|
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: 1118449-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Anna Parkin Anna.parkin@state.mn.us Suspected Maltreatment Reported: It was reported that there were supervision concerns for a vulnerable adult (VA) that allowed clients who were the opposite gender from the VA, to visit the VA’s bedroom to “groom” the VA for sexual purposes. Date of Incident(s): July 8 to September 2, 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 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 November 4, 2025; from documentation at the facility; and through two interviews conducted with the VA and the VA’s family member (FM). Two supervisory staff persons (P1 and P2) and two staff persons (P3 and P4) were each contacted and each referred to the VA’s progress notes and facility file in lieu of an interview. Attempts were made to contact and interview the VA’s case manager (CM), but the CM did not respond. The initial allegation provided information that there were concerns over the previous eight years that the VA was sexually abused by persons of the opposite gender while residing in multiple licensed programs. Given the length of time since those incidents occurred and lack of details, the focus of this investigation was on the most recent concern at the facility where the VA resided. The VA was diagnosed with borderline personality disorder and post-traumatic stress disorder. According to the VA’s Order Revoking Stay of Commitment Pending Possible Hearing, dated June 12, 2025, the VA’s stay of commitment was revoked pending a possible hearing and s/he was required to live at a licensed facility. [Note: There was no information in the order stating whether the VA was required to live with clients of the same gender.] The VA then moved into The Landing of Minnesota on July 8, 2025, and moved out on September 2, 2025. The facility was three levels that had 16 individual bedrooms. There were at least two staff persons working at all times. According to the facility’s Program Abuse Prevention Plan: · The facility served clients from “diverse sociodemographic backgrounds” and had “slightly more” clients the same gender as the VA compared to the opposite gender. Potential for “gender-related harm” was reduced through a “multifaceted approach.” Clients received a comprehensive client assessment that considered gender-specific risks, ensuring that the client plans were customized to address any vulnerabilities. · Ongoing monitoring and risk assessments along with client education on recognizing and reporting harm allowed clients to actively safeguard their own well-being. Staff persons received specialized training to identify signs of abuse or exploitation related to gender and the facility enforced “prompt” reporting and conducted thorough internal investigations. The facility did not assign shared bedrooms to ensure privacy and engaged in “open and informed discussions” regarding sexual relationships within the facility “fostering an atmosphere of respect and support for all genders.” · During the admission process, clients were encouraged to disclose any history of abuse ensuring that staff persons were informed about “potential triggers and sensitivities.” A specialized care plan, guided by medical staff persons and other experts, was developed. The tailored plan considered the specific effects of past abuse on a clients mental and emotional well-being and led to trauma informed care and interventions. Staff persons were trained to use a trauma-sensitive approach, recognize signs of distress, and use de-escalation techniques when necessary. Access to specialized services, such as certified peer support groups and psychiatrists was “readily available.” According to the VA’s Individual Abuse Prevention Plan, at the time of assessment, the VA was not susceptible to sexual abuse. The VA “verbalize[d] willingness to report safety concerns” to staff persons. Staff persons provided ongoing client monitoring and engaged in regular consultation to assess the VA’s susceptibility to sexual abuse. According to the VA’s Functional Assessment, the “lack of consistent, positive natural supports” for the VA may have contributed to feelings of “isolation and hinder[ed] long-term stability.” The VA expressed how his/her behaviors and mental health challenges affected other persons. Being in a facility gave the VA “the opportunity to observe and practice interpersonal boundaries and communication skills.” The VA did not display any interpersonal conflicts within the facility which “suggest[ed]” the ability to cooperate with other persons. This also gave the VA access to trained staff persons who offered therapeutic and interpersonal support and helped the VA “identify and build healthier support systems.” [Note: There was no information provided in the VA’s plans that the VA discussed his/her previous concerns at other facilities at the time of his/her admission.] The VA provided the following information: · When the VA was in court for his/her commitment revocation, the VA requested and agreed to go to a facility that had clients the same gender as the VA and the judge agreed to it. When the VA got to the facility, there were clients who were the opposite gender. The VA asked P1 if s/he was able to switch to another facility and P1 said that the other facility that was a possibility for the VA to attend was “full.” · While at the facility, on two occasions, the VA was in his/her bedroom and a client (C1) who was the opposite gender from the VA, knocked on the VA’s bedroom door. On both occasions, C1 stood outside the VA’s bedroom and spoke to the VA but did not enter the VA’s bedroom. On one of those occasions, at approximately 6 or 7 p.m., C1 invited the VA to walk to Dairy Queen but the VA declined because s/he wanted to be alone in his/her bedroom. C1 then gave the VA his/her cell phone number and the VA saved it in his/her phone. As C1 was giving the VA his/her phone number, another client (C2) who was the opposite gender from the VA, walked by and overheard. C2 asked the VA if s/he wanted C2’s phone number as well and the VA said, “Sure.” C2 then gave the VA his/her phone number. The VA stated that s/he did not contact either C1 or C2. · The VA said s/he was concerned for his/her safety because there were no locks on the bedroom doors so any person could come into the VA’s bedroom at any time. The VA told P1 about the concern and P1 responded it was because if a client had a medical emergency, staff persons needed access to the bedrooms. P1 told the VA s/he would review video footage and later on told the VA s/he had done so and it