regarding their relations with patients. Additional information stated: · Maintaining professional boundaries played an important role in creating a safe environment for patients. Professional boundary violations can be highly damaging to patients, their families, and community. · Workforce members were prohibited from sharing personal contact information, such as telephone numbers. Prohibited communication included calls, text messages, or social media platforms. · All workforce members were supposed to be cautious about initiating any touch with patients. Non-licensed direct care and non-direct care workforce members “are prohibited from touching patients outside of a professional handshake.” · Non-direct care workforce members were prohibited from engaging in a sexual, romantic, or intimate relationships with current patients. Regarding a former patient, workforce under this classification were prohibited from engaging in a sexual, romantic, or intimate relationship for two years following a patient’s discharge from services at the facility. Facility documentation showed that the SP was trained regarding professional boundaries, code of conduct, and the Reporting of Maltreatment of Vulnerable Adult Act. Conclusion: A. Maltreatment: The VA and SP each stated that on October 1, 2025, the SP wrote a note of encouragement to the VA when the VA decided to discharge him/herself from the facility. The VA said that the SP hugged the VA that same day; however, the SP did not “recall” if s/he had done so. After the VA was readmitted to the facility, the VA and the SP inadvertently met at a community support group. The VA said the SP smiled at him/her and approached the VA and gave him/her a hug. The SP said the VA approached him/her at the meeting. The SP said s/he was trained that in those circumstances (meeting a client in the community), s/he was supposed to “be anonymous and have no contact.” The VA and the SP each admitted they began texting/talking/snapchatting on October 24, 2025, and that evening, they met in a park and drove together to Stillwater where they went out to dinner, held hands and kissed. Regarding sexual abuse: The VA said sexual contact occurred in his/her vehicle on October 24, 2025, while they were on a date. The SP denied any sexual contact with the VA; however, the SP had reason to minimize his/her actions for fear of consequences. Without further information to either corroborate or refute the report, there was not a preponderance of the evidence whether sexual contact occurred between the SP and 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). Regarding neglect: Given the VA’s history of substance use disorder, it was reasonable that the VA would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety. The SP’s interactions with the VA hindered the VA’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the VA both now and in the future. Given the SP’s admission that s/he had the VA’s telephone number and talked/texted/snapchatted with the VA, that that s/he also went to dinner, held hands, and kissed the VA, there was a preponderance of the evidence that the SP’s interactions with the VA were a failure to supply the VA with necessary care and services to maintain the VA’s mental health and safety. It was determined that 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). 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. Facility documentation showed that the SP was trained regarding professional boundaries, code of conduct, and the Reporting of Maltreatment of Vulnerable Adult Act. The SP was trained not to share personal contact information and communication including calls and text messages were prohibited. 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 maltreatment for which the SP was responsible did not meet statutory criteria to be determined as serious because there was no injury to the VA. It was also determined that the substantiated neglect for which the SP was responsible did not meet the statutory criteria to be determined as recurring because it was considered a single pattern of behavior. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed because policies and procedures prohibit inappropriate contact between staff and clients. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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