|
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: 1076917-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP2) held a vulnerable adult (VA) down while another staff person (SP1) touched the VA inappropriately. Date of Incident(s): May 21, 2026 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), clauses (1) and (2): Any contact with the vulnerable adult that is not therapeutic conduct and a reasonable person would consider a sexual act or any nonconsensual sexual interaction with the vulnerable adult, including but not limited to: · making, viewing, or sharing sexual images or videos with or of the vulnerable adult; and · using oral, written, gestured, or electronic communication that is sexually harassing, including but not limited to unwelcome sexual advances or requests for sexual favors. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 15, 2026; from documentation at the facility and medical records; and through eight interviews conducted with three facility staff persons (SP1, SP2, and P1), two facility supervisory staff persons (P2 and P3), the VA, the VA’s case manager (CM), and the VA’s guardian (G). The VA’s diagnoses included mild intellectual disabilities, depression, unspecified convulsions, and ataxia. The VA enjoyed watching game shows on tv, playing video games, visiting a local mall, going to baseball games, and playing quiz and music games. The facility was a single-story residence in a residential neighborhood. The main level had a living room, a dining room, a kitchen, an office, a laundry room, four bedrooms, and two bathrooms. There was an unfinished basement that was used primarily for storage. The VA’s plans stated, “Due to [the VA’s] physical disability, if someone were to sexually abuse [the VA], [the VA] may try to hit with [his/her] hands or yell for help. [The VA] may be vulnerable to gentle coercion but would not likely participate in a violent sexual situation.” “[The VA] makes inappropriate sexual comments to [opposite gender] staff that [the VA] thinks are cute or sexy. [The VA] will not shower for weeks awaiting for these staff to shower [the VA].” “[The VA] has on several occasions, when upset, made allegations towards staff and then later retracted [his/her] story when talked to by [P2]/other staff when being interviewed about the situation.” During this investigation, persons interviewed and hospital records mentioned tetrahydrocannabinol (THC) and/or cannabidiol (CBD) gummies that the VA consumed. There was no mention of the THC/CBD gummies in the VA’s plans. The G’s friend brought THC/CBD gummies to the VA yearly and the VA consumed the THC/CBD gummies until they were gone. The facility verbally told staff persons they were not allowed to assist the VA with consuming the THC/CBD gummies. The VA indicated the following by pointing, motioning, and verbally confirming after this investigator used words to verbalize: · The VA said the alleged incident happened “yesterday,” which was June 14, 2026. · SP1 was in the VA’s room and the VA told SP1 to close the door but did not remember why. SP1 turned music on for the VA. · The VA motioned to the VA’s groin area and said SP1 “rode” the VA. The VA was wearing an adult absorbent undergarment and did not remember if SP1 took it off. SP1 had his/her clothes on during the incident. When asked if SP1 touched the VA, the VA pointed to his/her groin area. When asked what SP1 touched the VA with, the VA pointed to his/her mouth. The VA denied SP1 touched the VA with his/her hands. · The VA said SP1 was the only person in the VA’s bedroom and no one else was involved. · The VA did not want SP1 to “get in trouble.” The VA liked SP1 and did not have previous concerns with SP1. · The VA took THC/CBD gummies to “relax” but said they made the VA “angry” and “mad.” The VA took “two mints and one Skittle” at a time and the VA was only supposed to take one at a time. The VA said staff persons were not supposed to help the VA take the gummies, but the VA asked for help and P2 helped the VA take the gummies. The VA also asked SP2 for help taking the gummies but SP2 did not help. SP1 and SP2 provided the following information: · On May 21, 2026, the VA asked for help and said his/her legs cramped and the VA could not move them. The VA asked SP2 to call 9-1-1. SP2 was on the phone with 9-1-1 and the VA said, “Never mind.” SP2 gave the VA a cold towel and “fanned” the VA with a handheld fan. The VA wanted to go to bed and SP1 and SP2 helped the VA get into bed. · About an hour later, the VA rang a bell for assistance and SP2 went into the VA’s bedroom. The VA was wearing shorts and did not have a shirt on. The VA asked how s/he had gotten into bed. SP2 told the VA that SP1 and SP2 helped the VA get into bed after the VA wanted 9-1-1 to be called. The VA told SP2 that s/he did not remember any of that. SP2 told the VA to get some rest and left the VA’s room. · The VA rang the bell a second time and SP1 went to check on the VA. The VA told SP1 s/he was “super high.” SP1 put on “sensory music” to calm the VA down. SP1 was in the VA’s room for 30 seconds and then came out. SP1 then brought the VA a drink and was in the VA’s bedroom again for a “minute” to give the VA his/her drink. SP2 