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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: 1069196-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth Lindsay.arth@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) touched a vulnerable adults (VA’s) chest/breast. [Note: The use of chest/breast should not be used as an indicator of the VA’s gender.] Date of Incident(s): Unknown prior to October 17, 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 was obtained during a site visit conducted on October 30, 2025; from documentation at the facility and law enforcement records; and through five interviews conducted with a facility supervisory staff person (P1), two staff persons (P2 and P3), the VA’s guardian (G), and the VA’s case manager (CM). Additionally, the VA was interviewed by law enforcement and that information is below. Attempts were made via text and email to contact and interview the SP. The SP responded via email declining to provide information for this report. The SP provided information in the Internal Review and that information is included below. The facility was a single-family home and the VA was the only client who resided there. Information from the facility showed that two staff persons worked at the facility at a time. The overnight shift was from approximately 10 p.m. to 7 a.m., and for half of the overnight shift, one staff person was awake while the other staff person slept and then they switched halfway through. The VA was diagnosed with borderline intellectual functioning, schizophrenia, anxiety, obsessive compulsive disorder, and bipolar disorder. The VA had an ileostomy bag (a bag in your abdomen which fecal matter exits the body) that staff persons were to empty on a “regular basis” throughout their shift. The VA enjoyed shopping and singing. According to the VA’s Individual Abuse Prevention Plan, the VA was unable to identify dangerous situations due to his/her diagnoses and was unable to protect him/herself in “dangerous” situations. The VA had a limited understanding of sexuality due to his/her diagnoses and was “very eager” to please and trust others. If the VA were to be “hurt,” s/he would “more than likely” report the abuse. However, if the VA felt that a person was “attractive” and s/he liked their attention, the VA would not report the sexual abuse and instead would share it as a “positive retelling of the situation.” Staff persons were to report any concerns and intervene as necessary to protect the VA. The VA’s Individual Absolutes/Specific Instructions also said that the VA had a history of “inaccurate reports.” However, there was no additional information provided about this. The VA’s Support Pan said that the VA had short term memory loss. Facility documentation showed that the SP and P3 worked during the overnight shifts on October 15-16 and 16-17, 2025, from 10 p.m. to 7 a.m. P1, P2, P3, and the facility Internal Review provided the following information: · P1 and P2 said that on October 16, 2025, around 8 or 9 a.m., the VA told them that at some point, “That [guy/gal] touched [his/her chest]” while the VA was in bed. P1 and P2 then asked the VA who s/he was talking about and the VA said, “That good looking [guy/gal],” or the “[handsome/pretty guy/gal].” P1 and P2 said the VA never called the SP by his/her name but called the SP that “good looking [guy/gal]” so P1 and P2 thought the VA was talking about the SP. P2 asked the VA if “perhaps” the SP was assisting with “cleaning” the VA as part of his/her cares when the incident occurred, and the VA said, “Maybe [the SP] was cleaning me.” When P2 tried to get additional information, the VA told P2 that s/he did not want to “talk about it.” · On October 17, 2025, around 8 or 9 a.m., the VA told P1 and P2 that the SP “touched” and “played with” the VA’s chest “last night.” P1 asked the VA to “clarify” what s/he meant and “requested” that the VA demonstrate where the SP touched him/her. The VA then said that the SP touched his/her “nipple” and the VA make a “circular” motion with his/her hands. P1 asked the VA if any other contact occurred and the VA told P1 that the SP “looked down there.” P1 asked the VA what s/he meant and the VA told P1 that the SP looked down his/her shirt. P1 asked the VA if anything else happened and the VA said, “No,” but added that the SP was “not supposed to do that.” P1 agreed with the VA and then the VA said, “Well, maybe [the SP] kind of likes me.” · P2 spoke to the VA trying to get additional information from the VA regarding dates and how many times it occurred and the VA said it occurred “one time.” P1 and P2 also said that the VA had a history of “confusing” the date or time. · P1 then told a supervisory staff person (P4) who spoke to the VA. The VA told P4 that during the overnight shift, a staff person identified by gender, whom the VA did not name, touched his/her chest while the VA was in bed. The VA did not recall when or what time the incident occurred but said that it occurred four to five times during the night. The VA also said that it occurred over two days but later said it only