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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: 800257-DS (Detoxification Center) Investigator(s): Beth Virden Suspected Maltreatment Reported: It was reported that a staff person (SP) took medications belonging to a vulnerable adult (VA) without the legal authority to do so. Date of Incident(s): September 14, 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 for this investigation was obtained remotely, including documentation and video footage from the facility, and law enforcement records; and through an interview with a facility supervisory staff person (P). The VA was contacted for this investigation, but did not have additional information. The SP responded to this investigator’s request for an interview; however, then did not respond to subsequent attempts to schedule the interview. The facility provided detoxification services to individuals who were intoxicated or in withdrawal from alcohol or other substances, and who were unable to immediately care for themselves. The facility was a stand-alone building with capacity to serve 16 individuals at a time. The facility had cameras mounted throughout common areas, which recorded movement but not audio. On September 12, 2022, the VA arrived at the facility for services and supports relating to his/her substance use. The VA had come directly from the local jail with facility staff transporting him/her. On September 14, 2022, the VA was discharged and transported directly back to the jail. The P provided the following information: · On September 16, 2022, jail officials contacted the P regarding the VA’s medications. According to jail records, the VA had been given a prescription of 60 tablets of amphetamine Salt (Adderall) 20 milligrams (mg) just prior to being transported to the facility. The VA would have arrived at the facility with his/her full prescription. The VA was at the facility for two days (September 12 – 14, 2022); and when s/he returned to the jail, his/her prescription was short 22 tablets. · Prior to contacting the P, a jail official called the facility’s main line and spoke to the SP. The jail official asked that the VA’s medication administration record (MAR), specific to his/her Adderall 20 mg, be faxed to the jail. The SP then faxed paperwork to the jail stating that two tablets of Adderall 20 mg had been administered to the VA at the facility and that 20 tablets had accidentally been dropped in water and destroyed. The VA’s signature was on two forms within the paperwork. One form was regarding the VA’s other medications, and the second form was signed by the VA indicating that s/he was aware of the aforementioned water incident. However, the signatures on both forms were exact matches, including the manner in which the writing crossed over the signature line; the signatures appeared to be an exact copy of one another. · On September 19, 2022, the VA provided a written statement stating that s/he had been given one tablet of his/her Adderall 20 mg during his/her stay at the facility. The VA said that s/he “never signed anything for damaged pills” in water. · The P said that had the VA’s Adderall 20 mg been destroyed by water, there was a procedure for staff to follow in order to report such an occurrence. The facility’s nurse should have been contacted, two staff persons should have ensured the medication was disposed of properly, and work to replace the medication should have been started. The P said that staff, including the SP, were aware of this procedure, but there was no such information regarding any incidents of the VA’s Adderall 20 mg having been destroyed by water. · In response to the jail officials’ concerns, the P reviewed the facility’s medical file for the VA. The P noted that the VA’s MARs were photocopies, which was against the facility’s policy of maintaining original copies in the file. · The P then reviewed the facility’s camera footage of the VA’s admission to the facility and inventory of his/her belongings, and the VA’s discharge process back to the jail. · The P provided copies of the camera footage to this investigator and to law enforcement; however, the camera footage received did not include the VA’s discharge and/or subsequent footage (described below) of what happened later on regarding the VA’s MAR. This investigator contacted law enforcement, who also did not have copies of the aforementioned footage. The P said that the footage was no longer available on the facility’s camera system. However, the P was certain of what s/he had observed on the footage and was able to describe it in detail for this investigation. · The P’s description of the camera footage and that, which was provided for this investigation, provided the following information: o On September 12, 2022, at 12:05 p.m., the VA arrived at the facility. o The P observed, on the camera, that a staff person inventoried the VA’s medications and logged information on the VA’s MAR. (Note: The VA’s MAR stated that the staff person doing the initial inventory documented that the VA had arrived with 60 tablets of Adderall 20 mg. The P provided a copy of the MAR for this investigation.) o The VA’s Adderall 20 mg was in an orange medication bottle. The P observed, on the camera, the staff person putting the bottle in a pouch and then placing the pouch in a locked office drawer. (Note: The P told this investigator that only staff had access to this drawer, and the P was not aware of any times when the drawer was left open or accessible to anyone but a staff person.) o At 3:25 p.m., the camera showed a staff person removing the orange medication