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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: 1070711-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson 651-431-6578 Suspected Maltreatment Reported: It was reported that a staff person (SP) from another licensed facility operated by the same company, entered the facility and took financial pouches belonging to three vulnerable adults (VA1-VA3) that contained cash, debit cards, checks, identification cards and insurance cards. Date of Incident(s): April 20, 2024 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 as well as bank statements and law enforcement records; and through three interviews conducted with a supervisory staff person (P1), a facility staff person (P2), and VA3’s guardian (G) who was also VA3’s family member. Attempts were made via telephone and mail to contact and interview the SP, VA1’s guardian, and VA2 who was not subject to guardianship. Neither the SP, VA1’s guardian, or VA2 responded to the requests. According to VA1’s-VA3’s Individual Abuse Prevention Plans each was susceptible to financial exploitation and did not have the ability to handle financial matters. Finances, including check books, check registers, and cash were reviewed monthly by the program supervisor. According to P1 and P2, the financial pouches containing VA1’s-VA3’s cash and debit cards were stored in an unlocked cabinet above a washer and dryer at the facility. If a staff person needed to access a VA’s funds, they did so and then returned the pouch to the cabinet. (Note: After the incident, the pouches were stored in a locked cabinet.) According to the facility’s Internal Review dated May 1, 2024, On 4/26/24 it was discovered that [the SP] entered [the facility] on 4/20/24. [The SP] stated to [facility] staff that [s/he] was there to pick up some printer paper for the printer at the other [facility]. While at [the facility], [the SP] took three of the residents’ financial pouches. Two of the pouches contained [VA1’s and VA2’s] debit cards and one contained [VA3’s] cash. [The SP] is on the blink doorbell camera leaving with the pouches. There were several transactions out of both residents’ bank accounts that were fraudulent. When [the SP] was questioned about the situation [s/he] admitted to taking the pouches. [The SP] did return the ID cards and debit cards from the pouches. [The SP] stated that [s/he] got rid of the pouches and receipts that were in them. According to law enforcement report dated April 27, 2024, “[VA1’s] accounts was completely emptied by using ATM machines, [VA2’s] account had several fraudulent transactions, and [VA3’s] pouch only contained cash.” The SP was on video footage exiting the home with the VAs’ pouches and a law enforcement officer reviewed the video footage. Law enforcement was still investigating the allegations at the time of this report. According to VA1’s bank account records provided by the facility, the following unauthorized ATM withdrawals were made using VA1’s debit card: · On April 22, 2024, seven withdrawals of $203.50 each, totaling $1,424.50. · On April 25, 2024, two withdrawals of $203 and one withdrawal of $43.00, totaling $449.00. · The total amount withdrawn from VA1’s bank account was $1,873.50. According to VA2’s bank account records provided by the facility, on April 26, 2024, four charges were made using VA2’s debit card: · Three charges at Holiday Stations for $129.90, $125.97, and $60.52. · One charge at BP for $65.03. · The total charges from VA2’s bank account was $381.42. P1 provided the following information: · On April 26, 2024, P2 called P1 and said that the VAs’ financial pouches were not in an unlocked cabinet where they were usually kept. P1 told P2 to check with other staff persons to determine if anyone else had them or knew where they were. That same day, P2 did so and then told P1 that no one reported to have them or know where they were. · P1 asked P2 if anyone other than facility staff persons or the VAs had been to the facility recently. P2 said that on April 20, 2024, the SP came to get computer paper to bring to another facility. P1 then reviewed video footage from the doorbell camera from April 20, 2024. P1 said s/he saw the SP leave the facility with computer paper and the VAs’ financial pouches. · P1 said that VA1’s financial pouch contained his/her identification card, medical card, and debit card which the SP used to “clean out” VA1’s bank account. VA2’s financial pouch contained his/her identification card, medical card, and debit card which the SP used to make purchases. VA3’s financial pouch contained his/her identification card, medical card, receipts and $60 cash. Each financial pouch also contained the receipts and ledgers that were used to track each VAs’ finances. According to written notes provided to this investigator by P1 regarding a meeting with the SP on April 26, 2024, · P1 met with the SP on April 26, 2024, to discuss the concerns. P1 told the SP that s/he had camera footage of the SP leaving the facility with the VAs’ financial pouches and asked the SP to explain. The SP stated that s/he “didn’t know” how to explain. When asked if s/he still had the pouches, the SP stated that s/he “got rid of them.” When asked why s/he took them, the SP “shrugged [his/her] shoulders.” · P1 contacted the SP later the same day and asked if s/he would be able to retrieve and return the pouches and the information that was in them, to which the SP stated that s/he could return the debit cards, identification cards, and insurance cards but had thrown away the pouches and receipts. The SP then returned the various cards belonging to VA1-VA3, but did not return the cash that was in VA3’s pouch. P2 provided the following information in an interview with this investigator: · On a Saturday (April 20, 2024) P2 was looking for the VAs’ financial pouches, but they were not in the unlocked cabinet above the dryer where they were usually kept. P2 also checked around the facility and in the facility van to see if another staff person had forgotten to return them to the cabinet but P2 did not find them. P2 did not tell P1 about the missing pouches until April 26, 2024 (six days later). · The next time P2 worked, (April 26, 2024), when P2 arrived at work, P1 was at the facility, and they discussed the missing pouches. P1 asked P2 asked if anyone “suspicious” came to the facility and P2 told P1 that the SP came to the house the previous Saturday to get printer paper for another facility. P2 stated that s/he told the SP where the copy paper was, then went to use the restroom. When P2 came out of the restroom, the SP had left. · P2 did not see the SP leave the facility with the pouches and stated that it was “weird” to find out that s/he took them. The G was unaware of the allegations and did not have additional information to provide for this investigation. Requests were made for the facility’s video footage from the doorbell camera, but the video was not provided by the completion of this investigation. Facility documentation showed that P1 and the P2 were trained on the VAs’ support plans and P1, P2 and the SP were trained on the Reporting of Maltreatment of Vulnerable Adults Act. Because the SP did not provide direct care and services to VA1-VA3, the SP was not required to be trained on their plans. Conclusion: Information from the law enforcement report and P1 who watched doorbell camera footage from April 20, 2024, was consistent that the SP took VA1’s-VA3’s financial pouches (containing debit cards, ID cards and petty cash). The SP returned VA1’s-VA3’s identification cards but did not return the pouches or any receipts. VA3’s financial pouch also contained $60 in petty cash and the SP did not return the cash. Bank information showed that VA1’s debit card was used to withdraw money ten times from April 22 to 25, 2024, totaling $1,873.50 and that VA2’s debit card was used four times on April 26, 2024, totaling $381.42. Given that the SP took the VA’s financial pouches and subsequent withdraws and purchases were made using VA1’s and VA2’s debit cards and that VA3’s cash was not returned, there was a preponderance of the evidence that in the absence of legal authority, VA1’s-VA3’s funds were used or disposed of. 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 Reporting of Maltreatment of Vulnerable Adults Act, however, because the SP did not provide direct care or services to VA1-VA3 s/he was not required to be trained on the VAs’ plans. Although the SP did not provide care/services to VA1-VA3, the SP was a staff person of the license holder and therefore the SP was responsible for the maltreatment of VA1-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 maltreatment. Although the SP took the pouches at the same time (April 20, 2024), the SP used VA1’s and VA2’s debit cards on more than one occasion and took VA3’s cash. The incident did not meet the definition for serious maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, however there was a need for corrective action. The Internal Review stated, “going forward, staff will not have access to the pin number for [the VAs’] debit cards. All cash/debit cards will be checked out and checked back in and remain in a locked location.” 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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