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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: 1071900-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) took a vulnerable adult’s (VA1) electronic tablet. Allegation Two: It was reported that the SP took CD/DVD’s that belonged to a vulnerable adult (VA2). Allegation Three: It was reported that the SP took a vulnerable adult’s (VA3) Nintendo gaming console. Date of Incident(s): April 19 to September 22, 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 law enforcement records; and through six interviews conducted with a supervisory staff person (P3), VA3, VA2’s and VA3’s case managers (CM1 and CM2 respectively), and VA1 and VA2’s guardians (G1 and G2). Attempts were made via telephone and certified mail to contact and interview the SP, but the SP did not respond to the requests. Two administrative/supervisory staff persons (P2 and P4), the SP, VA1, and VA2 were each interviewed by a law enforcement officer (LEO) and that information was included below. According to the facility’s Management of An Individual’s Monetary Resources policy, staff persons did not borrow from, loan to, purchase personal items from, or sell any items from the clients. The facility’s personnel files and training records documented that staff persons, including the SP, were each trained on VA1’s-VA3’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The facility was unable to provide verification that the SP was trained on the facility’s Management of An Individual’s Monetary Resources policy, which was a violation of Minnesota Statute, section 245D.095, subdivision 5, paragraph (a), clause (2), which states in part that the license holder must maintain documentation of staff persons training. Allegation One: It was reported that the SP took VA1’s electronic tablet. VA1 was diagnosed with a developmental disability. According to VA1’s Risk Assessment Detail, VA1 was “very generous” with his/her finances and was “easily convinced” to loan persons money or buy things for other persons. Staff persons notified supervisory staff persons immediately if VA1 was taken advantage of. According to the law enforcement report: · VA1 provided the following information: o VA1 received the tablet as a birthday gift in April 2022. At one point, VA1 left the tablet on a kitchen table while s/he went to his/her bedroom. Awhile later, VA1 returned to the kitchen and the tablet was gone. The SP was the only staff person working at that time. o On a later date, the SP brought the tablet to VA1 and said that “someone” stole the tablet from VA1 and later sold it to the SP. The SP asked VA1 to unlock the tablet so VA1 did using his/her password. The SP then said s/he would pay VA1 $2 to “factory reset” the tablet and VA1 did so. The SP paid VA1 $2 and then took the tablet home with the SP. The $1 bills that the SP gave VA1 actually belonged to VA1 and were folded a specific way and stored in VA1’s locked bedroom but had gone missing prior to the incident. · P4 provided the following information: o On approximately April 19, 2022, VA1 received a tablet as a birthday gift from a family member. On approximately April 22, 2022, VA1 told P4 that his/her tablet went missing two days prior to VA1 talking to P4 and that only VA1 and the SP were at the facility at the time. P4 helped look around the facility but could not find it so P4 purchased the same tablet for VA1 for $56 off Amazon as a “personal gift” from P4 to VA1 because VA1 “really loved” the tablet. o Later, P4 reviewed video footage that showed VA1 carrying the tablet into the facility on the day it went missing. P4 did not see video showing the tablet leaving the facility. P4 did not have previous concerns with the SP taking items from the facility. (Note: The video footage was not saved and the facility was not able to provide the video to this investigator.) · P2 provided the following information: o On approximately April 19, 2022, at approximately 3 p.m, P2 arrived at the facility and VA1 told P2 that his/her tablet was missing. P2, P4, VA1, and the SP looked around the facility but did not find the tablet so P4 purchased the same tablet for VA1. P4’s last day working at the facility was July 7, 2022, and P2 went on vacation on July 8, 2022. o On July 11, 2022, VA1 came to P2 and said that the SP came to VA1 and asked VA1 to assist with unlocking a tablet that looked the same as the one VA1 used to own. VA1 put in his/her password, the tablet unlocked, and the same background that VA1 used came up on the screen. o P2 reviewed video footage of the front door and saw on April 19, 2022, VA1 arrived at the facility with a tablet. The SP was the only staff person working on that day. P2 then contacted P1 about the tablet, who then got the tablet from the SP on approximately August 25, 2022. The SP had a history of stealing things from the facility, such as bedding from the staff bedroom. · The SP provided the following information: o The SP worked at the facility for approximately 21 years and never “tr[ied] to steal anything.” On the day the tablet went missing, VA1 arrived at the facility from work, sat down to eat food, went to his/her bedroom, and then returned to the kitchen. The SP asked VA1 where VA1’s tablet was (the SP did not