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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: 1105716-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA’s) electronic benefit transfer (EBT) card to make purchases totaling approximately $3,000 for his/her own use on multiple occasions. During the course of the investigation, it was reported that the SP also took three of the VA’s prescription narcotic pain medications. Date of Incident(s): Ongoing, between August and December, 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 January 25, 2024; from documentation at the facility and law enforcement records; and through four interviews conducted with two facility administrative staff persons (P1 and P2), the VA, and the VA’s case manager (CM). Attempts were made by telephone, text, email, and letter to contact and interview the SP, but the SP did not respond to the requests. The VA enjoyed playing bingo, playing computer games, working on puzzles, going on “adventures,” and spending time with his/her friends and family members. The VA’s diagnoses included epilepsy and a seizure disorder due to brain lesions. The VA used a walker or can when ambulating. The VA was not subject to guardianship. According to the VA’s Coordinated Services and Supports Plan (CSSP), the VA was to receive homemaking supports for eight hours each week for cleaning, assistance with laundry and shopping, and assistance with meal preparation. The VA was also to receive fifteen hours each week of home management assistance, to assist with community access, budgeting, paying bills, going through his/her mail, socialization, and assisting with medical appointments. P1, P2, and the facility’s documentation provided the following information: · P1 stated that the VA and the SP each told P1 that they had a “great relationship.” The SP was “struggling financially” during the time s/he worked with the VA and was the VA’s primary caretaker. The VA and the SP frequently texted each other even when the SP was not working. P1 did not believe the VA had any difficulties with money management. The VA ordered most of his/her groceries online and often had the groceries delivered to his/her home. P1 and P2 each stated that the VA “was pretty good” at using a computer. · On January 1, 2024, the SP told P1 and P2 that s/he had “accidentally” used the VA’s EBT card to make purchases for him/herself on approximately 16 occasions between August and December 2023. The SP was initially unaware that s/he was using the VA’s EBT card instead of his/her card when s/he made the purchases, because s/he saved the VA’s EBT card information on his/her cell phone and sometimes used the VA’s EBT card info to make the purchases. As P1 and P2 talked to the SP, it “seemed” like the SP knew that s/he was using the VA’s EBT card when s/he made purchases. The SP “tried to figure out” how much money s/he took from the VA’s EBT card and believed it was approximately $3,200. The SP told P1 and P2 that s/he would repay the VA and that s/he had “tried” to repay the VA, but the VA told the SP that s/he did not want the SP’s money and that s/he wanted to help the SP. · As P1 and P2 questioned the SP about using the VA’s EBT card, the SP told P1 and P2 that the VA told the SP that s/he “wanted to help [the SP] out” and let the SP use his/her EBT card to make purchases for him/herself. P1 stated that the SP told him/her that the VA was aware that the SP was using his/her EBT card. When P1 asked the VA if s/he ever gave money to the SP, the VA first told P1 that s/he gave $50 to the SP and later told P1 that s/he gave $250 to the SP. · On January 3, 2024, the VA told P1 that the SP took an unknown number of the VA’s prescription narcotic pain medications from the VA. The staff persons were not trained on medication administration and were told to not touch the clients’ medications at any time. · P1 stated that the staff persons were trained to not take anything from the clients, even if they were offered food or something to drink. The staff persons were not to have access to the clients’ financial codes or their debit or EBT cards. If a staff person made a purchase for a client, they were to provide a receipt for the purchase to the client. The staff persons were not to see or contact the clients when “off the clock,” including sending text messages or contacting on Facebook, but they could contact each other for “work related” reasons. The staff persons were never to bring their family members to a client’s home. · After P1 and P2 learned that the SP stored the VA’s EBT card information on his/her cell phone, they changed the facility’s policies so that the staff persons were not allowed to store any of the clients’ information on their cell phones. P1 believed that the VA was an accurate reporter of events. The VA wanted to “protect” others, so might “downplay situations.” The VA provided the following information: · The VA stated that the SP worked with the VA for approximately two years. The SP helped the VA work on his/her anxiety and “brought [the VA] back down to earth.” The SP accompanied the VA to his/her medical appointments, purchased groceries for the VA, and “kept stuff organized.” The VA ordered his/her groceries online from Walmart and either had them delivered or had the SP pick the VA’s order up at the store. On multiple occasions, after the SP picked up the VA’s groceries, the VA asked the SP for the receipts, but the SP did not give the receipts to the VA and told him/her that s/he “didn’t think [the VA] would want that.” The VA did not know if the SP added items to the VA’s grocery