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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: 803826-SUD (Substance Use Disorder) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) took prescription medications from three vulnerable adults (VA1-VA3). Date of Incident(s): Multiple days in October 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 was obtained during a site visit conducted on November 2, 2023; from documentation at the facility; and through six interviews conducted with two facility supervisors (P1-P2), VA1-VA3, and the SP. The facility had a staff person office where medications were stored, and staff persons would complete medication administration. The facility used a Medication Administration Record (MAR) which tracked VA1-VA3’s prescribed medications. The facility also used a Narcotic Record (NR) to track the number of prescribed narcotics (controlled medication) for VA1-VA3, as well as other persons receiving services at the facility. After completing medication administration, a staff person would initial the MAR, and if that medication was a controlled medication the staff person would complete a count of that medication and document on the NR. There were also times in which persons served at the facility would leave the facility and that person would have medications packed in an envelope/container. In those situations, staff persons would document on the MAR and NR that the person served had medications packed for them to take while not at the facility. Any medication(s) which were discontinued by a doctor had a symbol on the MAR showing it was discontinued. VA1 was diagnosed with opioid dependence, and anxiety. VA1 was prescribed an 8 milligram (mg) tablet of buprenorphine (Subutex) twice daily. VA2 was diagnosed with opioid and stimulant dependence, and attention-deficit hyperactivity disorder. VA2 was prescribed a 4-1 mg film of buprenorphine (Suboxone) twice daily. The medication was noted on the MAR as discontinued on October 6, 2023, due to a medication change. VA3 was diagnosed with opioid dependence, and depression. VA3 was prescribed a 10 mg tablet of dextroamphetamine-amphetamine (Adderall) twice daily. The facility’s Internal Investigation, facility documentation, and interviews with P1 and P2 provided the following information: · On October 17, 2023, P3 was reviewing the NR and MAR and informed P1 and P2 of a discrepancy. · P1 and P2 spoke with the SP regarding the discrepancies and the SP admitted s/he had taken medications from “clients for the last couple weeks.” P1 and P2 said based on the information the SP provided they were able to cross reference the medications the SP admitted to taking and found VA1-VA3 and a client (C) who received outpatient services from the facility had medications that were taken by the SP which totaled 27 pills and an entire card containing roughly a month’s supply of Gabapentin. · The facility contacted a pharmacy and ensured VA1-VA3 did not miss any doses of prescribed medications and introduced a new medication process to reduce the likelihood of any further incidents. · The MAR showed VA1-VA3 received the above prescribed medications as ordered. The count written on the NR continued to correspond with the number of each of the medications remaining. · The NR for VA1 showed that on October 16, 2023, the SP made two separate entries for the VA’s prescription of Subutex “packed for pass,” but the MAR only documented VA1 received one. · The NR for VA2 showed the SP documented that s/he provided VA2 with his/her discontinued Subutex on October 7, 2023. It was noted on VA2’s NR and the MAR the medication was discontinued on October 6, 2023. There was no corresponding documentation on VA2’s MAR showing the SP administered the medication to VA2. · The NR and MAR for VA3 showed the following: § On October 8, 2023, the SP made three separate entries in the NR documenting s/he provided VA3 with Adderall but the MAR shows VA3 received one. § On October 11 and 12, 2023, the SP made thirteen separate entries in the NR documenting VA3 received Adderall 13 times. The MAR showed the SP did not administer Adderall to VA3 those two days and that VA3 received four total doses, as prescribed. § On October 13, 2023, the SP made four separate entries in the NR documenting VA3 received Adderall four times. The MAR showed the SP did not administer Adderall to VA3 that day and VA3 received two total doses, as prescribed.
§ On October 16, 2023, the SP made five separate entries in the NR documenting VA3 received Adderall five times. The MAR showed the SP did not administer Adderall to VA3 that day and VA3 received two total doses, as prescribed. VA1-VA3 said they were made aware of the incident by P1 and P2, but had no direct knowledge that the medications were taken. The SP said s/he took the aforementioned medications which belonged to VA1-VA3. Additionally, the SP said s/he had taken the C’s entire medication card of Gabapentin. The SP said s/he had removed the different medications over the course of a week and ingested the medications while working. The SP said s/he attempted to “fix the books,” and tried to make the medication record “look like nothing happened.” When the SP documented medications being taken on the NR, s/he took the medications making it appear that they were given to VA1-VA3. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act, medication administration, and on VA1-VA3’s programming. Conclusion: A. Maltreatment: On October 17, 2023, it was discovered VA1-V3 had missing medications. The facility informed VA1-VA3 of the concern, however they did not have any direct knowledge of the incident. P1 and P2 spoke with the SP regarding the medications, and the SP admitted to taking Adderall, Suboxone, Subutex, and Gabapentin which were prescribed to VA1-VA3 and the C over the course of a week. P1 and P2 cross referenced the medications the SP admitted to taking. Facility documentation, specifically the NR and MARs for VA1-VA3 showed there were medications discrepancies between how many pills were recorded as administered on the NR and on the MAR. During an interview with this investigator the SP admitted to taking VA1-VA3’s medications, as well as the C’s medications. Although the SP took the C’s Gabapentin, the C was receiving outpatient services at the time so was not determined to be a vulnerable adult. Therefore, the Department of Human Services, Licensing Division did not have jurisdiction regarding the C. Given that the SP admitted taking medications that belonged to VA1, VA2, and VA3, there was a preponderance of the evidence that in the absence of legal authority, the SP willfully used and or disposed of VA1’s, VA2’s, and VA3’s property. 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 on the Reporting of Maltreatment of Vulnerable Adults Act. Therefore the SP was responsible for the maltreatment of the 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 not “serious” maltreatment because it did not meet the definition but was “recurring” maltreatment because the financial exploitation of VA1, VA2, and VA3, that the SP was responsible occurred on more than one occasion. Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were not adequate but were followed. The facility determined the policies and procedures did not account for errors to be immediately found if the medication count was correct. The facility identified a need to implement an additional medication procedure and completed training with all staff persons. The SP was no longer employed at the facility, and the facility did not take any additional corrective action. 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.
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