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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: 1120749-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 (SP) purchased alcohol for an underage vulnerable adult (VA) with the SP’s money and the VA consumed the alcohol. Date of Incident(s): March 17, 2025, and an unknown date. 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 for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through nine interviews conducted with the vulnerable adult (VA), the VA’s two case managers (CM1 and CM2), three facility supervisory staff persons (P1, P2, and P3), and three facility staff persons (P4, P5, and the SP). The VA’s diagnoses included unspecified mood disorder, adjustment disorder with mixed anxiety and depressed mood, and fetal alcohol syndrome. The VA had “unlimited” alone time in the community, as well as at the facility. The VA enjoyed social media and spending time with friends. The VA was not subject to guardianship. A report was made with law enforcement regarding the allegation. However, no follow up was conducted as the law enforcement agency did not have jurisdiction over the location where the alcohol was allegedly given to the VA. The VA provided the following information: · The VA described his/her relationship with the SP as “almost like a romantic relationship without sex” and there were “zero boundaries.” · The VA and SP “hung out” twice outside of the SP’s work hours. On March 17, 2025, the VA and the SP discussed a plan over text message that the SP would go to the facility and say s/he forgot something, and the VA would ask for a ride to a family member’s house. The two carried out the plan and left the facility together. After the VA and the SP left the facility, they stopped at a liquor store, bought a 24-pack of Truly alcoholic beverages, and went to the SP’s house. The VA stated they drank the alcohol, danced, watched television, and fell asleep on the SP’s couch. The next day, the SP and the VA picked up one of the SP’s children at a family member’s house and dropped the child off at daycare. The SP and the VA watched television all day and the SP brought the VA back to the facility around 5 p.m. · The VA stated there was another incident, on an unknown date, in which the SP took the VA to a liquor store and bought “shots.” The VA and the SP drank the shots in the vehicle and then went into a “sex store.” The SP and the VA then went to buy toothbrushes for the facility, and the SP dropped the VA off at the facility. · On June 7, 2025, the SP texted the VA and asked for a phone call. The VA called the SP and the SP told the VA s/he had been suspended. The SP asked the VA if s/he told the facility that the two drank together or that the VA stayed the night at the SP’s house. The VA told the SP that s/he did not know anything. · The VA had missed calls from the SP on June 13, and June 16, 2025. The SP also texted the VA on June 13, 2025, to let the VA know to call CM1, as CM1 was unable to leave a voice mail for the VA. · The VA stated s/he met one of the SP’s children, that the SP and VA texted, called, and Facetimed each other regularly. “A lot of times, it was just checking in.” The VA stated there were 8 Facetime calls and over 200 phone calls with the SP. · The SP was the VA’s “best friend” and the VA did not realize how unhealthy that was. The VA did not think the SP should have allowed the VA’s behavior. The VA thought the SP should have reported his/her behavior to CM2. The SP sent the VA a long text message when the VA got close to moving out and told the VA s/he was “going back to old behavior.” The VA did not respond and did not talk to the SP after that. · On several occasions, the SP drove the VA to and from friends’ houses. · The VA was in the process of moving out of the facility. The VA got a new job and the facility was not able to provide transportation in the morning, so the VA got an apartment with a family member. · The SP told the VA several times that s/he could “lose my job” if anyone found out about the relationship. · The VA was bothered that the SP knew about the behaviors the VA had been engaging in, and that the SP did not inform CM2. The VA thought if CM2 had known, the VA would have had privileges taken away and the behavior would not have been allowed to continue. The VA thought the SP should have communicated this to CM1 and CM2. The SP provided the following information: · The VA had a history of false reporting. · The SP and the VA had a “great” relationship. · The SP stated s/he had nothing to worry about because the SP never bought the VA alcohol. · The SP told CM1, CM2, and the VA, that the SP had concerns about the VA moving out of the facility and in with a family member. CM2 shared the SP’s concerns. The VA “always had issues” with the family member and stopped going to therapy. The SP thought the VA “was falling into old patterns.” · The SP believed the VA made up the allegations in retaliation for the SP telling CM1 and CM2 his/her concerns about the VA moving out. The relationship between the SP and the VA “went down” as soon as the VA knew how the SP felt about the VA moving out and the concerns that were voiced. · The VA called the SP “all the time” to report staff and client issues, to ask to order groceries, and to let the SP know when the VA was going to a family member’s or friend’s house. The SP did not know why the VA did not tell on duty staff instead, but believed it was because the SP followed up on issues that other staff persons did not follow up on. · Other clients have also texted the SP. The SP was told it was acceptable to use his/her personal phone for work purposes and stated, “Everybody kind of does it.” Staff persons got a stipend to help pay the phone bill. · The SP admitted to crossing boundaries with the VA and added that s/he “maybe gave mixed signals that we were friends.” The SP had a problem saying “no” to people. The VA asked the SP to “hang out” and the SP made