bottle and administering one tablet to the VA. The staff then returned the bottle to the VA’s pouch and locked drawer. The staff person documented this on the VA’s MAR (which was provided for this investigation). o According to the VA’s MAR, the SP documented that s/he administered one tablet of Adderall 20 mg to the VA on September 13, 2022, at 7:45 a.m. However, the P did not observe any medications being administered the VA at that time. (Note: The VA had also told jail officials that s/he had only received one tablet during his/her stay at the facility – previously mentioned as having occurred at 3:25 p.m., on September 12, 2022.) o On September 14, 2022, the VA was scheduled to be discharged back to the jail. The P observed, on the camera, that at 7:32 a.m., the SP took out the VA’s Adderall 20 mg and dumped the contents into a counting tray. The SP then turned away from the camera view. According to the P, it appeared as though the SP were touching the tablets with his/her hands. The SP then turned back towards the camera and transferred the tablets from the tray back into the bottle. The P observed that the SP’s left hand was in a fist at this time, as though s/he were holding something in his/her hand. The SP then briefly put his/her left hand into his/her pocket. o Later that same day, at 5:20 p.m., the SP was observed answering the facility’s main line telephone. Immediately following this phone call, the SP retrieved the VA’s medical file. The SP then retrieved a blank MAR from an office drawer where blank forms were stored. The P observed the SP make a copy of the VA’s MAR from the VA’s file, and then use scissors to cut off the bottom portion of the MAR. (Note: According to the documentation provided for this investigation, this was where the VA’s signature was located.) o The SP then wrote on the blank MAR and placed the items on the scanner so that the cut off portion containing the VA’s signature lined up with the newly created MAR. The SP printed the form and then used the fax machine (presumably to send the fax to the jail official as previously mentioned). The SP then placed documents into the shredder. A New Ulm Police Department Report stated the following: · On September 19, 2022, a law enforcement officer (LEO) explained the reported incident to the SP, including that it was alleged the SP took 20 tablets (pills) of Adderall 20 mg from the VA and that the documentation regarding this medication had been falsified. · “At this time, [the SP] admitted to the theft of the 20 Adderall pills from [the VA].” · “[The SP] stated that [s/he] made a bad decision and took the pills on impulse … [the SP] stated that [the pills] were at [the SP’s] residence.” The SP agreed to give the pills to the LEO. The LEO then followed the SP to his/her residence. “[The SP] went inside and returned shortly with a plastic bag and 10 Adderall pills. Some of the pills did appear to have been exposed to some type of liquid.” The LEO secured the pills into an evidence locker. · The LEO’s case was referred to the county attorney for review of criminal charges. (Note: The criminal proceedings were pending at the completion of the Department of Human Services investigation.)
Facility documentation stated that the SP received training on the facility’s policies and procedures, including Medication Administration, Preventing Medication Errors, Professional Boundaries, Employee Code of Ethics, Clients’ Rights, and Abuse Prevention Plan; and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: According to jail records and facility documentation, on September 12, 2022, the VA arrived at the facility with 60 tablets of Adderall 20 mg. On September 14, 2022, the VA was discharged from the facility to a local jail, and at that time, it was discovered the VA’s Adderall 20 mg was short 22 tablets. The P reviewed video footage that showed that SP handling the VA’s Adderall 20 mg just prior to his/her discharge. The P noted concerns with the SP’s conduct on the camera footage, including that s/he turned away from the camera while handling the medication; that s/he placed his/her hand into his/her pocket immediately after handling the medication; and that s/he appeared to alter documentation regarding the medication. On September 19, 2022, the SP admitted to the LEO that s/he was responsible for the missing tablets of the VA’s Adderall 20 mg. The SP stated that s/he “made a bad decision and took the pills on impulse.” The SP then retrieved ten tablets of Adderall 20 mg and turned them into the LEO. Given the aforementioned, there was a preponderance of the evidence that the SP willfully used or disposed of medications belonging to the VA. 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. At the time of the incident, the SP was employed by the facility. The facility provided training to the SP on policies and procedures, including Medication Administration, Preventing Medication Errors, Professional Boundaries, Employee Code of Ethics, Clients’ Rights, and Abuse Prevention Plan; and on the Reporting of Maltreatment of Vulnerable Adults Act. The SP told the LEO that s/he took the VA’s Adderall tablets. 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 recurring or serious. The SP was responsible for a single incident of maltreatment that did not meet the definition for “serious” maltreatment. Action Taken by Facility: The facility completed an internal review, and determined that policies and procedures were adequate, but not followed by the SP. The SP was no longer employed by 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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