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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: 1069241-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kimberly Huettl Anderson 651-431-6553 Suspected Maltreatment Reported: It was reported that a staff person (SP) took $89 from a vulnerable adult (VA). Date of Incident(s): April 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 for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through two interviews conducted with the VA’s guardian and a facility staff person. Attempts were made to contact and interview the SP, but the SP did not respond. The SP was interviewed by law enforcement and the facility and that information is included below. The facility’s Assessment of a Person’s Preferences, Talents, Dreams, and Goals for the VA stated that the VA enjoyed biking, swimming, sewing, reading, writing, and crafting. The VA’s Admission Information Sheet stated that the VA was diagnosed with post-traumatic stress disorder, reactive attachment disorder, borderline traits, autism spectrum disorder, and major depressive disorder. The facility was authorized to assist with the safekeeping of the VA’s funds and property. The VA’s Individual Abuse Prevention Plan stated that the VA exhibited a limited ability to maintain adequate accountability with oversight of his/her personal finances. Staff persons were to assist the VA with budgeting his/her money and record financial transactions on a financial ledger. The facility’s Incident/Emergency Report stated that on April 12, 2022, the VA’s petty cash financial book and money pouch showed that the VA was missing $89. The VA did not have the money in his/her possession and a search of the immediate area was unsuccessful. The VA’s guardian (G) stated that s/he was notified that a staff person took the VA’s money, the incident was reported to the local law enforcement, and the facility reimbursed the VA’s money. The VA was aware that his/her money was missing, but was not told that a staff person took the money because that knowledge would upset the VA. The facility staff persons were responsible for the safekeeping of the VA’s personal needs spending money. Facility documentation, the local law enforcement’s Incident Report, and interviews with facility management persons provided the following information: · The VA’s Petty Cash Resource Record for April 2022, stated that the VA’s beginning balance was $21.70. On April 5, 2022, there was a withdrawal of $19. On April 7, 2022, there was a deposit for $100 and a withdrawal for $10.93, leaving a balance of $91.86. · On April 12, 2022, a facility management person (P1) received a message from a staff person at the home stating that the VA only had $2.86 in coins in his/her petty cash. · P1 stated that all staff persons had access to the VA’s petty cash. P1 spoke to several staff persons who had worked during the time the money went missing and all of those staff persons denied taking the VA’s money until P1 spoke to the SP. On April 15, 2022, the SP told P1 that there was a “75% to 80% chance” that s/he took the VA’s money but his/her memory was “foggy” because of some medications that s/he was taking. Later that day a second facility management person (P2) spoke to the SP. At that time, the SP told P2 that s/he already “admitted” to taking the money and that s/he took the VA’s money off of the property and was not returning it. · P1 stated that at the time of the incident, the SP had reached out to P1 and asked for an advance on his/her pay as a loan. The SP told P1 that s/he needed the money to pay an overdue bill. · When the law enforcement officer (LEO) spoke to the SP, the SP “admitted” that s/he took the VA’s money without the VA’s knowledge and did not return the money. The facility’s Funds and Property Procedures of the Individual’s We Serve policy stated that the facility must ensure that persons served by the program retain use and availability of personal funds or property; immediately document receipt and disbursement of the persons funds and property at the time of receipt or disbursement; and assist persons with safekeeping of funds to ensure that overdrafts do not occur. A summary of the individual’s funds was completed at the end of each month. The summary included beginning and ending balances of checking, savings, and petty cash. Employees must not borrow money from an individual served, sell merchandise or personal services to an individuals served, or purchase personal items from an individual served. The facility’s personnel files showed that P1, P2, and the SP were trained on Reporting of Maltreatment of Vulnerable Adults prior to the incident. In addition, the SP was trained on the facility’s Funds and Property Procedures of Individual’s We Serve prior to the incident. Conclusion: A. Maltreatment: On April 12, 2022, the VA’s financial records showed that the VA was missing $89. The SP told P1 that there was a “75 to 80% chance” that the SP took the VA’s money but s/he could not remember. Later that day, the SP told P2 that s/he “admitted” to taking the VA’s money, that s/he took the VA’s money off property, and did not return it. The SP acknowledged taking the VA’s money when s/he spoke to the LEO. Given that the VA’s money was taken without his/her knowledge and that the SP told P2 and the LEO that s/he took the VA’s money and did not return it, there was a preponderance of the evidence that the SP willfully used the VA’s money without legal authority. 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 on the facility’s policies and procedures and Reporting of Maltreatment of Vulnerable Adults prior to the incident. 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 because this was a single incident of maltreatment and did not meet the definition of serious.
Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures are adequate but were not followed at the time of the incident. The SP no longer worked at 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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