|
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: 1070820-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a staff person (SP) took games, totaling about $800, from two vulnerable adults (VA1 and VA2). Date of Incident(s): prior to October 3, 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 from the facility and through seven interviews conducted with VA1, VA2, VA1’s legal representative (LR1), VA2’s legal representative (LR2), the SP, and two facility management staff persons (P1 and P2). The facility had an attached garage. Inside the garage, there was one garbage can and one recycling container. VA1’s Annual Plan showed that s/he enjoyed fishing and attending football games. His/her Behavior Support Plan showed that s/he engaged in property destruction, but there was no information to show that s/he threw items away. VA2’s Annual Plan showed that s/he enjoyed earning money, spending time with friends, and getting “healthier.” A review of his/her file did not identify throwing items away as a concern. P1 provided the following information: · When P1 arrived to the facility on the morning of October 3, 2022, VA1 and VA2 told P1 that various electronic gaming equipment, that was previously stored in the living room, was missing. P1 looked around to see if s/he could find the games, but did not find them. · P1 called other staff to see if they had knowledge about the games. When P1 talked to the SP, who had worked from 4-10 p.m. the evening prior, the SP told P1 that when s/he left the facility the night before, the SP saw “trash bags” in the garage that contained the games, so the SP took them home and gave “some” of the games to his/her friends. P1 told the SP to bring the games back that night when s/he came to work. P1 then notified P2 of the concern. · When P1 was asked whether it was possible that VA1 and/or VA2 put their games in trash bags to put in the garbage, P1 said it was “really unlikely.” P1 also stated that s/he purchased some of the games for VA1 and VA2 to use that were missing. P2 provided the following information: · Although P2 did not remember the date, s/he talked to the SP after the gaming equipment was found missing. During that conversation, P2 told the SP to return the games when s/he came to work that afternoon. P2 was at the facility when the SP arrived at the facility, but the SP did not have any of the games so P2 told the SP to leave. · A short time later, the SP returned to the facility and brought back five gaming cases, but three of the cases did not contain the games so P2 told the SP to leave again. · P2 did not remember the date, but when s/he and the SP talked again, the SP agreed to come to the facility to return the games, but the SP did not come to the facility at the agreed upon time. VA1 and VA2 each denied that they put the games in the garbage bags in the garage. The SP provided the following information: · Although the SP did not remember the date, toward the end of his/her shift, the SP collected the garbage bags inside the facility to take to the garbage cans in the garage. When the SP got to the garage, s/he noticed two bags on the garage floor. When the SP lifted those two bags to put into the garbage container, s/he noticed that they made a “click sound” so the SP opened the two bags and noticed that the bags contained games. The SP did not ask the VAs why the games were in the trash bags and “assumed” that the VAs wanted the games “gone” so the SP took the games. · The next morning, P2 called the SP to ask if s/he knew anything about the games. The SP told P2 that s/he found the games by the garbage and that s/he took them home the night before. When P2 told the SP to return the games that night, the SP told P2 that s/he had “donated” some of the games to his/her friends, but that s/he could get the games back. · When the SP got to the facility, s/he returned a “few” of the games, but that the rest of them were already “donated” to his/her friends and stated, “It’s not an issue getting the games back.” The SP then left. The SP also said that s/he had been having trouble getting ahold of some of his/her friends to coordinate getting all the games back to be returned to the VAs. · In the days that followed, the SP tried a number of times to connect with P2 to return the games, but they were not able to agree on a time for the SP to return the games. The facility’s Investigation Report and Summary provided information that was similar to the information provided in this report, but added that although the facility asked the SP on a number of occasions to return the games, the SP only returned 2 of 17 games. The facility’s training records showed that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VAs specific care plans. Conclusion: A. Maltreatment: On October 3, 2022, VA1 and VA2 told P1 that the gaming equipment they owned was missing. When P1 talked to the SP, who worked the night before, the SP said that s/he found trash bags in the garage that contained the gaming equipment and the SP took the items home. Although P2 told the SP to return the items, the SP only returned some of the games because the SP had difficulty getting gaming equipment back from his/her friends. Given that VA1 and VA2 denied discarding the gaming equipment and that the SP acknowledged taking property belonging to VA1 and VA2, there was a preponderance of the evidence that the SP took property of VA1’s and VA2’s without the legal 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 was trained in the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of VA1 and VA2. 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 SP took property belonging to both VA1 and VA2. Therefore, it was determined that the substantiated financial exploitation for which the SP was responsible meets the definition of recurring maltreatment. The maltreatment was not serious because it did not meet the definition of serious maltreatment. Action Taken by Facility: The completed an internal review which stated that although policies and procedures were adequate, they were not followed by the SP related to “employee professionalism and conflicts of interests.” The review also stated that no additional training was needed because the SP was no longer employed by 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.
|