said SP1 was alone in the VA’s room twice for a total of less than two minutes and the door was open the entire time. · A short time later, SP1 was working with another client and heard the VA “yelling.” SP1 went into the VA’s room and checked on the VA. SP1 did not understand what the VA said. SP1 closed the VA’s door and continued working with the other client. · The VA rang the bell a third time and SP1 and SP2 both went to check on the VA. The VA was “wide-eyed,” pointed to SP2, and said, “Just you.” SP1 left the room and closed the door. The VA said s/he was “scared” and gestured out towards SP1. SP2 asked, “What about [him/her]?” The VA said SP1 went into the VA’s room. SP2 told the VA that s/he had requested a drink of water and SP1 had brought the water to the VA. The VA had “wide” eyes and was gesturing towards his/her “private area.” SP2 told the VA s/he did not understand. The VA said, “[S/he] touched me.” SP2 told the VA when SP1 brought the VA water the door stayed open. The VA got “emotional” and SP2 told the VA s/he had to report the allegation. · SP2 contacted P2 and said the VA made an allegation against SP1. SP2 told P2 that it “didn’t seem possible” because SP1 went in the VA’s bedroom to see what the VA wanted, left, went back in and brought the VA water, and then left again. The VA’s door was open the entire time. · SP2 told SP1 about what the VA said about SP1. SP1 said the only time s/he touched the VA was when SP1 and SP2 helped the VA get into bed. SP1 denied touching the VA inappropriately. · SP2 then brought the VA medications and the VA said, “I swear.” SP2 told the VA that what the VA shared was being taken seriously and was going to be looked into. SP1 was sent home and the VA stayed in bed until SP1 left. · On May 22, 2026, the VA seemed “sad.” P2 came to the facility to speak to the VA. After P2 left, the VA told SP2 that s/he did not remember anything from the previous day. · On May 23, 2026, the VA “was doubling down and adding things” to what the VA previously told SP2. The VA asked if SP2 heard the VA scream on May 21, 2026, and SP2 said s/he did not. The VA told P1 that SP1 put “ocean music” on during the incident and told SP2 that it was an R&B song. SP2 heard that the VA brought up his/her name and alleged a second staff person held the VA down during the incident. SP2 denied holding the VA down or witnessing SP1 touch the VA inappropriately. · SP2 did not work on May 26 and 27, 2026. On Thursday, May 28, 2026, SP2 learned the VA was hospitalized for a “demonic experience” and was discharged on May 29, 2026. · On May 30, 2026, SP2 worked with the VA for the first time since the VA was discharged from the hospital. The VA spoke in a “demon voice” and said things such as, “I’m not [the VA]” and “Demon doesn’t want to take meds.” Later in the day, the VA said s/he did not remember things again. · On May 31, 2026, the VA’s “demon persona” escalated. The VA growled and was more “animated.” The VA told staff persons, “You better run, bitch,” and banged on the wall for staff persons to come in the VA’s room. The VA was lying in bed with an absorbent undergarment pulled down, exposing him/herself, “humping the air,” motioning like the VA was “squeezing breasts,” and “touching [him/herself].” A staff person took the VA’s vital signs and told the VA that behavior was not appropriate with others in the room. The VA started “humping the air” again and said, “It’s [SP2’s] turn,” and pointed at SP2. Staff persons called 9-1-1 and the VA was transported to the hospital to be evaluated. · SP2 said that the G’s friend provided the VA with THC/CBD gummies and P2 said staff persons were not to touch the gummies or assist the VA with taking them. The VA asked SP2 to get the gummies for him/her and SP2 refused. SP2 was unsure if any other staff persons helped the VA take gummies. SP2 stated the VA was physically able to open the dresser drawer and get the gummies him/herself and consume them. SP2 did not mention if the VA had taken gummies on the day of the incident, however, said that it “seemed” like the VA took gummies “every other day.” · SP1 did not know how long the VA had been taking gummies and said the VA got the gummies him/herself and staff persons did not assist with getting the gummies. · SP1 said that the VA told other staff persons that s/he had a “crush” on SP1. The VA made “flirting” comments to all staff persons. SP1 was not in the “best mood” that week and felt the VA was possibly upset that SP1 wasn’t as friendly as usual or because SP1 told the VA that s/he should not take “edibles.” · SP2 said that the VA previously made comments about wanting to be closer to SP2’s age and referred to SP2’s “cute butt.” “Boundaries” had to be set, “especially by [SP2] and [SP1],” and the VA’s comments had to be “shut down” and the VA was told that comments were inappropriate. P1-P3 provided the following information: · On May 21, 2026, SP2 told P2 that the VA said SP1 “stroked” the VA’s genitals. SP2 said that SP1 told SP2 that prior to the allegation, SP1 told the VA that s/he should not be taking gummies. · On May 22, 2026, P2 spoke to the VA. P2 asked the VA what happened and the VA “nodded towards [his/her] crotch” and said, “[S/he] touched