|
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: 1085949-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) took funds from three vulnerable adults (VA1, VA2, and VA3). Date of Incident(s): Prior to March 14, 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 facility staff persons (P1 and P2), VA1’s guardian (G1), VA2’s guardian (G2), and VA3’s guardian (G3). The VAs were unaware of the concerns investigated in this report, had significant developmental disabilities, and were not interviewed. The SP did not complete an interview with this investigator but provided information to officers from a law enforcement agency (LEOs) which was included below. Facility documentation showed that the VAs each had a developmental disability and were vulnerable to financial exploitation. The facility was authorized to manage the VAs’ funds for them. The VAs communicated through gestures and vocalizations. VA1 liked cars and enjoyed turning their knobs and opening their doors, but s/he did not ride safely in cars and might grab the gear shift or steering wheel, hit others, or pull their hair (including the driver’s) or open car doors when the car was moving. VA1 was to sit in the back of the facility van when being transported where s/he could not reach the driver. VA2 might pinch, hit, bite, or choke others or pull their hair or fingers. When VA2 had physically aggressive behaviors, staff persons were to redirect him/her to a preferred activity including listening to music or playing games. VA3 liked to spend time with his/her family members. P1 and P2 provided consistent information that in January of 2023, the facility conducted a routine check of the VAs’ finances and discovered that some of VA1’s and VA2’s funds were unaccounted for and then completed an extensive audit of the finances for each individual who resided at the facility. It was initially thought that VA1 was missing $2,891.12 and VA2 was missing $1,275.63 over the last few months. The SP, who was a supervisory staff person, had “abruptly” taken leave from his/her position at the facility in October of 2022, and was unavailable to P1 and P2 to explain what had happened to the unaccounted-for funds. The SP and possibly other staff persons had access to the VAs’ funds and debit cards which were kept in the facility’s office in a locked box. Report 202302309 was received by DHS, a law enforcement agency was made aware of the missing funds, and the audit into the finances of VA3 continued. The audit showed that VA3 was also missing money and on June 9, 2023, DHS received report 202304960 regarding VA3’s missing funds. There was a fourth individual who resided at the facility and his/her finances were also audited. However, s/he was not missing funds. Records from a law enforcement agency showed that LEOs investigated the allegations in this report regarding funds missing from VA1, VA2, and VA3. The LEOs reviewed the VAs’ banking information and the results of the audits into the VAs’ finances, then interviewed the SP. The SP told the LEOs that the VAs’ money was kept in a locked cabinet at the facility that was opened with a key which was locked in the SP’s desk at the facility. The SP was one of a few staff persons who had access to the cabinet that contained the funds but knew that staff persons had opened the cabinet with a knife when they needed to when the SP was not at the facility. Facility records obtained by the LEOs showed that the SP documented that s/he took the VAs to a casino, but information obtained from the casino by the LEOs showed that the SP did not bring the VAs to the casino and played gaming machines at the casino alone, on some dates that s/he said s/he was with the VAs at the casino. According to the law enforcement records, the SP told LEOs that s/he took money from the VAs but was unsure when s/he began taking it. The SP thought that s/he began taking the VAs’ money at the end of 2021 or the beginning of 2022 and did not recall how much money s/he took but admitted that s/he spent all of it at the casino. The SP fabricated deposits into the VAs’ accounts and reconciled their finances to make it appear that the VAs were not missing funds. The SP told the LEOs that s/he knew what s/he had done and expressed concern that s/he might be “going to jail.” The SP thought that if the money “matched up” everything would be “fine,” but the facility’s audit of the VAs’ funds determined that VA1 was missing $3,352.32, that VA2 was missing $2,815,61, and VA3 was missing $2,200.55, which totaled $8,369.48 according to the records. The LEOs completed their investigation and sent it to the county attorney in August of 2023, for charging of the SP. Personnel files, including training information was reviewed. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VAs’ plans of care prior to March of 2023. Conclusion: A. Maltreatment: Information was consistent that the VAs were vulnerable to financial exploitation and unaware of the allegations in this report. The VAs’ debit cards and funds were locked in a cabinet in the facility office and the key to the cabinet was locked in the SP’s desk at the facility. A routine check of the VA1’s and VA2’s finances in early 2023 showed that some of their funds were unaccounted for and the facility audited the funds of all individuals who resided at the facility. The audit determined that VA1 was missing $3,352.32, that VA2 was missing $2,815.61, and VA3 was missing $2,200.55, which totaled $8,369.48. The SP suddenly took leave from the facility in October of 2022, and was unavailable to explain the missing funds to the facility, but s/he was interviewed by the law enforcement agency. The law enforcement agency investigated the allegations in this report and their records showed that the SP told the LEOs that s/he began taking money from the VAs in late 2021 or early 2022. The SP was unsure how much s/he had taken but stated that s/he spent the money at a casino. The agency submitted its investigation to the county attorney in August of 2023, and asked that the SP be charged for his/her actions. Although the SP was unsure how much money the VAs’ were missing and said that other staff persons might have had access to the VAs’ funds, given that the facility’s audit determined that the VAs were missing $8,369.48, and that the SP said s/he took money from the VAs, there was a preponderance of the evidence that the VAs’ funds were willfully used, withheld, or disposed of, 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. The SP said that s/he took money from VA1, VA2, and VA3, and spent it at a casino. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act. Therefore, the SP was responsible for financial exploitation of VA1, VA2, and VA3. 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 took money from VA1, VA2, and VA3 over a period of time. The substantiated financial exploitation for which the SP was responsible was not serious because it did not meet the definition. Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but were not followed. The facility reimbursed the VAs for the money the SP took. The funds and debit cards for the individuals at the facility were placed in locked boxes in the facility office which were only accessible to facility supervisory staff persons. Staff persons who worked with the VAs were retrained on the facility’s financial policy. The SP took leave from his/her position at the facility in October of 2022 and as of April 12, 2023, the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring 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.
|