excuses instead of saying no. · The text messages exchanged on March 17, 2025, were in regard to the SP taking the VA to a friend’s house and dropping the VA off. The SP denied that the VA went to his/her house, that s/he purchased alcohol for the VA, or that the VA spent the night at the SP’s house. The SP denied ever spending time with the VA outside of work hours. · The SP stated the texts in which s/he said s/he wanted to hang out with the VA and sent a picture to the VA were sent when the SP was drinking alcohol. The SP had intentions to meet the VA, but “never would’ve acted on it.” The SP stated that s/he would not have said those things sober. · The VA never met the SP’s children. The SP denied that s/he ever drank with the VA, and denied ever being out with the VA. · On one occasion, the VA accompanied the SP when the SP ran errands and stopped home. The VA stayed in the car but would know what the SP’s house looked like and where it was located. · The SP took the VA to an adult store but had permission to do so from P1. · The SP got suspended on June 6, 2025. The VA called the SP on June 7, 2025. The SP did not answer but called the VA back. The VA called to tell the SP s/he was back at the facility, and asked if they could hang out when the SP was back at the facility. The SP told the VA, “I have a lot going on, we can’t hang out.” The VA responded, “I hope we can be lifelong friends.” The VA Facetimed the SP that night and the SP did not answer. The VA called one more time later in the week. The SP gave screen shots of the calls to the facility investigator. The SP called the VA on June 13 to tell the VA to call CM1. The VA did not answer and the SP sent the VA a text to call CM1. P1 provided the following information: · P1 learned about the allegations from P2, who was told by CM2. · P1 was at the facility at least once a week and never saw any inappropriate interactions or boundary issues between the VA and the SP. · The VA suddenly had a job and needed to be at work at 7 a.m. The facility could not commit to transportation that early due to staffing. The VA started staying with a family member during the week and got rides to work from the family member. The VA stayed at the facility on the weekends. · The VA decided to move out of the facility and in with the family member, whom s/he previously removed from his/her care team. CM2 and the SP had concerns about the new living arrangement. The SP voiced those concerns to the VA. P1 did not know if the VA made the allegations towards the SP out of retaliation. The VA did have a history of false reporting. P1 stated that the VA, “can twist things a lot” and “not everything is true when [the VA] talks to you.” P1 did not believe the SP provided the VA with alcohol. · P1 said there were inconsistencies in the VA’s story. The VA said the SP had one child, and the SP had two. The VA said one child went to daycare, and both children did. The VA named the city that the SP lived in, and it was incorrect. · P1 and the SP talked about how the SP’s children’s daycare was close to the facility, and the VA likely overheard that. P1 stated, “[The VA] can make it sound convincing, but you’d have to ask somebody else if that was the truth or not. If [the VA] doesn’t have anything to back it up, then I have a hard time believing [the VA].” · The VA arrived at the facility intoxicated on a previous occasion and told staff persons s/he was at a local establishment. P1 was unsure if the VA had a fake identification. P2 provided the following information: · On June 6, 2025, P2 was contacted by CM2, who worked with the VA when the VA was a minor. CM2 told P2 that on June 5, 2025, the VA told CM2 that the SP picked the VA up from the facility, purchased alcohol, and took the VA to the SP’s house, where the VA and the SP drank alcohol. CM2 stated the VA has not always been an accurate reporter and CM2 was not sure how true the allegations were. · The VA told P2 that the SP and the VA conspired to make up a false story that the SP was taking the VA to see a family member. The SP actually took the VA with him/her to go to a liquor store, purchase a 12-pack of Truly alcoholic beverages, pick up the SP’s child at daycare, drop the child off at a family member’s house, and finally stop at the SP’s house. The VA stated that at the SP’s house they drank the alcoholic beverages, danced, watched television, and fell asleep on the SP’s couch. The SP dropped the VA off at the facility the next day around 5-6 p.m. · P2 saw screen shots of text messages exchanged on March 17, 2025, in which the SP stated s/he was going to say that s/he forgot something and told the VA to ask the SP to bring him/her to a family member’s house. · Text messages were reviewed and were mostly conversations about things that occurred at the facility. There were some boundaries crossed when the SP and the VA discussed hanging out and the SP said, “I miss you.” · The VA had a history of not being an accurate reporter. However, since the VA had been at the facility, the VA had been “for the most part, an accurate reporter.” · There were no previous issues with the SP that involved boundary issues or persons served. P3 provided the following information: · P3 learned that the VA told P2 that the SP did not have professional boundaries. The SP and VA texted each other, the VA spent the night at the SP’s house, the SP provided the VA with alcohol, the VA wanted to go to a bar with the SP, and the SP spoke to the VA about his/her intimate issues. · On March 17, 2025, there was a text message exchange between the SP and the VA. The SP said s/he forgot paperwork in order to return to the facility, and then picked up the VA. There was nothing in the text messages that referred to the purchase of alcohol. The SP told P3 that s/he picked the VA up, and brought the VA to a friend’s house, not the SP’s house. The text messages did not say where the two planned to go. The SP denied that the VA had ever been to the SP’s house or