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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: 1071820-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: It was reported that a staff person (SP) made purchases for him/herself using a vulnerable adult’s (VA’s) credit card. Date of Incident(s): Ongoing, prior to January 5, 2023 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 interviews conducted with a facility staff person and two family members/guardians of the VA. Attempts to contact the SP for an interview were unsuccessful. The VA’s diagnoses included a profound intellectual disability. The VA’s support plans stated that the VA did not comprehend the value or concept of money and staff persons were to manage the VA’s finances (due to VA’s communication skills the VA was not able to provide information pertinent to the investigation). A supervisory staff person (P1) stated that the VA enjoyed quiet time, watching television, going into the community, and watching airplanes at the airport. P1 stated that prior to the first concerns about the VAs finances, the VA kept cash, a checkbook and/or debit card at the facility in a locked box in a locked office. All staff persons had access to the office and the locked box. Staff person took the VA to make purchases and kept receipts of the purchases. A law enforcement report and two facility internal reviews included the following information: · On October 15, 2022, a supervisory staff person (P2) reviewed the VA’s finances and determined that the VA had $322.08 of unaccounted for transactions from his/her checking account as well as $10 in cash missing. The transactions that could not be accounted for the VA were as follows: o September 30, 2022, $67.50 at Amazon o October 12, 2022, $54 at Comcast o October 12, 2022, $25.14 at Domino’s o October 13, 2022, $21.30 at Domino’s o October 15, 2022, $36.58 at Domino’s o October 19, 2022, $24.38 at Domino’s o October 20, 2022, $14.35 at Subway o October 21, 2022, $25.42 at Domino’s o October 22, 2022, $47.62 at Domino’s o October 26, 2022, $5.79 at Door Dash · An administrative staff person (P3) talked with five facility staff persons (P4 - P7, and the SP), who all had access to the VA’s cash and debit card, and they each denied making any of the above transactions. P1, P2, and another administrative staff person (P8), who all had access to the VA’s cash and debit cards, each denied making any of the above transactions. (P1 told this investigator that s/he was not aware of the VA ever ordering pizzas. Staff persons were told that facility funds could be used for ordering pizza, not any consumer funds.) · The VA’s bank account was reimbursed for the missing money. The lock box code was changed so only supervisory staff persons had access to the lock box. · On November 4, 2022, the bank canceled the VA’s debit card and issued new cards and mailed them to the facility. P2 stated that two replacement debit cards were mailed to the facility and while waiting for separate PINs (personal identification number) numbers to be mailed, the cards sat on P2’s desk. One PIN number arrived and one card was then locked up, but the second card sat out for another week and after no PIN arrived, P2 put the debit card in the lock box. P2 did not think a debit card could be used without a PIN number. · On January 4, 2023, P3 discovered several purchases were made with the VA’s new debit card which were not made for the VA. Between December 20, 2022, and January 3, 2023, five purchases were charged to Uber Eats totaling $106.94, and on December 29, 2022, there was a purchase at Walmart for $138.51. The disputed purchases were reimbursed to the VA’s account. · On January 6, 2023, a law enforcement officer (LEO) began an investigation. The LEO contacted a Domino’s Pizza where two delivery orders were made that was located near the facility. Both orders were made by the SP and delivered to the facility. On October 12, 2022, at 10:30 p.m., an order was placed for $25.14 and on October 13, 2022, at 11:30 p.m. an order was placed for $21.30. Time records at the facility showed that the SP was working when the orders were delivered. · The LEO contacted Domino’s Pizza where three delivery orders were placed at a Domino’s pizza located in Minneapolis and delivered to an address in Minneapolis. All three orders were made by the SP. On October 15, 2022, a delivery order was placed for $36.58, on October 19, 2022, a delivery order was placed for $24.38, and on October 12, 2022, a delivery order was placed for $47.62. · On October 12, 2022, there was a $54 charge to Comcast for internet services. The LEO, via a search warrant, was able to obtain information from Comcast. The Comcast service address was the same address in Minneapolis where the Domino’s deliveries were made and the address listed a community person (whom the LEO was able to determine also had an address listed that was the same as the SP’s address). The phone number on the Comcast account was a known phone number for the SP (the facility provided the LEO with three phone numbers for the SP from the SP’s personnel file). The Comcast account also included an email address with the first and last name of the SP. · The LEO contacted Walmart and obtained information about the purchase on December 29, 2022. The $138.51 purchase was for a computer that was shipped to the SP’s address. The information from the order had the SP’s name and address under billing and shipping