me.” P2 asked if SP1 tickled, pinched, or stroked the VA and the VA said SP1 “stroked” the VA’s genitals. Later that day, the VA had an appointment with a therapist and told the therapist that the VA was “sexually assaulted” and that SP2 held the VA down while SP1 was on top of the VA. P2 later heard the VA tell P3 that SP1 “had sex” with the VA. · The VA told P1 that SP1 turned music on and “sat on top” of the VA. The VA cried while sharing the information with P1 and told P1 s/he was “afraid” of the opposite gender. The VA did not share any other details regarding the sexual abuse allegation with P1. · On May 26, 2026, P3 met with the VA and the VA said SP1 “was on top” of the VA and made the VA ejaculate. The VA said s/he was not mad or upset at any staff person. P3 said that the VA was “usually” mad or upset with staff persons when the VA “does things like this” or made statements that were not true. The VA also told an overnight staff person that the VA hated all staff persons of the opposite gender, that the VA was possessed, that the VA wanted his/her bedroom cleansed and sprinkled with holy water, and that SP1 was not the one that sexually assaulted the VA, but rather a demon that possessed SP1. · A few days later (determined to be May 27, 2026), the VA was admitted to the hospital due to telling staff persons they were “going to die,” talking in a “possessed” voice, saying s/he was a demon, growling, and asking staff persons of the opposite gender to “sit on” the VA. The VA stated that s/he saw an old roommate who had passed away and said that roommate was sitting on the VA’s legs. The VA later said SP1 had a “demon” inside him/her, and it was that demon “that did it” not SP1. · P2 visited the VA at the hospital and the VA “was not [him/herself].” The VA seemed like s/he was “tweaking out” or was “wired.” The VA refused to put his/her glasses on because s/he saw “demons.” The VA was worried staff persons were “mad” at him/her. Sometimes the VA got him/herself “in a lie” and did not know how to get out of it. · On May 30, 206, SP2 told P2 that the VA asked about SP1 and said s/he wanted to apologize to SP1. · The VA previously got “pissed at” staff persons for not helping the VA take gummies. The VA knew staff persons were not allowed to touch the gummies. The VA was able to get the gummies out of a drawer and consume them by him/herself. The VA asked P1 for help a “couple of times” but P1 denied helping the VA take gummies. · P1 did not have any concerns with prior interactions between the VA and SP1. The VA had a “crush” on SP1 and another staff person. · P2 said that previously, the VA “made up some stuff” and got an overnight staff person fired. The VA was not an accurate reporter. The VA previously made inappropriate comments to SP2. The G provided the following information: · The G was told that the VA said a staff person had “sexual conduct” with the VA and that the VA was talking about people that had died. The VA told the G that s/he was “seeing dead friends and family members,” and that s/he was “sorry.” The VA said s/he had a “demon” in him/her and SP1 had a “demon.” The VA did not say anything “specifically” to the G about the alleged sexual contact with SP1. · The G’s friend started bringing the VA THC/CBD gummies about three years ago. The last time the VA received gummies was in April or May of 2026. The VA took them until they ran out and did not get anymore until the G’s friend visited again (once a year). The VA was “physically unable” to take the gummies him/herself and staff persons helped the VA take the gummies. The CM provided the following information: · The CM was initially told that the VA said SP1 touched the VA “inappropriately.” The CM received a follow up call from P3 and learned that the VA had told a counselor and other staff persons that SP2 held the VA down, while SP1 sat on top of the VA and made the VA ejaculate. · The VA was hospitalized and showed signs of psychosis. The VA claimed s/he and SP1 were both possessed by demons. · The hospital case manager told the CM that the VA gave “inconsistent responses.” The hospital was not aware of the sexual allegations prior to the CM informing them. · The VA was discharged from the hospital and continued having “strange behavior.” The VA went back to the hospital and was admitted for suicidal ideation and visual hallucinations. The facility’s Internal Review stated, “A review of photos of [the VA’s] gummies shows at least 6 varieties of fruit-flavored and other gummies containing THC and sometimes CBD, some with recommended doses of ½ a gummy. Doses of THC per gummy appear to range from [5 to 10 to 20 milligrams (mg)]. Some of the packages don’t appear to have been opened. The 20 mg dose package is open, as are two others.” On May 31, 2026, the VA wanted to apologize to the staff person the VA accused of inappropriate touch and wanted SP1 to come back to the house. The hospital social worker said the doctor thought “this has been caused by the gummies [the VA] was taking, whether too much or just that [the VA] was just reacting to them as everyone reacts differently.” The VA previously made statements that the VA “knows how to get rid of staff.” Hospital records