|
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: 1068663-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 vulnerable adult (VA1) had $2,332.95 that was unaccounted for with receipts for expenditures and that another vulnerable adult (VA2) had $3,183.31 that was unaccounted for with receipts for expenditures. Date of Incident(s): ongoing between April 2022 and March 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 three interviews conducted with VA1’s guardian and facility staff persons. Attempts to reach VA2’s guardian via telephone were unsuccessful. A letter notifying VA2’s guardian of the investigation was mailed to the guardian. VA1’s Emergency Data Form stated that VA1 was diagnosed with autism and mild intellectual disability. VA1’s Coordinated Services and Supports Plan stated that VA1 enjoyed swimming and bowling. VA1’s Individual Abuse Prevention Plan stated that VA1 did not demonstrate an understanding of the value of money and that s/he was unable to manage his/her financial resources or recognize mismanagement of his/her finances. Staff persons were to assist VA1 with guidance on his/her purchases and recording his/her purchases on a petty cash ledger. VA2’s Emergency Data Form stated that VA2 was diagnosed with neurological impairment and moderate intellectual disability. VA2’s Community Support Plan stated that VA2 enjoyed reading and watching television. VA2’s Individual Abuse Prevention Plan stated that VA2 did not demonstrate an understanding of the value of money. VA2 was unable to provide the correct amount of money for purchases or identify the change received back. Staff persons were to assist VA2 with all purchases and ensure the accuracy of the transactions. VA1’s General Event Reports stated that on March 20, 2023, a facility management person (P) reviewed VA1’s bank statements and petty cash ledger and noticed that there were ATM withdrawals that were not documented in VA1’s petty cash ledger. VA2’s General Event Reports stated that on March 20, 2023, the P reviewed VA2’s bank statements and petty cash ledgers and noticed that there were ATM withdrawals that were not documented in VA2’s petty cash ledger. Facility documentation, information from a law enforcement officer (LEO), and interviews with the P and the SP provided the following information: · The P reviewed VA1’s bank statements from July 2022 through March 2023 and noticed that there were ATM withdrawals from VA1’s bank account that were not entered into VA1’s petty cash ledgers. In addition, there were no receipts for expenditures to account for the money withdrawn. The P also reviewed VA2’s bank statements from April 2022 through March 2023 and discovered several ATM withdrawals that were not documented in VA2’s petty cash ledgers and several receipts for expenditures that were not consistent with VA2’s normal purchases. · The P discovered twenty-one transactions totaling $2332.95 withdrawn from VA1’s bank records between July 2022 and March 2023 that were unaccounted for with receipts for expenditures. The P asked VA1 about the money and VA1 did not have any knowledge of the missing money. · The P found thirty-two transactions totaling $3183.31 withdrawn from VA2’s bank records between April 2022 through March 2023 that was unaccounted for with receipts for expenditures. VA2 did not have any knowledge of the missing money. · During the P’s review of VA1’s and VA2’s financial accounts, the P discovered that the transactions that were unaccounted for with receipts for expenditures for VA1 and VA2 occurred on days that the SP was scheduled to work. When the P talked to the SP about the transactions, the SP told the P that s/he did not have any information about VA1’s or VA2’s missing money. · The LEO obtained pictures of the SP withdrawing money from an ATM machine using VA1’s and VA2’s bank cards. · The SP told this investigator that s/he was struggling financially and that s/he used VA1’s and VA2’s bank cards to withdraw money from their accounts on “more than one occasion.” The SP was not able to provide a timeframe as to when s/he took the money. The SP stated that s/he “intended” to pay the money back to VA1 and VA2, but that s/he had not had a chance. The facility’s Management of Individual Funds and Property policy stated that the staff persons were responsible for the handling and supervision of all individual’s funds and property. Staff persons were to document purchases, deposits, and disbursements; document with a receipt for all funds received; and document checking and savings account transactions. Staff persons were prohibited from borrowing money or lending money to an individual. The facility’s personnel files showed that the SP was trained on his/her job description and the facilities Employment Policies and Procedures on October 29, 2019, the Management of Individual Funds and Property on February 1, 2022, August 3, 2022, and February 1, 2023, and the Reporting of Maltreatment of Vulnerable Adults Act on February 1, 2023. The P was trained on Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Information from VA1’s and VA2’s bank statements and facility documentation showed that between July 2022 and March 2023 VA1 had $2332.95 that was unaccounted for with receipts for expenditures and that between April 2022 and March 2023 VA2 had $3183.31 that was unaccounted for with receipts for expenditures. The P spoke to the SP about the missing money because the SP worked on the days that the transactions occurred, but the SP denied knowing anything about the missing money. The LEO obtained pictures of the SP withdrawing money from an ATM using VA1’s and VA2’s bank cards. When this investigator spoke to the SP, the SP stated that s/he took money from VA1 and VA2 because s/he was struggling financially. Given that the LEO had pictures of the SP using VA1’s and VA2’s bank cards and that the SP acknowledged taking VA1’s and VA2’s money for his/her own use, there was a preponderance of the evidence that in the absence of legal authority, the SP willfully used and withheld money from VA1 and VA2. 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 Management of Individual Funds and Property policy and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for maltreatment of VA1 and 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 abuse for which the SP was responsible was “recurring” because there were multiple transactions withdrawn over an extended period of time from VA1’s and VA’2 accounts. Action Taken by Facility: The facility completed an internal review and determined that their policies were not followed at the time of the incidents. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
|