details. It also included an email with the SP’s first and last name and one of the phone numbers for the SP provided by the facility. · At the time of issuance of the law enforcement reports, Uber Eats had not responded to search warrants served by the LEO. There was no information in the law enforcement report regarding the Amazon, Subway, or Door Dash purchases or the missing $10. (The LEO referred the information to the County Attorney for consideration of felony financial fraud.) The LEO contacted and arranged to interview the SP on January 9, 2023. The SP called the City Hall and spoke with a receptionist and canceled the interview. Further attempts by the LEO to reach the SP via telephone were unsuccessful. On January 11, 2023, P3 contacted the LEO and said the SP was scheduled to work at the facility at 10 p.m. The LEO arrived at 9:30 p.m. and at that time P3 was also at the facility. When the SP arrived, the SP agreed to talk with the LEO. The SP provided the following information: · The SP denied knowledge of any of the transactions on the VA’s debit card. The SP said that the VA’s debit card was kept in a secure area that s/he was not able to access. The SP said that s/he worked overnights and did not take the VA to community places where his/her debit card would be used. · The SP said that staff person ordered Domino’s and s/he had seen Domino’s boxes with the VA’s name on them. The LEO showed the SP the three Domino’s purchases that were made by the SP and delivered to an address in Minneapolis. The SP said that s/he did not live in Minneapolis, and when asked who lived at the address, the SP replied, “Not me.” Later in the interview, the SP said that s/he did not know who lived there, but it was friend’s family who lived there and s/he went over there a few times with his/her friend. The SP denied ordering Domino’s delivered to the Minneapolis address. The SP denied using the VA’s debit card. · The SP denied using the VA’s debit card to pay a Comcast bill. The LEO asked the SP if the Comcast bill was going to be linked to the Minneapolis address where Domino’s was delivered and the SP said, “I don’t know.” · The SP said that s/he did not use Uber Eats, but then said s/he used it in the past but quit using it. · The LEO asked the SP to be honest with him/her about the transactions and the SP responded, “I have nothing else to say.” The SP said that s/he would talk further with the LEO at the police station the following day and would contact the LEO to arrange a time (At that time, P3 removed the SP from the schedule). The SP never contacted the LEO (P3 said that the SP never showed up for an arranged meeting at the facility and had not contacted anyone at the facility). This investigator attempted to reach the SP for an interview via telephone (the SP’s name was on the voicemail), via email, and via written correspondence, including a certified letter (which was signed as delivered but the signature was not clear who signed for it). The SP did not respond to the requests. The LEO determined that the following transactions were made by the SP using the VA’s debit card: Domino's Pizza for $36.58, $24.38, $47.62, $25.14, and $21.30; Wal-Mart for $138.51; and Comcast for $54. The total amount for transactions made by the SP were $347.53. Two family members/guardians of the VA (FM1 and FM2) each did not have concerns about the care provided to the VA prior to this allegation. Facility documentation showed that the SP received training specific to the VA and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: On October 15, 2022, the facility determined that purchases made with the VA’s debit cards were not for the VA ($10 cash was also unaccounted for). At that time all staff persons had access to the VA’s funds and debit cards. All staff person denied using the VA’s funds for the purchases in question. After, the VA’s lock box was only able to be accessed by a supervisory staff person, the VA’s debit cards were canceled, and new debit cards were obtained. While waiting for PIN to be mailed for the two new debits cards, the debit cards for the VA were out on a desk accessible to all staff persons. It was then discovered purchases were made with the VA’s new debit cards. The LEO was able to obtain information from Domino’s, Walmart, and Comcast that showed that the SP made multiple purchases with the VA’s debit card that were not for the VA. The LEO was able to determine that the SP made seven purchases that totaled $347.53. (Several other transactions that were questionable were not able to be verified by law enforcement as being made by the SP.) Given the above, there was a preponderance of the evidence that in the absence of legal authority a staff person willfully used, withheld, or disposed of funds or property of 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. The SP received training specific to the VA and on the Reporting of Maltreatment of Vulnerable Adults Act. 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 was recurring because the SP used funds belonging to the VA on more than one occasion. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate, but not followed. The VA’s debit card and cash were to be kept in a locked box that only three supervisory staff persons had access to. The SP no longer worked at the facility. All of the VA’s missing funds were reimbursed to the VA. 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.
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