provide information on VA1’s response). The SP called the van driver that provided VA1 a ride to the facility. The driver checked the van but did not find a tablet. o A few months later, the SP saw a client (C) who resided at another facility location at a mall. The SP was not able to provide information on the C’s name but knew the C rode the same van as VA1. The C told the SP that when the van dropped VA1 off at the facility, VA1 left the tablet so the C took it. The C told the SP s/he was not able to unlock the tablet so s/he gave the tablet to the SP so that the SP could bring it to VA1 and have VA1 unlock it. The SP did not pay the C for the tablet. o “After some time went by” the SP brought the tablet to the facility and told VA1 about the C taking the tablet from the van. VA1 entered his/her password in the tablet and it unlocked. VA1 told the SP that s/he could keep the tablet since VA1 had a new tablet. The SP denied asking VA1 to do a factory reset on the tablet. · The LEO obtained information from P2 as to the identity of the C. The C told the LEO that s/he knew who the SP was because s/he was a staff person at the facility. The C and VA1 “sometimes” rode in a van together. The C denied knowing about VA1’s tablet, denied having VA1’s tablet, denied meeting the SP at a mall, and denied knowing why the SP would say that the C gave the SP the tablet. · The law enforcement report was forwarded to the county attorney’s office for review of possible charges. P3 told the LEO and this investigator that on August 1, 2022, VA1 told P3 that s/he lost his/her tablet back in May 2022 but it had been replaced. On August 1, 2022, the SP had the same tablet as VA1 at the facility. The SP came up to VA1 and asked VA1 to unlock the tablet with VA1’s password so VA1 did and the tablet unlocked. G1 was aware of the allegations and that the facility replaced tablet and did not have any concerns with the facility. Conclusion Allegation One: A. Maltreatment: Consistent information was provided that on approximately April 19, 2022, VA1’s tablet was missing. VA1 provided information to the LEO that s/he brought it into the facility, which video surveillance later viewed by P2 and P4 confirmed. VA1 stated s/he set the tablet on the kitchen tablet and left the kitchen. When VA1 returned, the tablet was gone and the SP was the only staff person working at that time. Although the SP provided information that on a later date, the C gave the SP VA1’s tablet, given that the C denied this interaction and that the SP had reason to minimize his/her actions, it was more than likely that the SP took the tablet while at the facility which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. The SP took VA1’s tablet without VA1’s permission, therefore, there was a preponderance of the evidence that in the absence of legal authority a staff person willfully took VA1’s tablet. 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 626.556, subdivision 10e, paragraph (i): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on VA1’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for maltreatment of VA1. C. Recurring and/or Serious Maltreatment: See Conclusion Allegation Two, Part C. Allegation Two: It was reported that the SP took CD/DVD’s that belonged to VA2. VA2 was diagnosed with a developmental disability. According to VA2’s Risk Assessment Detail, VA2 was vulnerable to financial exploitation, including persons asking him/her to borrow money and VA2’s inability to say no. Consistent information was provided that VA2 kept his/her bedroom door locked at all times. Staff persons were not allowed to access VA2’s bedroom without his/her permission and only for medication administration. The keys for VA2’s bedroom were stored in the staff office and staff persons had access to the bedroom keys at all times. According to the law enforcement report: · VA2 told the LEO that prior to July 28, 2022, the SP asked VA2 if s/he could borrow CD/DVD’s from VA2 and VA2 told the SP, “No.” VA2 told the SP s/he was allowed to watch the CD/DVD’s while at the facility but was not allowed to take them home. VA2 denied lending the CD/DVD’s to the SP. On August 6, 2022, VA2 realized over 100 CD/DVD’s were missing from his/her bedroom which was always locked. · P2 stated s/he reviewed video from the facility’s front door and saw on July 28, 2022, the SP arrived at the facility at 7:05 a.m. and did not have anything with him/her. At 11:04 a.m., the SP walked out of the garage with a black bag that belonged to VA2. Approximately 15 minutes later, the SP then walked through the front door with his/her personal computer bag. (Note: The video footage was not saved and the facility was not able to provide the video to this investigator.) · P3 stated s/he had previously seen the SP go into VA2’s bedroom to administer medications but had not seen the SP take items from VA2’s bedroom. P3 reviewed the video footage from July 28, 2022, that showed the SP walking to his/her personal vehicle with a black bag that appeared to contain CD/DVD’s. · The SP stated on a previous unknown date, VA2 gave the SP approximately 11 or 12 CD/DVD’s for the SP’s personal use. After using the CD/DVD’s, the SP returned them to VA2. The SP denied taking the CD/DVD’s from VA2. On August 17, 