|
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: 1105221-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Neubauer-Hoffman, Deb Deb.Neubauer-Hoffman@state.mn.us 651-431-6567 Suspected Maltreatment Reported: It was reported that unidentified staff persons sexually assaulted a vulnerable adult (VA). Date of Incident(s): Prior to December 30, 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 11 interviews conducted with the VA, seven facility staff persons (SP1, SP2, P1-P5), a case manager (CM), a therapist (T), and an emergency medical staff person (EMS). The VA liked walking, sewing, coloring, and watching Duck Dynasty. The VA’s diagnoses included schizoaffective disorder, major depressive disorder, borderline personality disorder, autism spectrum disorder, and post-traumatic stress disorder. The VA was not subject to guardianship. The VA’s Positive Behavior Support Plan stated that if s/he left the facility without staff person supervision, staff persons were to offer alternative activities to redirect him/her and to immediately follow him/her while maintaining safety. If additional support was needed, staff persons were to contact a supervisor for assistance while continuing to follow the VA. The EMS provided the following information. On December 30, 2025, the VA left the facility and was without the supervision of staff persons. Drones and K9 units were needed to locate the VA in a state forest. After about “two hours,” the VA was found without shoes and “severe frostbite” was observed on his/her feet. The VA told the EMS that s/he liked to take walks to “clear [his/her] mind.” While riding in an ambulance to a hospital, the VA told the EMS that s/he was “raped” by unidentified staff persons at the facility. When the EMS asked the VA to identify specific persons, the VA replied, “All of them.” The EMS asked the VA if s/he had any discharge or pain as a result, and the VA said, “My butt hole is bleeding because that is where they are doing it.” An Incident Report from the Crow Wing County Sheriff’s Office documented that on December 30, 2025, the VA left the facility without the supervision of staff persons. Although an unidentified staff person followed the VA as required, that person lost sight of the VA near a snow-covered swamp that was not completely frozen over. The VA was located via drone. When found, the VA said s/he walked into a swamp and lost his/her shoes about the same time s/he last saw the staff person. The VA was transported by ambulance to a hospital for a blistered left foot. During that transport, the VA told the EMS that the VA had been anally “raped by group home staff.” Two law enforcement officers (LEO1 and LEO2) separately attempted to obtain information from the VA. LEO1 said the VA would not talk to him/her. When LEO2 attempted to talk to the VA, s/he made a comment about “invisible people” and declined to provide additional information. P1 told LEO2 that s/he was not aware of the VA making any reports of staff persons assaulting the VA in any way. When offered sexual assault services, the VA did not respond. Given the VA was “not cooperative” with providing a statement and did not disclose any staff persons by name, no further investigation was completed. Information showed that because of a stayed commitment, the VA moved into the facility on October 28, 2025. While at the facility the VA was required to follow a plan that included taking prescribed medications and voluntarily remaining at the facility. However, due to the VA’s continuous attempts to leave the facility and refusal to take his/her medications, a court hearing resulted in an order revoking his/her stay of commitment. On January 6, 2026, ten weeks after the VA was admitted to the facility, s/he was discharged and placed at a community behavioral health hospital. The VA provided the following information to this investigator: · The VA said that although s/he was a “heavy sleeper,” s/he believed s/he was raped “at night” in his/her bedroom at the facility. The VA did not know what the rape entailed but s/he woke up “in pain” in his/her “privates.” The VA initially said s/he did not know if the persons who assaulted him/her were male or female, did not know how many times this occurred, did not know if bleeding occurred as a result, and did not know the last time it occurred. · When asked who worked at the facility, the VA identified multiple staff persons by name. When the VA was asked if s/he believed any of them were the persons who raped him/her, the VA identified SP1 and another staff person with a name very similar to SP2; however, when asked why s/he believed it was those two, s/he said, “I don’t know.” The VA’s therapist (T) knew the VA for six years and saw the VA three times while s/he resided at the facility. Despite medication changes, the VA “was not getting better” and was “very delusional” and had “distorted reality.” On December 29, 2025, the VA told the T, “I do not want to live here anymore two [persons of opposite gender than the VA] have raped me.” The VA did not identify those staff persons by name, only by gender. The T did not believe the VA was able to accurately report events and said the VA’s statements were “part of [the VA’s] delusions and mental illness.” The VA provided no additional information, and the T did not question him/her further. The CM worked with the VA for approximately six years and said the VA’s “perception skews