that the SP ever purchased alcohol for the VA. The SP did confirm s/he “didn’t have the best boundaries with [the VA].” · The VA stated s/he slept on a gray sectional couch at the SP’s house. The VA did not have any photos or videos from the night in question to corroborate the story. · The SP stated that on one occasion the SP took the VA along when the SP ran errands. The SP stopped at his/her house to pick something up. The VA stayed in the vehicle and did not go inside. The SP lived in a different city than where the VA stated the SP lived. · The SP denied talking to the VA about going to a bar or about the SP’s intimate issues. P3 asked the SP to see the text conversations with the VA and the SP stated s/he deleted everything on the phone once s/he was suspended because, “it was taking up too much data.” The SP did not bring his/her phone to the meeting with P3. · No other staff persons had concerns about the SP or thought the SP had inappropriate boundaries. The SP’s supervisor, P1, did not have any concerns with the SP, other than the SP calling and texting persons served on a personal level. P4 provided the following information: · The VA tried to “befriend” P4 and asked P4 to hang out after the VA moved from the facility. P4 declined and kept things “professional.” P4 was unaware if the VA asked other staff persons to hang out. · P4 stated relationships between staff persons and clients were “good and respectful.” P4 did not have any concerns over staff persons’ relationships with clients. · P4 had not heard of any staff person that hung out with a client outside of work hours. · The VA had “everybody’s numbers” and contacted staff on their personal phones. The VA contacted staff persons for rides and shared his/her location to be picked up. Other clients did not have staff persons’ numbers and were usually with staff and did not spend time away from the facility like the VA did. P5 provided the following information: · P5 had only worked a few shifts when the VA was at the facility. · None of the clients had P5’s cell phone number, and P5 stated it was not normal for clients to have staff persons’ phone numbers. · P5 did not provide transportation to any of the clients. · P5 did not have any concerns about unprofessional relationships between staff persons and clients and felt staff persons had good boundaries. CM1 provided the following information: · On June 7, 2025, CM1 received an email from P1 that stated the VA had alleged a staff person bought him/her alcohol. · CM1 has emailed the VA but has not received any responses. The VA was more engaged with CM2. · The VA had history of drug and alcohol use and put him/herself in “dangerous” situations. · The SP and the VA communicated regularly. However, CM1 did not know what that entailed. · When asked about the VA’s ability to provide accurate information, CM1 stated that the VA “might shade something depending on [his/her] relationship with that person at the time. What you get could depend on how [the VA] sees [the SP] at the time.” CM2 provided the following information: · On June 5, 2025, the VA told CM2 that the SP had the VA over to his/her house and “got [the VA] drunk.” The VA was “in a sense laughing about it” and said, “Do with it what you will.” The VA showed CM2 texts, pictures, and videos from the SP and “insinuated” that they acted more like friends than staff and resident. · The VA had admittedly made false reports before. In previous reports, it was “hard to differentiate what was true and false.” Facility documentation showed that the SP, P1, P2, P4, and P5 were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that on June 6, 2025, the VA told CM2 that the SP purchased alcohol for the VA and the VA spent the night at the SP’s residence on March 17, 2025. The VA gave a description of the SP’s residence, a couch, and information about the SP’s family. The VA told this DHS investigator that the SP also purchased alcohol for the VA on an unknown date when the SP took the VA to an adult store. The VA stated the SP purchased “shots” at a liquor store, which were consumed in the SP’s vehicle before entering the adult store. The SP admitted to crossing boundaries with the VA. However, the SP denied ever purchasing alcohol for the VA, or bringing the VA to his/her house. The SP stated s/he made excuses when the VA asked the SP to hang out instead of telling the VA it would have been inappropriate. Although the VA provided text messages that were exchanged between the VA and the SP, no specific details of the alcohol purchases or the VA spending the night at the VA’s house were mentioned. There was communication about the SP picking the VA up on March 17, 2025. However, the SP stated the conversation pertained to when the SP picked the VA up and drove the VA to a friend’s house for the evening. The VA told this DHS investigator there were no pictures or photos from the night of March 17, 2025. The SP's behavior was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. However, given that the SP denied providing the VA with alcohol and bringing the VA to his/her house, that the VA had a history of providing inaccurate information, and that the text messages between the VA and the SP did not provide conclusive information, 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’s Internal Review stated the reported event was not similar to past events with the person served, the reported event was not similar to past events at that location, and that related policies and procedures were adequate but were not followed. The facility identified that there was not a need for additional staff training, but there was a need for corrective action by the facility to protect the health and safety of the person served. The SP’s job description “interact with all support services in a positive and professional manner” was not followed. The SP was no longer at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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