was “okay” and that the VA was “safe” at the facility. The FM stated that the VA had previously lived in residential programs and had a history of being “lured away” from them by persons of the opposite gender. After the VA was admitted to the facility, the FM told an unknown staff person (later determined to be P1) that clients of the opposite gender should not be near each other. P1 told the FM that “everything will be fine” and gave the FM his/her phone number. The FM had concerns that C1 was “grooming” the VA to get the VA outside the facility to “do stuff.” The FM spoke to P1 about the concerns with C1 and P1 told the FM that the VA was “making it up.” The FM felt that P1 “coached” the VA to tell the FM that s/he was “okay.” The FM drove to the facility and despite the court order for the VA to remain at the facility, took the VA from the facility and the VA did not return. The VA’s Progress Notes provided the following information: · On August 29, 2025, the VA told P1 that C1 came and knocked on his/her bedroom door. C1 asked the VA if s/he wanted to walk to Dairy Queen and the VA responded, “I don’t know about that.” The VA also told P1 that C2 gave the VA his/her phone number but the VA was “uncomfortable” with it. P1 discussed refusal skills with the VA and provided statements that the VA could use when wanting to say “no” to a person. P1 also offered a therapy session the next weekday to work on refusal skills. P1 encouraged the VA to notify evening or weekend staff persons if s/he was uncomfortable again and to ask for assistance if needed. P1 encouraged the VA to use refusal skills as his/her “DBT IMPROVE skills” if triggered by events that that remind him/her of past traumatic experiences. · On August 31, 2025, the VA and a staff person (P5) had the following discussion: o The VA told P5 that s/he received “unwanted attention” from a client who was the opposite gender from the VA. P5 told the VA that staff persons would continue working with the VA to feel safe and encouraged the VA to meet with P1 to “process [his/her] feelings regarding the attention.” o The VA then “recanted everything” s/he previously said. The VA said C1 invited the VA out in his/her car to go places and the VA told P5 that s/he did not want anyone except staff persons to knock or open the VA’s bedroom door. P5 told the VA that peer groups were encouraged to invite other clients out in the community but P5 understood that the VA did not want that. o The VA told the FM a “different version of events” and then the FM contacted P5. P5 listened to the FM’s concerns and “assured” the FM that s/he would notify supervisory staff persons. The VA told P5 that s/he did not want to discharge early. · On September 1, 2025, P2 spoke to the VA who said s/he only wanted staff persons knocking on his/her bedroom door and that other clients do not invite the VA on walks. P2 informed all staff persons and the other clients about the VA’s request. · On September 2, 2025, after the VA requested a discharge (see notes below), P3 spoke to the VA. The VA said s/he was scheduled to discharge later that afternoon because s/he did not feel safe because clients of the opposite gender “outnumber” the VA’s gender. P3 asked if the VA was threatened or intimidated by persons of the opposite gender and the VA explained that s/he had a “fear” of the opposite gender. P3 discussed options for after the VA left the facility if s/he felt unsafe in the future and P3 encouraged the VA to continue his/her medications after leaving the facility. · There was no other documentation of the VA having concerns about supervision. According to the VA’s Discharge/Transfer Plan completed by P1: · On September 2, 2025, the VA wanted to discharge against facility recommendation to live with the FM and return to work. The VA agreed with the discharge plans; however when P1 spoke to the VA to clarify what the VA would like to do regarding his/her treatment, the VA said s/he felt “safe” at the facility and wanted to complete the full treatment. · The VA then called the FM and told the FM that s/he was “safe” and that s/he wanted to complete treatment at the facility. The FM told the VA s/he did not know if the VA could live with the FM and the VA became “distressed” and the FM hung up the phone. The VA called the FM back and asked to come home and the FM told the VA that s/he wanted the VA back home that day. · P1 recommended the VA continue care with an outpatient mental health therapy and medication management. P1 contacted the CM who agreed to find the VA a same gender facility but then the VA refused assistance from the CM with another facility placement. Facility documentation showed that P1-P4 were trained on the VA’s plans, the facility’s Program Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: The VA did not want to reside at a facility with persons of the opposite gender but was required to live at a licensed facility and resided at the facility, which served both genders, from July 8 to September 2, 2025, and on two occasions, C1 knocked on the VA’s bedroom door and invited the VA into the community and/or to Dairy Queen. The VA declined and told P1 about his/her concerns. According to the facility’s documentation, it used a “multifaceted approach” to reduce gender related harm, including customizing client plans to their vulnerabilities. According to the VA’s plans, the VA was not susceptible to sexual abuse and s/he “verbalize[d] willingness to report safety concerns” to staff persons. Although the VA stated that s/he did not feel safe because clients of the opposite gender “outnumber” the VA’s gender and that the VA had a “fear” of the opposite gender, given that the facility provided services to different genders; that when the VA had concerns about C1 knocking on the VA’s bedroom s/he notified P1 and P5 and they each gave the VA the opportunity to work on his/her interpersonal boundaries and communication skills in accordance with the VA’s plans; that there was no information provided that C1, C2 or any other clients attempted sexual contact with the VA; and that there was no other information from any source that the VA was harmed or at risk when at the facility, there was not a preponderance of the evidence whether there was a failure to supply the VA with reasonable and necessary care to maintain his/her physical or mental health or safety. 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. Staff persons provided “appropriate” supervision to the VA and each time s/he was asked, the VA said s/he felt “safe” at the facility including immediately before leaving. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
|