2022, the SP gave the LEO 28 CD/DVD’s that belonged to VA2. On August 22, 2022, the SP called the LEO and said s/he found an additional 12 CD/DVD’s of VA2’s at his/her house. The LEO went to the SP’s house on August 26, 2022, and the SP gave the LEO 15 CD/DVD’s. CM1 and G2 each did not have concerns with the facility. Conclusion Allegation Two: A. Maltreatment: VA2 stated on August 6, 2022, over 100 of VA2’s CD/DVD’s were missing. The SP gave the LEO 43 CD/DVD’s that belonged to VA2. Although the SP said that VA2 gave the SP the CD/DVD’s, given that VA2 denied this and that the SP had reason to minimize his/her actions, it was more than likely the SP took the CD/DVD’s from VA2 which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. The SP took VA2’s CD/DVD’s without VA2’s permission, therefore, there was a preponderance of the evidence that in the absence of legal authority a staff person willfully took VA2’s CD/DVD’s. 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 626.556, subdivision 10e, paragraph (i): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on VA2’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for maltreatment of 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 substantiated financial exploitation for which the SP was responsible was recurring maltreatment because s/he took items from VA1 and VA2. The SP was disqualified from providing direct contact services. Allegation Three: It was reported that the SP took VA3’s Nintendo gaming console. VA3 was diagnosed with attention deficit disorder and high spectrum autism. According to VA3’s Risk Assessment Detail, VA3 was vulnerable to financial exploitation and staff persons encouraged VA3 not to borrow money to other persons. VA3 was not subject to guardianship. According to the facility’s internal review: · P1 stated that because of the other allegations, on August 3, 2022,s/he asked VA3 if s/he noticed anything missing and VA3 said that “a couple of months” prior s/he walked past the SP’s computer bag that was open and saw VA3’s ear buds inside. VA3 took his/her ear buds out of the bag and brought them back to his/her bedroom. At that time, VA3 did not say anything about a Nintendo console. · On September 2, 2022, VA3 told P3 that in early summer 2022, s/he remembered seeing his/her Nintendo console in his/her bedroom but at some point it went missing but none of VA3’s games for the Nintendo console were missing. VA3 kept his/her bedroom door locked when s/he was not there, so whoever took the Nintendo console needed a key to enter. VA3 saw the SP walk out of VA3’s bedroom before but did not have any items with him/her and VA3 did not know why the SP was in VA3’s bedroom. The internal review stated that the SP was “most likely” to have taken the Nintendo console. · P2 said s/he saw VA3’s Nintendo console in the past but had not “for quite some time.” On September 2, 2022, VA3 and P2 looked through VA3’s bedroom and did not find the Nintendo console. “A good portion” of VA3’s bedroom was checked but not all because there were “a lot of items” and VA3’s room was “disorganized.” VA3 had a history of losing items and “sometimes” they turned up and other times they did not. VA3 was not always accurate with information and had “memory trouble.” VA3 provided the following information to this investigator: · VA3 kept his/her Nintendo console in his/her locked bedroom in a specific spot. One day in May or June of 2022, VA3 noticed the Nintendo console was missing. The only persons who had access to VA3’s bedroom was staff persons since his/her door was locked and the key to get in was kept on staff persons’ lanyard. · VA3 asked the other clients if they saw the Nintendo console and each responded, “No.” VA3 then looked “everywhere” in his/her bedroom and around the facility but was not able to find it. · On later dates, VA3 heard the other clients discussing how the SP took items from them. VA3 remembered that the SP had asked VA3 multiple questions about the Nintendo console, including where the SP could purchase one, so VA3 assumed the SP took the Nintendo console. CM2 stated that VA3 had a history of “victimizing” him/herself and had a history of losing items and not knowing where his/her belongings were at all times. VA3’s team met a few months back and the allegations came up in conversation but VA3 did not tell CM2 directly about the Nintendo console missing. Conclusion Allegation Three: Although VA3’s Nintendo console was missing, given that VA3 had a history of losing items and not knowing where his/her belongings were at all times; and that there was no information provided that VA3 or any other person saw the SP take the Nintendo console, there was not a preponderance of the evidence that in the absence of legal authority a staff person took VA3’s Nintendo console. It was not determined whether financial exploitation occurred (In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Action Taken by Facility: The facility completed three internal reviews and determined that policies and procedures were adequate but not followed. 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. On January 6, 2023, the facility was issued a Correction Order for lack of training documentation.
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