|
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: 1109282-H_CRS (Home and Community-Based Services-Community Residential Setting) 1079030-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon/Danielle Morrison 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was unable to locate his/her debit card after being helped by a staff person (P3) with an ATM transaction. Four days later, unauthorized withdrawal of money was made. Date of Incident(s): Between November 12, 2022, and November 16, 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 December 9, 2022, from documentation at the facility; and through seven interviews conducted with the vulnerable adult (VA), the VA’s family member (FM), the VA’s case manager (CM), supervisory staff persons (P1-P2), and staff persons (P3-P4). The VA was diagnosed with adjustment disorder with mixed anxiety and depressed mood, mild intellectual disabilities, and paraplegia. The VA enjoyed working, traveling, going to festivals, playing Candy Crush and Pokémon, and spending time with his/her family. The VA was not subject to guardianship. The VA lived at the facility for many years. Recently the VA started managing his/her own finances and was responsible to track his/her own bank cards and cash. The VA and the FM provided the following information: · On November 12, 2022, during the afternoon, the VA and P3 went to McDonald’s and then to the VA’s bank to withdraw cash. At the drive-up ATM the VA told P3 the personal identification number (PIN, handed P3 the debit card, and asked for $40 to be withdrawn. The VA who was in a wheelchair, in the middle row of the van, saw P3 insert the debit card, enter the PIN, and withdraw the money. P3 then gave the VA the cash and receipt by P3. The VA returned the receipt to P3 so it could be put on P1’s desk. The VA did not recall if his/her debit card was included when P3 gave him/her the cash and receipt. · “A couple days later” the VA looked through his/her belongings but could not find the debit card. The VA told the FM, P1, and staff persons the debit card was missing. P1 told the VA that because s/he managed his/her own finances they could not help the VA find it. P1offered to help the VA contact his/her bank about the debit card, but the VA declined the help. · On November 21, 2022, the VA and the FM called the VA’s bank and closed the debit card and had it replaced. On November 25, 2022, the VA and the FM reviewed the VA’s bank statement and saw a transaction on November 16, 2022, for a $400 ATM withdrawal at a bank the VA did not use. They notified the bank and filed a police report. (Note: Per the bank statement, on November 16, 2022, at 5:16 a.m. $440 plus processing fees was taken from the VA’s account.) · The VA said that in addition to him/herself, P1 and P3 knew the VA’s PIN and the PIN was not written on the debit card itself. P1 provided the following information: · Prior to October 27, 2022, staff persons were more involved in the VA’s financial management, including holding the VA’s debit card and tracking purchases and receipts. P1 took the VA to withdraw funds from the ATM and P4 helped the VA with banking. On October 28, 2022, the VA’s team including the VA, P1, the CM and the FM, decided the VA would have increased independence with his/her banking and finances and staff were no longer responsible for holding the VA’s debit card or tracking purchases and receipts. The VA was solely responsible for his/her finances and money management. · P1 said that s/he, the VA, and P3 knew the VA’s PIN. P1 thought P4 “might” also know the PIN since helped the VA in the past with banking. · On November 18, 2022, the VA told P1 that his/her debit card had been missing since the transaction with P3 (November 12, 2022). P1 offered to help the VA call the bank and cancel the debit card but the VA declined and wanted to continue to look for it. On November 25, 2022, P1 and the VA looked at the VA’s online bank statement and saw that on November 16, 2022, $440 was withdrawn at a different bank. The VA told P1 that s/he did not make the withdrawal. P1 printed out the summary and gave it to the VA. · P1 then called the bank and explained his/her role with the VA. P1 was told that withdrawal occurred on November 14, 2023, but posted November 16, 2023. The bank did not have an outside ATM and P1 was told that a police report needed to be filed to view the ATM camera footage. P1 then called the FM and asked that a police report be filed. · The VA told P1 that s/he did not remember if P3 gave the debit card back to him/her after their transaction. P1 denied taking and/or using the debit card. P2 said that P1 told him/her about the VA’s missing money. P2 told P1 to inform the corporate office and to follow up regarding the police report. P3 provided the following information: · On November 12, 2022, around 11:30 a.m., P3 took the VA to McDonald’s to eat. Around 12:45 p.m. after eating, they drove to the VA’s bank to withdraw $40. The VA sat behind P3, handed P3 his/her debit card, and told P3 the PIN. After the transaction, P3 handed the debit card and cash to the VA. The VA typically put the debit card back into his/her phone case, but P3 did not recall whether the VA did so. After returning to the facility, P3 put the bank receipt on P1’s desk. P3 denied having the VA’s debit card. · On November 19, 2022, the VA told P3 the debit card was missing and P3 told P1. P3 also checked in the VA’s phone case and looked inside the van, but s/he did not find the debit card. P3 denied taking and/or using the debit card. P4 provided the following information: · On November 15, 2022, P4 worked the overnight shift starting at 10 p.m. and did not see the VA throughout the night. On November 16, 2022, in the morning, P4 assisted the VA with his/her usual supports. During this time, the VA did not say anything about the missing debit card. P4’s shift ended about 8:30 a.m. · P4 denied helping the VA with banking in the past, being aware of the PIN, and taking and/or using the VA’s debit card. Law Enforcement obtained the ATM footage from bank where the VA’s debit card was used. The identity of a person shown making the withdrawal was unknown because the person was wearing a full head covering and mask. Facility documentation showed that the P1 and P3-P4 were trained on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. Conclusion: A. Maltreatment: Information obtained showed that on November 16, 2022, an unauthorized ATM withdrawal of $440 plus fees was made using the VA’s debit card. The VA last used the card on November 12, 2022, when P3 assisted the VA withdraw $40 using the VA’s PIN. The VA did not remember whether P3 gave him/her back the debit card, but P3 stated that s/he handed the VA the debit card with the cash. Information was consistent that P1, P3, and the VA were likely the only persons who knew the PIN to the VA’s debit card. While it was possible that the VA lost the debit card, given that the PIN was used to access the funds and that the VA said the PIN was not written on the card, it was determined that only a person with knowledge of the PIN could have used the card and accessed the funds. Given that the VA did not withdraw the money, there was a preponderance of the evidence that a staff person had access to the card to make the unauthorized withdrawal. 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. P1 and P3 were the only other persons aside from the VA who knew the VA’s PIN number to withdraw money. P3 was the last one the VA remembered having the card, but P3 stated s/he gave the card back to the VA. P1 and P3 each denied taking the money and ATM footage from bank where the VA’s debit card was used showed that the identity of a person shown making the withdrawal was unknown because the person was wearing a full head covering and mask. Therefore, it was not determined who took the money and the responsibility for the maltreatment was inconclusive. Action Taken by Facility: Facility Internal Review showed that company policies and procedures were adequate, but not followed by P1 not submitting a report to the Minnesota Adult Abuse Reporting Center (MAARC). The VA’s bank reimbursed the VA. Action Taken by Department of Human Services, Office of Inspector General: On March 8, 2023, the facility was issued a Correction Order for failing to report maltreatment as required.
|
