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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: 1096993-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Kyle Youker/Anna Parkin 651-431-4056 Suspected Maltreatment Reported: It is alleged that a staff person (SP) used a vulnerable adult’s (VA) debit card to make multiple unauthorized cash withdrawals. Date of Incident(s): November 14, 2022 to January 12, 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 through four interviews conducted with the SP, a staff person (P1), and two supervisory staff persons (P2 and P3). Law enforcement was notified but had not yet determined whether they were going to investigate. The VA was diagnosed with Down Syndrome. The VA enjoyed going shopping and bowling on the weekends. Facility documentation provided the following information: · The VA’s Individual Abuse Prevention Plan stated the VA was at-risk of financial exploitation. · The VA had a wallet containing his/her cash and debit card that was kept in the staff office. The cash was counted three times per day and logged on the Cash Count that was kept in pouch in the staff office. All transactions for the VA’s debit card are logged in an Expenditure Log that was kept in the VA’s wallet. P1, P2, and P3 provided the following consistent information: · Staff persons carried the VA’s wallet when on community outings with the VA. The VA’s debit card stayed in his/her wallet and should not be in a pocket or wallet of a staff person. The debit card’s personal identification number (PIN) was written on a piece of paper that was kept in the VA’s wallet. · On January 21, 2023, P1 and the VA went to a bowling alley and when the VA and P1 went to pay, the VA’s debit card was not in his/her wallet. The Expenditure Log showed that the SP was the last staff person to use the debit card with the VA on January 14, 2023. · P1 immediately texted the SP asking him/her if s/he knew where the VA’s debit card was. Initially the SP stated s/he did not know, then a short time later the SP told P1 that s/he had the debit card. Later that day, the SP brought the debit card back to the facility before P1 and the VA returned. · When P1 and the VA returned to the facility, the SP had returned the VA’s debit card and left $20 cash but did not provide any reasons or receipts for the cash. P1 put the VA’s debit card into his/her wallet and put it back into the staff office. P1 then logged the $20 into the VA’s Cash Count. P1 logged the morning and afternoon Cash Count on January 21, 2023, before and after the $20 was brought by the SP. · On January 23, 2023, P1 and the VA went to a store to purchase a soft drink for the VA and attempted to pay with the VA’s debit card, but it was declined. P1 looked at the Expenditure Log and saw that the balance for the VA’s account should have been $81.11. P1 and the VA did not purchase the item and then P1 contacted P2 and told him/her about the situation. · When P1 called P2, s/he told P1 to take the VA to the bank to get a Bank Statement and bring it to P2. P1 said that s/he looked at the bank statement prior to giving it to P2 and noticed that there were multiple $20 automated teller machine (ATM) withdrawals that were not documented on the Expenditure Log. · P2 stated s/he and P3 reviewed the VA’s Bank Statement and Expenditure Log and found seven transactions on the VA’s debit card totaling $134.51 that were not annotated on the Expenditure Log. · P3 immediately called the SP and asked the SP if s/he used the VA’s debit card to withdraw money and make purchases for himself/herself and the SP said, “Yes,” and that s/he planned on paying the money back to the VA. P3 did not ask the SP about the $20 returned and the SP did not repay the VA all the money. According to the Bank Statement the following transactions were made without the permission of the VA for $134.51: · January 9, 2023, an ATM withdrawal at Bremer Bank for $20. · January 10, 2023, an ATM withdrawal at Heritage Bank for $28. · January 11, 2023, an ATM withdrawal at Heritage Bank for $20. · January 11, 2023, an ATM withdrawal at Kwik Trip for $20. · January 11, 2023, a purchase at Kwik Trip for $6.51. · January 11, 2023, an ATM withdrawal at Bremer Bank for $20. · January 12, 2023, an ATM withdrawal at Bremer Bank for $20. · The Bank Statement did not show any fees for the ATM withdrawals by the SP. The SP provided the following information: · The SP stated s/he used the VA’s debit card to withdraw “around $68” and that the total could be higher, but s/he was not certain. The SP stated s/he used the VA’s money for himself/herself. · Sometime in mid-January 2023, the SP worked at the facility and took the VA’s debit card from the VA’s wallet that was in the staff office and did not return it for a “little while.” The SP had the VA’s debit card “over a weekend” and withdrew money multiple times from ATMs. · On an unknown date in January 2023, P1 texted the SP asking about the VA’s debit card, so later that day, the SP returned the card. Prior to going to the facility, the SP withdrew $20 from his/her personal bank account to put into the VA’s cash to repay some of the money s/he had taken from the VA. The SP said s/he did not have permission to withdraw money using the VA’s debit card. P1-P3, and the SP were trained on the Maltreatment of Vulnerable Adults Act and the VA’s plans. Conclusion: A. Maltreatment: Information from all sources was consistent that the SP used the VA’s debit card seven times to withdraw cash and make a purchase totaling $134.51. Given that the VA did not authorize the SP’s used of the debit card, there was a preponderance of evidence that in the absence of legal authority the SP willfully used the VA’s debit card. 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 VA’s plans 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 maltreatment because the SP used the VA’s debit card seven times on four dates. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and found the policies were adequate but not followed by the SP. The VA was reimbursed $167.51 by the facility. 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.
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