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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: 1113952-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adults (VA) debit card for the SP’s personal use. Date of Incident(s): May 26, 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, from the VA’s bank records, and through three interviews conducted with the VA’s guardian (G) and two facility management staff persons (P1 and P2). The VA did not have information regarding the investigation. Although the SP was contacted to request an interview, the SP did not respond to requests. The VA’s support plan showed that the VA enjoyed going on walks, making trips to casinos, and fishing. The VA’s Individual Abuse Prevention Plan showed that the VA had a moderate developmental disability. The plan showed that the VA “does not fully understand the value of money” and that staff persons assisted the VA with making purchases. P1 provided the following information: · In mid May 2023, the VA’s debit card was reported missing and the G was notified at the time that the card was missing. · On May 26, 2023, the G sent an email to P2 because the G noticed a charge at a liquor store that did not appear to be one that the VA made. · When the SP, who was working on May 26, 2023, was asked about the charge, the SP denied using the VA’s card, but later, the SP send a text message to P2 “admitting” that the SP used the VA’s debit card for the SP’s personal use. P2 said that the VA’s debit card went missing in early May, 2023 and that when s/he asked various people about it, no one knew where it was. P2 also stated that when the G notified P2 that a new charge was on the VA’s bank statement to a liquor store, s/he asked the SP because the charge was the same day when the SP worked, but the SP denied using the card. About ten minutes later, the SP sent the text message to P2 and admitted to using the VA’s card. When the SP sent the text message to P2, the SP indicated that s/he placed the card in a cushion of the VA’s chair after the transaction. P2 looked in the cushion in the VA’s chair and found the card. P2 also stated that the VA’s debit card was typically stored in a locked office, but that it was not unusual for the VA to hold onto the card and have it in his/her bedroom. The G stated that s/he did not remember dates, but when s/he reviewed the VA’s bank statement, s/he noticed a charge that likely did not belong to the VA. As a result, the G notified P2. The VA’s bank statement showed that a charge of $7.73 was made to “Andy’s Express Liquors,” on May 26, 2023. Payroll records for the SP showed that the SP worked from 4:04 p.m. on May 25, 2023, until 7:17 a.m. the following day.
The text message, from the SP to P2, did not identify the date, but stated, “Ok, here goes nothing,” and “I got the bottle with the card…found it in [the VA’s] chair in [his/her] room and put it back. Should still be there…took me a minute to let this truth out, I’m ashamed for sure…I don’t expect you to save me, it is what it is and if it comes down to it, I’ll deal with the consequences…I don’t wanna talk about it anymore, but that’s the truth.” The facility’s training records showed that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act on March 23, 2023, and the VA’s care plans on August 31, 2022. The facility’s Internal Review of an Alleged Maltreatment Report provided information that was consistent with the information provided in this report, but when the SP was interviewed as part of the facility’s review, the SP stated that s/he did not drink the alcohol s/he purchased with the VA’s card while the SP worked. Conclusion: A. Maltreatment: In mid-May 2023, the VA’s debit card went missing. On May 26, 2023, the G noticed a charge on the VA’s bank statement that did not appear to be from the VA. The G notified P2 of the $7.73 charge to a liquor store and when P2 initially asked the SP, the SP denied using it, but the SP later admitted to using the VA’s card. Given that the SP used the VA’s funds to purchase a bottle of alcohol for the SP, there was a preponderance of the evidence that the SP willfully used the VA’s funds in the absence of 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. Given that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act on March 23, 2023, and used the VA’s debit card for the SP’s personal use, 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 in this report did not meet statutory criteria to be determined as recurring maltreatment because it was a single incident or serious maltreatment because it did not meet the definition. However, information obtained by the Department of Human Services, in combination with this report, resulted in the SP being disqualified for serious and recurring maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility’s Internal Review of an Alleged Maltreatment Report showed that policies and procedures were adequate, but not followed by the SP (VA policy and employee conduct policy). The facility provided additional training to all staff persons, reimbursed the VA, and the SP was no longer employed by 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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