happened once. The VA said that person did not touch any other parts of his/her body. The VA said that s/he felt “funny” and was “a little upset.” · On October 28, 2025, the VA told P2 that s/he “liked” the SP and asked P2 where the SP was and if the SP was returning to work. P2 told the VA that the SP was going to be at the facility anymore and the VA said, “Why? [The SP] never did anything bad to me.” The VA said that s/he felt “bad” but at the time of the incident, the VA was “mad” that the SP did not give the VA coffee. P2 and P3 each said that the VA did not typically sleep during the overnight shift and often asked for coffee. P1 and P3 also said that following the incident, the VA “kept asking” when “that [guy/girl]” was returning to the facility. · Information was consistent that the VA “often” made “exaggerated or false claims” and P1 said that the VA typically “admitted” later that s/he was “lying,” such as saying staff persons, including P1, did not feed him/her or that P1 was “mean.” P1 and P2 said that if staff persons did not buy the VA “mochas,” the VA said that s/he would tell others, including the G, that staff persons were trying to “kill” him/her. P1 said that staff persons had been told by the VA’s team not to purchase items such as a coffee for the VA with their own money because the VA would become “angry” when one staff person refused something that another staff person had previously allowed. P2 said that the VA had a history of becoming “really angry” if staff persons did not provide food to the VA during the middle of the night but that staff persons provided food to the VA but that the VA’s doctors said that they needed to “control” the amount they gave. · P2 also said that the VA made “untrue” statements that staff persons did not “take care” of him/her or that “no one” helped him/her, even shortly after the VA had been assisted. According to P2, the VA said that staff persons “pushed” him/her when changing the VA’s ileostomy bag, which staff persons did not do. P2 said that the VA tended to “lie” when s/he wanted attention or did not get his/her “way.” · P1 also said in approximately May 2025, P1 was assisting the VA with bathing and then the VA told another staff person that P1 “touched [him/her] down there.” P1 said that s/he was only providing typical cares to the VA but that the VA made it sound “really bad.” · P3 said that s/he often worked with the SP during the overnight shift. The VA required staff persons assistance during the overnight including for his/her ileostomy bag which required staff persons to lift the VA’s shift “just enough” to access the area. However, when that occurred, staff persons would not touch the VA’s chest and P3 never saw the SP touch the VA’s chest. The VA also requested to “change outfits” during the overnight shift and other “hygiene” needs. The SP and P3 “divided” the overnight responsibilities but P3 said that s/he “rarely” slept. P3 never observed any concerns with the SP’s interactions with the VA and said that the VA often asked when the SP would work again. P3 never heard the VA in “distress” or yell for help. P3 did not have any concerns during the overnights of October 15 or 16, 2025 and described the shifts as “typical.” The VA never mentioned any concerns to P3 and P3 was “shocked” by the allegation. · P1 and P2 did not have concerns regarding the SP. P1 and P2 never saw the SP touch the VA’s chest and said that the SP was “always” respectful. P1 also said that when the VA called the SP “that good looking [guy/girl]” or that “handsome” guy/girl prior to the incident, P1 heard the SP tell the VA, “Stop.” At times, staff persons “teased” the SP about the VA calling him/her “good looking” but when staff persons did so, the SP said, “Please stop. That’s weird.” P3 also said that the VA complimented staff persons, including the SP, saying that they were “[handsome/pretty].” · P1 and P2 said that staff persons, including the overnight staff persons, “regularly” applied powder or cream on or near the VA’s chest due to frequent redness and skin irritation. Staff persons did so two to three times a day and as the VA requested which P2 said was “a lot.” · P1 “heard” that the G only wanted staff persons of the VA’s gender at the facility but P1 did not know why. P1 did not have “control” regarding the schedule and said that there were not aways two staff persons available who were the same gender as the VA. P3 said that the VA preferred persons of his/her own gender to bathe him/her but all staff persons could assist the VA with other cares such as the VA’s ileostomy bag. The SP provided the following information for the facility’s Internal Review: · The overnight shift on October 15, 2025, was “without incident” and because the VA slept through the night the SP did not need to change the VA’s ileostomy bag. The overnight shift on October 16, 2025, was “difficult” because the VA was awake for the majority of the night and “repeatedly” requested to watch television or eat. The SP attempted to help the VA fall asleep by providing food and assisting the VA with his/her