the reality” of what the VA said. The CM provided examples such as the VA identifying him/herself by a different name and talking about relationships with persons who did not “exist” and said s/he was raped by them. The CM said the VA was “deep in psychosis” and “recently” the VA had “so many delusions” that the CM did not know what to believe. P1-P5, SP1, and SP2 were each interviewed by this investigator and provided the following consistent information: · P1-P5, SP1 and SP2 each denied any sexual contact with the VA. · P1 said that after the VA moved into the facility, the VA “started hearing voices.” · P2 documented on December 5, 2025, P2 was outside of the facility trying to redirect the VA back inside when the VA asked P2, “Why do you rape me when I am sleeping?” P2 told the VA, “I do not do that.” On December 11, 2025, P2 documented that when the VA left the facility, P2 followed and attempted to redirect him/her to return to the facility. The VA said, “You only want me back so you guys can get paid for having sex with me.” P2 assured the VA that was not true and that P2 wanted the VA to return to the facility to be warm and safe. On December 30, 2025, the VA was at the hospital when s/he talked about being raped but provided no further information. · P3 said the VA was “very delusional” and heard that while at the hospital on December 30, 2025, the VA talked about being raped. P3 recalled once when the VA left the facility without supervision, s/he said s/he “just got off the phone” with his/her significant other and was going to meet him/her; however, the VA had been in his/her room, did not have a phone, and did not have a significant other; therefore the VA could not have been in communication with a significant other. · P4 said on one occasion an unidentified staff person asked the VA, “How was your outing?” and the VA asked the staff person, “Why are you flirting with me?” P4 “never witnessed anyone do anything inappropriate” to warrant that type of comment from the VA. P4 heard the VA “talk to voices” of persons who were not there and said things like s/he needed to go with his/her significant other and their children. However, the VA did not have a significant other or children. · P5 said there were times the VA left the facility and would “walk for hours.” The VA talked about leaving to meet a significant other. P5 recalled one incident when staff persons tried to redirect the VA from leaving the facility and the VA shouted, “The only reason you want to keep me here is to fuck me for money!” P5 said these types of statements from the VA were “a regular occurrence” when the VA was “in that state.” · SP1 said that the VA did not like him/her but SP1 “could not figure out why.” When the VA first arrived at the facility, SP1 worked a few overnights but the VA “slept all night and never came down.” SP1 recalled reading in the VA’s notes that on one occasion the VA left the facility and went to a gas station and told an attendant that s/he needed help because staff persons were trying to return the VA to the facility “to sell [him/her] for sex.” SP1 described the VA as “delusional.” SP1 did not see any behaviors from coworkers that were concerning, and s/he did not believe any staff persons had sexual contact with the VA. · SP2 said that the VA heard “voices” and left the facility “a lot.” The VA told SP2 that s/he did not like him/her. SP2 had no concerns with coworkers and did not observe any inappropriate touching. The facility completed an internal review that included interviews with 13 staff persons. Each of the 13 staff persons denied sexually assaulting the VA or witnessing another staff person sexually assaulting the VA. Facility documentation showed that staff persons were trained regarding the VA’s program plans, conflict resolution, working with difficult individuals, maintaining professional boundaries, behavior management, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information from multiple sources (P1-P5, SP1, SP2, the CM, and the T) showed that the VA had significant mental health issues. The VA’s mental health resulted in a court ordered discharge from the facility and subsequent admission to a community behavioral health hospital. Prior to the VA’s discharge from the facility, the VA left without supervision on multiple occasions, violating his/her stayed commitment. On December 30, 2025, the VA told the EMS that s/he was anally raped by unidentified staff persons at the facility. That same day the VA declined to provide a statement or provide any names to law enforcement officers or P2. The only time the VA identified SP1 and a name similar to SP2’s name as the persons who raped him/her was after telling the investigator the names of multiple staff persons who worked at the facility. However, the VA did not know why s/he believed it was SP1 and SP2. All staff persons interviewed, including SP1 and SP2, each denied sexual contact with the VA. Given the VA’s current delusions and psychosis as identified by the CM and the T, and that there were no witnesses to the incidents, there was not a preponderance of the evidence whether there was sexual contact between the VA and any staff persons. 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 and were followed. Staff persons were retrained regarding the facility’s Maltreatment Policy and completed a maltreatment evaluation. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
|