showed that the VA was hospitalized May 27-29, 2026, and was diagnosed with suicidal ideation and visual hallucinations. On May 27, 2026, the VA told the ambulance crew that s/he took twice the dose of THC gummies the previous night and that “demons” were out to get the VA. The VA said s/he also took a “double dose” of THC gummies on May 22, 2026. A social worker said the VA’s behavior seemed “attention-seeking” and noted that the G was out of town. Hospital records did not mention the VA’s allegation of sexual abuse. On May 27, 2026, the VA said s/he had a bad dream about a roommate being “raped” and that the VA “knew who did it.” The VA told hospital staff s/he did not feel safe at the facility due to “demons” in his/her room that the VA called using a “spirit box.” The VA was hospitalized a second time from My 31 to June 12, 2026, for “behavioral outbursts and agitation in the setting of recent THC abuse,” ”sexually inappropriate behavior,” and “endorsing SI (suicidal ideation) and HI (homicidal ideation).” SP1, SP2, P1, P2, and P3 were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on May 21, 2026, the VA asked SP2 to call 9-1-1 due to the VA’s legs sticking out straight in front of the VA and the VA not being able to move them. The VA changed his/her mind, told SP2 to not call 9-1-1 and asked for help getting into bed. SP1 and SP2 helped the VA into bed. The VA rang the bell and asked SP2 how s/he got into bed and stated s/he did not remember being helped into bed or wanting 9-1-1 to be called. The VA rang the bell a second time and asked SP1 for water. SP1 went and got a glass of water, gave the VA a sip, and turned on calming music due to the VA telling SP1 s/he was “high.” The VA rang the bell a third time and SP1 and SP2 went to see what the VA wanted. The VA said s/he just wanted SP2 in the room. SP1 left and the VA told SP2 that SP1 had touched the VA’s “private area.” SP2 said SP1 was alone in the VA’s room twice for a total of less than two minutes and the door was open the entire time. On May 22, 2026, the VA told P2 that SP1 touched his/her “crotch” and “stroked” his/her genitals. Later that day, the VA told SP2 that s/he did not remember anything from May 21, 2026. The VA told his/her therapist that SP2 held him/her down while SP1 was on top of the VA. P2 heard the VA tell P3 that SP1 “had sex” with the VA. On May 23, 2026, the VA said that s/he screamed during the incident and told P1 that SP1 put on “ocean music” but told SP2 that it was an R&B song. The VA told this investigator only SP1 was involved in the allegation, that SP1 used his/her mouth on the VA’s genitals, and did not use his/her hands on the VA’s genitals. SP1 denied touching the VA inappropriately and SP2 denied holding the VA down or seeing SP1 touch the VA inappropriately. On the day of the incident and in the days following, the VA had visual hallucinations including seeing a deceased roommate sitting on the VA’s legs and being unable to move his/her legs. The VA spoke in a “growling,” “possessed” voice and said that s/he as possessed by demons. The VA also said SP1 was possessed by a demon, and it was the demon that touched the VA. On May 27, 2026, the VA was transported to a hospital and diagnosed with suicidal ideation and visual hallucinations. On May 29, 2026, the VA was discharged back to the facility. On May 31, 2026, the VA exposed him/herself, was “humping the air,” motioned like s/he was “squeezing breasts,” and was touching him/herself. The VA pointed to SP2 and said, “It’s [SP2’s] turn.” The VA was transported to the hospital for a second time to be evaluated and was admitted. On June 12, 2026, the VA was discharged. The hospital stated the VA’s behavior was “caused by the gummies [the VA] was taking, whether too much or just that [the VA] was reacting to them.” The G’s friend started bringing the VA “gummies” a few years ago. The VA received gummies in May of 2026 and was physically able to get and take the gummies him/herself. Staff persons were not allowed to help the VA get the gummies out of the dresser or assist the VA take the gummies. The VA said P1 helped him/her take gummies, however, P1 and all staff persons denied helping the VA take gummies. The VA said s/he took more gummies than were recommended, up to three times the recommended dose. Although the VA provided information that SP1 touched his/her genitals while SP2 held the VA down, given that the VA provided inconsistent information about the incident, that the VA did not always provide accurate information, that SP1 was in the VA’s room alone for a total of less than two minutes with the door open, that the VA was diagnosed with visual hallucinations shortly after the date of the allegation, and that SP1 and SP2 denied the allegations, there was not a preponderance of the evidence whether any sexual contact occurred. 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 and internal review and determined policies and procedures were adequate and were followed. The VA’s staffing increased to two staff persons to provide personal cares to the VA whenever possible. The THC gummies were removed from the facility at the request of the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action.
|