ileostomy bag. At approximately 2 or 3 a.m., the VA’s bag leaked so the SP changed it because P3 was asleep. Around 3:30 a.m., the VA fell asleep but then awoke around 4 a.m. requesting to watch television. · The SP said that it was “possible” that s/he “accidently” touched the VA’s chest when lifting the VA’s shirt to get “access” to the VA’s ileostomy bag but denied any “intentional contact.” The SP denied touching the VA underneath his/her clothing and said that s/he only performed “authorized cares.” The SP said that the VA was a “handful” during the overnight shifts because the VA required “significant attention,” but the SP had never known the VA to make “serious allegations.” The law enforcement report provided the following information: · On October 17, 2025, law enforcement asked the VA if the SP “touched” him/her in “any way” that the VA “did not like.” The VA said that the SP did and when law enforcement asked where, the VA said on his/her “boob.” The VA said that this happened the “previous night” when the SP was trying to help the VA sleep. The VA “thought” that it only occurred one time but later said, “I don’t know if [s/he] ever did before.” · Law enforcement also spoke to the SP who said that because of the VA’s size, when the SP checked or changed the VA’s ileostomy bag, the SP may have “inadvertently touched” the VA’s breast when moving the VA’s clothing out of the way to access the bag. At times, the VA also needed assistance changing his/her clothing. However, the SP never “intentionally” touched the VA’s breast. · Law enforcement sent their report to the county attorney for review of charges and the county attorney declined to charge. The G said that s/he spoke to the VA daily. On October 17, 2025, the VA told him/her that a staff person touched and “rubbed” his/her chest the night prior and the VA was “shaken up.” The VA did not name the staff person. The G described the VA as “very vulnerable,” so the VA always had two staff persons with him/her. Additionally, the two staff persons were supposed to be staff persons of the VA’s gender which was in the VA’s “paperwork.” [Note: There was nothing noted in the VA’s plans regarding same gendered staff persons.] The G was not aware of any reason why the VA would say the incident occurred if it was not true. The VA had not made similar prior “accusations” but may not be “correct” with everything s/he said including saying that staff persons made “fun” of him/her when they had not. The CM said that due to the VA’s diagnoses, the VA may “exaggerate” things such as staff persons being “unkind” or not having food in the home. However, the VA had not made allegations of sexual abuse. Due to the VA’s diagnoses, s/he may be “difficult” to work with so required two staff persons. The CM thought that a staff person may have touched the VA’s chest while providing cares changing the VA’s ileostomy bag or assisting the VA with bathing or dressing. The CM said that the G “requested” staff persons of the VA’s same gender because that was the VA’s “preference,” but the CM did not know if the facility was aware of that and said that it was not in the VA’s plans. The CM did not have any concerns with the facility. Facility documentation showed that P1, P2, and the SP were each trained on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act Conclusion: Although the VA told law enforcement, P1, P2, P4, and the G that a staff person, who the VA did not name, but who matched what the VA typically called the SP, touched his/her chest, the VA provided different accounts regarding dates and how many times it occurred and the VA later told P2 that the SP “never” did anything “bad” to him/her but that the VA was “mad” that the SP did not give the VA coffee. Given the inconsistent information provided by the VA; that P3 worked with the SP on October 16 and 17, 2025, and did not have any concerns; that no other staff persons had concerns with the SP’s interactions with the VA; that the SP denied sexual contact and his/her account of “inadvertently touching” the VA’s breast when moving the VA’s clothing out of the way to access the bag was reasonable; and that there were no additional witnesses to support or refute either the VA’s or the SP’s account, there was not a preponderance of the evidence whether sexual contact occurred between the SP and the VA or whether the SP touched the VA incidentally during the course of providing the VA’s cares. 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed because staff persons failed to “immediately” report the “initial disclosure” made by the VA and did not report until the following day. The staff persons were retrained on the mandated reporting policy. The facility also “increased supervisory oversight” of overnight staff persons. Following the incident, the facility added a sign that two staff persons were to be present during all activities of daily living, including toileting with the VA, and that staff persons were to only be of the VA’s gender. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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