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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: 1057584-SUD (Substance Use Disorder) Investigator(s): Sarah Schumacher Suspected Maltreatment Reported: It was alleged that a staff person (SP) took several of a vulnerable adult’s (VA) gabapentin tablets for the SP’s personal use. Date of Incident(s): May 21 and 22, 2022, and possible prior unknown dates 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 9, paragraph (b), clause (1): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 15, 2022; from documentation at the facility; and through two interviews conducted with a facility supervisor (P) and a facility nurse (N). Attempts made via telephone and United States mail to contact each the VA and the SP to request an interview were unsuccessful. However, the SP provided information to the P which was included below. The VA’s diagnoses included opioid dependence, cocaine dependence, major depressive disorder, and post-traumatic stress disorder. The VA was not subject to guardianship. The VA reported chronic neck pain and took medications to control the pain. The VA had a traumatic brain injury that caused some difficulty with memory. The VA had “motivation for change/treatment” and had a goal to process his/her mental health struggles. The facility had a medication office which was also the N’s office. In the medication office was a medication closet where the medications were stored. Each client had a medication bin for their medications. All staff persons had access to both the medication office and the medication closet. There were surveillance cameras in the medication office pointed at the medication closet. Interviews with the P and the N and facility documentation provided the following information: · On April 1, 2022, the VA was admitted to the facility and on May 24, 2022, the VA voluntarily discharged “against staff [person] advice.” · When the VA moved into the facility the VA was prescribed gabapentin 800 milligram (mg) tablets, one tablet three times per day for “pain,” which had been filled on March 28, 2022, with a 30 day supply. The facility’s Medication Administration Record showed that the VA’s doses were scheduled at 8:30 a.m., 12:30 p.m., and 4:30 p.m. · Each Sunday night, a staff person looked at all client medications and recorded on a Medication Refill List how many days of medications clients had left. · On April 18, 2022, the facility’s Medication Refill List stated that the VA had “five days left” of gabapentin 800 mg tablets (based on supply, four days/12 tablets were missing). On April 18, 2022, the N requested a refill from the pharmacy. · On April 20, 2022, the VA’s gabapentin 800 mg tablet prescription was refilled and 90 tablets were delivered to the facility. · On April 30, 2022, the facility’s Medication Refill List stated that the VA had “seven days left” of gabapentin 800 mg tablets (based on supply, 23 days/69 tablets were missing). On May, 2, 2022, the N requested a refill from the pharmacy. · On May 9, 2022, the facility’s Medication Refill List stated that the VA had “one day left” of gabapentin (there should have been at least 14 days remaining). The N again requested a refill from the pharmacy. The pharmacy told the N that the VA’s gabapentin could not be filled because it was “too soon” for a refill and that it could not be refilled until May 14, 2022. The N looked back at the VA’s previous refill and discovered that the VA should have had more tablets left than were there. At that time, the N decided to start counting the VA’s gabapentin tablets each day Monday through Friday when the N was at the facility. · The N contacted the VA’s provider for an “emergency” refill so that the VA would have enough gabapentin until it could be refilled but the provider was not able to do so. The N told the VA that s/he would be “short” on gabapentin so the VA had the option to go to an emergency room or take less gabapentin than prescribed. The VA did not want to go to the emergency room so told the N s/he was “okay” with taking less than prescribed. The VA had a bottle of gabapentin 300 mg tablets from a previous prescription that was in a “to be destroyed” bin in the medication office. The N decided to use those tablets so that the VA could take gabapentin while waiting for the refill. The N wrote a note in the VA’s medication bin and verbally communicated to staff persons that the VA was to take two tablets of gabapentin 300 mg three times per day until the refill was delivered. · On May 10, 2022, the N documented “out of 800s, 2-300mg per dose 3 times per day until new supply comes in” and began counting the gabapentin documenting how many tablets remained. · On May 14, 2022, the N requested the gabapentin refill from the pharmacy. The VA took the morning and evening doses of gabapentin and not the afternoon dose. · On May 15, 2022, the VA “declined” the morning and afternoon doses of gabapentin and then took the evening dose. · On May 16, 2022, the morning dose of gabapentin was documented as “out of supply.” The VA’s gabapentin was then delivered and s/he took the afternoon and evening doses as prescribed. The VA told the N that s/he had a “rough weekend” but did not report specific withdrawal symptoms. · From May 10 to 20, 2022, the N counted the gabapentin tablets and none were missing other than what the VA was administered. Since the N did not work, the N asked another staff person to count the gabapentin on May 22, 2022. On May 22, 2022, the staff person counted the VA’s gabapentin and eight tablets were missing. The staff person notified the N after discovering the missing tablets. The N notified a facility administrator who notified the P. The P then began reviewing video surveillance of the medication office from May 20 to 22, 2022. · Video surveillance from the medication office showed the following: o On May 21, 2022, at 9:55 p.m., the SP was in the medication office and opened the medication closet. The SP reached into what the N identified was the VA’s medication bin and took a bottle that the N identified as the VA’s gabapentin. The SP’s back was facing the camera so the SP opening the gabapentin bottle was not seen but then the SP put the bottle back and turned around with two tablets in his/her hand. The SP shut the medication closet and went to a desk. The SP picked up a beverage can, placed one tablet at a time in his/her mouth ingesting each followed by a drink of the beverage. The SP then left the medication office. o On May 22, 2022, at 1:20 a.m., the SP was in the medication office sitting in a chair at the desk looking at his/her cell phone. The SP stood up and opened the medication closet taking the same bottle which was identified by the N as the VA’s gabapentin and then put it back. When the SP turned around facing the camera, s/he had two tablets in his/her hand. The SP closed the medication closed and then sat at the desk. The SP placed one tablet at a time in his/her mouth ingesting each followed by a drink of a beverage. The SP remained in the medication office. · On May 25, 2022, the P interviewed the SP. Initially the SP told the P that s/he knew there was a camera in the medication office and that s/he was not aware of medications missing. Then the P told the SP that the facility was aware that a “significant” amount of gabapentin was missing and the SP said, “That is on me. I don’t understand what I did or why I did it but I’ve been taking gabapentin.” The SP stated this “just started now” and had been happening “not long.” The SP did not know how many gabapentin tablets s/he took. The SP told the P that s/he made a “horrible” choice. The SP said no one else knew about this or was involved. The SP estimated it had happened the past two to three weeks “a couple times” because it made the SP “stay awake” and the SP realized the affects and started taking it. The SP denied taking any other medications from the VA or other clients. The P, the N, and the SP were each trained on the Reporting of Maltreatment of Vulnerable Adults and on the VA’s treatment plan. Conclusion: A. Maltreatment: Information showed that the VA was missing gabapentin tablets (based on prescriptions likely 89 tablets). Video surveillance of the medication room showed the SP taking and ingesting two tablets on May 21, 2022, at 9:55 p.m. and on May 22, 2022, at 1:20 a.m. When the P asked the SP about the missing gabapentin, the SP initially denied knowing any were missing but then told the P that s/he had been taking the VA’s gabapentin for two to three weeks. Given that only staff persons had access to the VA’s medications, that the SP was on video surveillance taking four of the VA’s gabapentin tablets, and that the SP told the P that s/he had been taking them for two to three weeks, there was a preponderance of the evidence that the SP willfully used the VA’s property without legal authority. It was determined that financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and told the P that s/he had taken the VA’s gabapentin tablets over the course of two to three weeks. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated financial exploitation for which the SP was responsible was not “serious” maltreatment because the maltreatment did not meet the definition of “serious” but was “recurring” maltreatment because the SP took the VA’s gabapentin on more than one occasion. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were not adequate and updated their policies to limit use of the medication office to only when staff persons were working with the medications and medications that were “at risk of diversion,” including gabapentin, were to be monitored more closely. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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