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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: 1070061-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Rebecca Mesto Suspected Maltreatment Reported: It was reported that on various dates in July 2022, a staff person (SP) used a vulnerable adult’s (VA’s) debit card and withdrew money totaling $1192.50 (including fees) for the SP’s personal use. After the SP admitted to taking the VA’s money, the SP paid the VA back. Date of Incident(s): July 2022 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 August 29, 2022; from documentation at the facility; and through four interviews conducted with an administrative facility staff person (P1), the SP, the VA’s case manager (CM), and the VA’s guardian (G). This investigator met the VA, but the VA was unable to provide any information for this investigation. The VA enjoyed attending and watching sporting events and going on vacation. The VA’s diagnoses included anxiety disorder, unspecified mood disorder, severe intellectual disabilities, and cerebral palsy. The VA’s Coordinated Services and Supports Plan stated that the VA required 24 hour supervision. The VA required assistance with money management and other activities of daily living. The VA worked with a community supported employment company and earned wages which helped pay for his/her cost of care. The VA enjoyed going on vacations, but did not have a lot of extra money to do so. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to financial exploitation. Staff persons were to oversee the VA’s purchases in the community and obtain receipts for each purchase. Staff persons were to reconcile the VA’s spending and check his/her bank statement. P1 and the facility’s Internal Review provided the following information: · On August 9, 2022, P1 and another administrative staff person (P2) were reviewing the residents’ monthly bank statements. P1 saw that on the VA’s statement there were $1192.50 in unauthorized ATM withdrawals and charges. · The VA’s debit card was typically stored in a locked cabinet at the facility, which staff persons had access to. The VA’s debit card required a personal identification number (PIN) in order to be used. Due to the VA’s diagnoses, s/he was unable make the withdrawals on his/her own. · Later that day, the SP called P1 and said that s/he “accidentally” used the VA’s debit card because s/he had left it in his/her wallet after taking the VA to the store. P1 instructed the SP to pay the amount missing from the VA’s account “immediately.” On August 10, 2022, the SP came to the facility and paid the total amount in cash. The G deposited the amount back into the VA’s bank account. · All staff persons who worked at the facility knew the PIN number for the VA’s card. The SP told P1 that s/he had a sticky note on the VA’s card with the PIN number. · Prior to the incident, the SP had the facility’s business credit card and made two or three personal charges on it. The SP told P1 that s/he had “accidentally” used the facility’s card to make the purchases and then paid it back. The SP provided the following information: · Sometime at the end of June 2022, the SP took the VA to the store to buy the VA’s personal items and then they went to a restaurant. The VA was unable to use the debit card on his/her own. The SP kept the VA’s debit card in the SP’s wallet. When the SP left the facility that day, s/he forgot to take the VA’s debit card out of his/her wallet. The SP was going on a trip and prior, had borrowed his/her family member’s (FM) debit card to use to purchase gas, food, and hotel rooms during the trip. The SP could not recall the exact dates of the trip (sometime at the beginning of July), but during the trip, the SP stopped at a few ATM machines and withdrew money, using what s/he thought was the FM’s debit card. When the SP returned from his/her trip, s/he talked to the FM to see the total amount that s/he owed the FM, but the FM did not see any withdrawals from his/her bank account. Then, the SP called P1 and told him/her that s/he had made a “mistake” and inadvertently withdrew money using the VA’s debit card. The following day, the SP paid the VA in full. · The FM’s and the VA’s cards looked “identical” and each had a post it note with the corresponding PIN attached. · Prior to the incident, the SP had the facility’s credit card in his/her wallet and inadvertently used it for two personal purchases. The SP informed P1 and paid it back. The VA’s bank’s Transaction History showed the following transactions: · On July 5, 2022, automated teller machine (ATM) withdrawals were made in the amounts of $400, $200, $200, and $150. A transaction fee of $2.50 was also charged on this day. · On July 11, 2022, an ATM withdrawal in the amount of $80 was made. · On July 12, 2022, an ATM withdrawal in the amount of $100 was made. · On July 19, 2022, an ATM withdrawal in the amount of $60 was made. · The total amount of unauthorized withdrawals and fees was $1192.50. The VA’s Transaction Receipt showed that on August 10, 2022, $1192.50 was deposited into the VA’s account. The G stated that P1 informed him/her of the incident and then the G cancelled the VA’s debit card. The SP returned the VA’s money and it was put back into the VA’s account. The VA had a “hard time” getting to know staff persons and trusting them, so when the SP no longer worked at the facility, it was hard for the VA to understand why the SP no longer worked there. The CM stated that s/he did not have any prior concerns regarding the VA’s care at the facility. This investigator contacted the law enforcement agency regarding the allegation, but did not receive any information regarding their investigation. The facility’s Handling Funds and Property stated that staff persons were not permitted to borrow money from any clients. Each client’s bank statement and corresponding ledger of purchases was to be reconciled monthly. Facility documentation showed that the SP had received training on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies prior to the incident. Conclusion: A. Maltreatment: The SP, P1, and documentation from the VA’s bank was consistent that in July 2022, the SP used the VA’s debit card to make withdrawals and fees totaling $1192.50. The SP paid the VA back in full. Although the SP stated that s/he inadvertently used the VA’s debit card and paid the VA back, there was a preponderance of the evidence that the SP withheld and/or used the VA’s money and did not have the authority to do so. 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 received training on the facility’s policies and the Reporting of Maltreatment of Vulnerable Adult’s Act. 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 did not meet statutory criteria to be determined as serious, however, it was recurring because the SP used the VA’s ATM seven times over a two week period. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but not followed by the SP. The SP no longer worked at the facility. 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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