order for his/her personal use. The VA used his/her computer to place orders for groceries, but believed that the SP added items to the VA’s order using the SP’s cell phone. The SP had the VA’s password for the VA’s EBT card account. The VA was not aware that the SP used the VA’s EBT card until the SP told P1 and P2. The SP never told the VA that s/he used the VA’s EBT card to make purchases for the SP’s own use and never offered to repay the VA for the amount of money the SP took from the VA’s EBT card. · On one occasion, the VA left his/her EBT card on the counter and the SP could have written down the EBT card number to keep. On occasions, the SP took the VA’s EBT card with him/her because s/he planned on stopping to pick up the VA’s groceries the following day. The VA “questioned that” and told the SP that s/he had to leave the VA’s EBT card with the VA. The VA began to get a “gut feeling” that the SP was using the VA’s EBT card to make purchases for him/herself. The SP told the VA that s/he could use his/her EBT card at a local pizza restaurant and to make purchases at a gas station. The VA did not know how the SP learned where an EBT card could be used because the SP had told the VA that s/he was denied when s/he applied for an EBT card for him/herself. · The SP had a breathalyzer in his/her car and on one occasion in the fall of 2023, the SP told the VA that s/he needed money to keep the machine so that s/he could continue to drive the VA to his/her appointments and community outings. The VA gave $250 to the SP so that s/he could keep the breathalyzer in his/her car, but told the SP that s/he had to repay the money. The SP repaid the $250 to the VA approximately one month later. · In March or April 2023, the SP saw a container of prescription narcotic pain medications in the VA’s desk drawer and asked the VA if s/he could take one for his/her headache. The VA told the SP that s/he did not think the SP should take them, but the SP opened the medication container and took one. Approximately a month later, the VA noticed that there were three pills missing from the bottle. The VA began counting the medications because s/he was “curious” about where they went. The SP was the only visitor to the VA’s home that would have access to the pain medication. · The VA gave a bracelet to the SP after the SP saw it and “seemed to like it.” The VA believed s/he gave the zirconia bracelet to the SP in December 2023. The VA did not recall how much the bracelet cost. The VA gave three or four brass commemorative “coins” that the VA won at a casino to the SP. The VA also gave an unknown number of Beanie Baby toys to the SP so that s/he could sell them for the VA but the VA did not get the toys back from the SP or get money for them. · On approximately 14 occasions, the SP brought two of his/her young family members to the VA’s home during the SP’s work shift. The family members remained at the VA’s home while the SP cleaned, talked to the VA, or did other tasks. At times, the SP would be doing something on his/her cell phone during his/her work shift. The CM stated that the VA was an accurate reporter of events. The VA received services from the facility in his/her home that included homemaking, assistance with purchases groceries, and assistance with making and going to appointments. The VA seemed to understand managing his/her finances and had talked to the CM about ordering his/her groceries online with his/her EBT card. The VA was aware that the SP had used the VA’s EBT card to purchase items for him/herself. The VA also told the CM that s/he loaned $250 to the SP. The VA also believed that the SP took some of the VA’s prescription narcotic pain medications from the VA’s bathroom. The VA had a computer and a cell phone. The VA told the CM that s/he typically shopped for groceries at the Monticello Walmart, but not the Bentonville or Buffalo Walmart. The VA did not order from Papa Murphy. A law enforcement officer (LEO) reviewed the VA’s EBT card purchases and estimated that between September and December 2023, the total amount taken by the SP from the VA’s EBT card was $4,737.21. The LEO submitted the information to the county attorney for charges of felony theft and felony theft of a vulnerable adult. According to the VA’s medication bottle, the VA was prescribed hydrocodone/acetaminophen for pain relief. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: A. Maltreatment: Although the VA stated that the SP took three of his/her pain medications, given that the VA did not see the SP take the medications and was uncertain when the SP might have taken them, it was unclear if the SP took the pain medication. In addition, the VA lent the SP $250 and was repaid approximately one month later. The VA was not subject to guardianship and managed his/her own money. Although the SP did not provide information for this report, information from all sources was consistent that the SP used the VA’s EBT card multiple times between September and December 2023 to make purchases for his/her own use. The LEO estimated that the total amount taken from the VA’s EBT card was $4,737.21. Given that the VA stated s/he did not authorize the SP’s use of the VA’s EBT card, there was a preponderance of the 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. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. 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 EBT card multiple times between September and December 2023. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. 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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