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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: 802787-DS (Detoxification Center) Investigator(s): Jason Pehler Suspected Maltreatment Reported: It was reported that a staff person (SP) took $500 from a vulnerable adult’s (VA) personal belongings. Date of Incident(s): May 12, 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 July 28, 2022; from documentation at the facility and through nine interviews conducted with the VA, facility staff persons (P1-P3), two facility supervisors (P4-P5), the VA’s guardians (G1-G2), and the SP. Law enforcement (LE) was contacted during the investigation, however a criminal investigation did not occur within this investigation. Facility documentation showed the VA enjoyed fishing, lived in his/her own apartment, and had a significant other. The VA was diagnosed with post-traumatic stress disorder, autism, schizophrenia spectrum, and other psychotic disorder, and cannabis use disorder. The VA voluntarily admitted to the facility for safe detoxification The facility had three staff offices. Two of the offices were located in the middle of the facility and were connected by a doorway. Those offices required a key to enter either door, however clients were allowed in the office while staff was present. One of the offices was a main staff office and had multiple windows providing sightlines into the facility’s common area and towards the facility bedrooms. The other office was the medication office and within there was a file cabinet where the VA’s personal belongings were stored after the intake process was completed. The VA’s belongings were kept inside a clear storage bag and placed in the file cabinet. The third office, which was locked at all times, was across the hallway and the clients did not have access to that office. There was a camera located in the main staff office and the medication office respectively, but not in the third office across the hallway. The facility provided two video recordings, one from each office, during the timeframe of when the alleged financial exploitation occurred. Video one was from the medication office and was dated between May 12, 2022, at 3:41:31 p.m. and May 13, 2022, at 8:56:57 a.m. Video two was from the main office and was dated between May 13, 2022, at 6:59:59 and 9:58:32 a.m. Information from P1, P2, P3, P4, and P5; the VA’s progress notes; and video provided the following information: · On May 12, 2022, at 3:45 p.m., the VA’s intake into the facility was completed by P1. The VA’s belongings included cash, a wallet, shoes, a belt, a watch, two cigarette boxes, sunglasses, and a lighter. P1 and P2 each counted and confirmed that the VA had $1,750 cash. The belongings and cash were put into a property bag and then into the file cabinet in the medication office. P1 and P2 each provided information that the SP was focused on the VA’s money during the intake and asked to put it in a different envelope and recount it. However, neither P1 nor P2 did so. · On May 13, 2022, at 8:28 a.m., the VA wanted $10 so P3 and the VA went into the office. When P3 took out the VA’s belongings it was discovered that the VA was missing approximately $500 from his/her belongings. · The videos provided the following information: o Between May 12, 2022, at 4:48:36 p.m. and May 13, 2022, at 8:48:31 a.m., staff persons, including P1, P2, and the SP, were in and out of the medication and main offices. o On May 12, 2022, the SP spent a majority of his/her time in the adjoined offices. At 9:32:51 p.m., the SP opened the file cabinet, removed the VA’s bag, and walked out of the camera view and towards the office across the hallway. The SP exited the camera view at 9:32:59 p.m. o 9:34:06 p.m., (one minute seven seconds later) the SP re-entered the medication office with the VA’s bag and a white envelope. The SP appeared to talk with P2, who was sitting in the main office. P1 then entered the medication office as the SP was writing on the envelope. The SP then put the envelope in the VA’s bag and returned the bag into the file cabinet at 9:34:48 p.m, before leaving the staff office at 9:35:01 p.m. The SP returned to the medication office at 9:35:28 p.m. o 9:36:20 p.m., the SP opened the file cabinet and took out the VA’s bag. Then the SP took the envelope out of the bag and put it in the garbage. The SP returned the bag to the file cabinet and at 9:36:47 p.m. s/he left the medication office. o During the video there was no other times, when a staff person took the VA’s bag out of view of the camera. · P1 said there would be no reason for the SP to bring the VA’s belongings into the staff office across the hallway. In addition, the SP told P1 that s/he did not take the VA’s money into the office across the hall. The SP told P1 that s/he was “frustrated” with the facility administration when s/he was talking to them about the missing money and so s/he confessed. The SP also told P1 that the confession was made out of frustration and the SP felt like supervisors were not going to “hear what [s/he] had to say.” · P5 talked to the SP about the missing money and the SP told P5 that s/he did not want his/her co-workers to “get in trouble,” and that s/he would take “the fall for it.” P5 also said that the SP then wavered between admitting to the incident, and recanting his/her involvement. · P1 said on May 12, 2022, the SP seemed “worked up” about the money and P1 was “confused” by the SP’s behavior because it was different than other times they had worked together. Additionally, in the days after the incident occurred, the SP acted “weird” and was “constantly” bringing up the incident. · P5 said the facility determined the SP had opportunity and access to the VA’s belongings, and based on the information they collected no other employee(s) were involved in the incident.
G1 and G2 each said they were made aware of the missing money, and G2 said the facility reimbursed the VA. The SP provided the following information: · The SP denied taking the VA’s money, and said staff normally did not recount money while persons were at the facility, but P3 “magically” found out there was missing money after re-counting the money. The SP said there were multiple things that went missing during P3’s shifts in the past, and P3 had other personal legal issues involving finances. · The SP did not handle the VA’s belongings and/or money during his/her shift on May 12, 2022. · The SP was informed of the video recording which showed him/her going through the VA’s belongings on May 12, 2022. The SP then said the VA had a medication that needed approval so s/he made a copy of approval card in the other office. The SP was not aware what time s/he would have completed the task. The SP explained the process and estimated it would have taken him/her three to five minutes to complete. The SP said the VA would have had to request the medication, and then the SP would complete the process. · The SP said s/he did not have a “play by play” of each of his/her shifts, and did not want to “incriminate myself and say what I didn't do.” · On May 27, 2022, the SP met with P5 about the incident, and the SP felt P5 did not give the SP “respect” and/or “dignity.” The SP said the situation was not handled “fairly,” and s/he made a brash statement about taking the money, but it was with a “little bit of sarcasm" and did not “sincerely confess.” During the interaction about the missing money the VA said s/he told P5, “That's your decision? I know it is. So why don't I just get it on record for you? I did it. You're not going to see it any other way.” The SP, P1 and P2 were trained on the VA’s client specific programming, facility policy and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information obtained was consistent that when the VA arrived to the facility on May 12, 2022, s/he had $1750 in cash. The VA’s money was counted multiple times and put into a bag with the VA’s other belongings and stored in a file cabinet in the medication office. On May 13, 2022, at 8:48 a.m., P3 discovered that $500 was missing from the VA’s belongings. Information was consistent and supported via video that staff persons were the only persons who had access to the VA’s belongings including the cash. Therefore, there was a preponderance of the evidence that a staff person took the VA’s $500. It was determined financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult; and/or acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud). 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 Reporting of Maltreatment of Vulnerable Adults Act. Although the SP denied to this investigator having taken the money, P5 said the SP initially acknowledged having taken the money, and the video showed that the SP was the only staff person who accessed the VA’s belongings prior to it being discovered that the money was missing and the SP was the only staff person who took the VA’s belongings out of view of the camera without additional persons present. 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 recurring or serious maltreatment. It was a single incident that did not meet the definition of serious. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. The facility completed staff training, specifically related to ensuring person(s) money was counted during employee shift change. The facility completed an investigation and corrective action was completed by the facility to protect the persons that received services. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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