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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: 1072891-H_CRS (Home and Community-Based Services-Community Residential Setting) 1072888-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) stole $1000 of a vulnerable adult’s (VA) cash. Date of Incident(s): May 8, 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); and subdivision 17, paragraph (a): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 20, 2024; from documentation at the facility and through five interviews conducted with the VA, a facility staff person (P1), facility supervisors (P2-P3), and the SP. Facility documentation showed the VA was “pleasant” and enjoyed watching movies, hanging out with friends and completing art projects. The VA valued his/her independence and wanted to live independently and have pets. The VA was open to support with his/her mental health and “chemical health issues.” The VA was diagnosed with depression, borderline personality disorder, amphetamine and heroin use disorder, and multiple physical health conditions. The VA was responsible to pay rent to the facility. The facility’s Funds and Property Authorization and Individual Abuse Prevention Plan showed that the VA received financial benefits that posted to a debit card. Staff persons could transport the VA to an automated teller machine (ATM) to withdraw funds when needed (including for his/her rent), and the VA could store cash in the facility safe if s/he chose to. The VA would be provided a receipt if the facility was safekeeping the VA’s funds in the safe. The facility’s Resident House Guidelines stated that if a vulnerable adult entrusted cash resources to the facility the following must be followed: · There was a lock box where money could be stored, and the balance of money in the box should be checked during each staff shift change. · The vulnerable adult must be provided a receipt for money entrusted to the facility. · The facility should not be entrusted with cash resources in excess of $300 for each vulnerable adult. · The vulnerable adult must have access to the written records of the vulnerable adult’s funds. The facility’s staff office had a doorknob with a keyed entry, and a combination lock box hung around the doorknob which contained an extra key for the staff office. The medication cabinet was located inside the staff office, and a keyed padlock was used to lock the cabinet. The staff person who was the medication passer carried the key to the medication cabinet. The facility’s Client Cash Bag Policy and Procedure showed the vulnerable adults “cash bag(s)” were kept in the medication cabinet, and staff persons were to document all cash transactions on a cash log that was in the cash bag. The facility completed an Internal Review (IR) which provided the following information: · On an unspecified date, the VA told P3 that s/he withdrew $1,000 cash and gave it to the SP for his/her rent. P3 asked P2 to confirm this and P2 said the VA showed P2 a $1,000 withdrawal on the VA’s phone, and said the money was in the safe, but that the SP did not give him/her a receipt for the cash s/he gave to the SP. · P2 asked the SP to show him/her where the money was and the SP went to the staff office to show P2, but the SP was not able to locate the money. · P2 said the staff office was unlocked when s/he arrived at the facility, and the medication cabinet was unlocked. · P3 spoke with the SP, who was upset. P3 felt the SP was “trying to deflect blame” regarding the staff office and medication cabinet being unlocked. · P3 noted the office door was “never” to be left unlocked, “especially when the medication cabinet [was] unlocked.” The VA provided the following information: · On May 7, 2024, the VA withdrew money from his/her bank account, and after returning to the facility in the afternoon s/he provided the SP with $1,000 cash for rent. The VA saw the SP go into the office with the money, but did not observe where the SP placed the money, and was not provided a receipt. The VA said s/he went into his/her bedroom after giving the SP the rent money. · The VA said P1 worked the overnight, and P1 gave the VA his/her morning medications. However, the VA did not have any further interaction with P1 as the VA went back to sleep after getting his/her medications. · The VA was notified the money was missing the next day, and thought s/he may get in trouble as that was the first time s/he paid rent at the facility. However, the facility credited the money towards his/her rent. The VA said the SP seemed “nervous” and “scared”, and the SP said s/he was “going to get in trouble for this.” · The VA said the staff office was closed and locked most of the time, but the SP had previously left the door open on a couple occasions. The medication cabinet was always locked. · The VA did not have any previous concerns or “suspicions” with the SP. · The SP did not say anything to the VA about the money, but after speaking with P3 the SP was “pissed off” before leaving the facility. Facility documentation showed that on May 7, 2024, the SP worked from 12 noon to 8 p.m., and was the only staff person scheduled to work at the facility between 2 and 8 p.m. P1 was the only staff person scheduled to work at the facility from 8 p.m. on May 7, to 8 a.m. on May 8, 2024. The SP returned to work at the facility at 8 a.m. on May 8, 2024. Although P2 was also scheduled to begin working at the facility at 8 a.m. on May 8, 2024, other information showed that P2 did not arrive at the facility until approximately 9:15 a.m. P1 provided the following information: · P1 said the SP did not inform him/her of the VA’s rent money that was in the staff office, and therefore P1 was not aware of the money and did not count the money during the overnight shift of May 7-8, 2024. · P1 did not hear any other person enter the facility during his/her shift, and did not believe any other person opened the staff office during his/her shift. On the morning of May 8, 2024, at the end of P1’s shift s/he gave the SP the staff keys, and left the facility. P1 did not observe the SP’s behavior being abnormal during the time they interacted on May 8, 2024. · P1 was not aware of the alleged incident until the SP contacted him/her via phone call asking whether P1 knew where the money was. P2 provided the following information: · P2 arrived at the facility around 9:15 a.m., on May 8, 2024, and both the staff office door and the medication cabinet were unlocked. P3 requested that P2 look for the VA’s rent money, but P2 was not able to locate the money. · P2 had the SP come downstairs and look for the rent money, but the SP was not able to find it. The SP said s/he had never handled rent money before and was not aware a receipt was needed. P2 observed the SP was pacing, called P1 to see if P1 took the money, and seemed nervous, “mad,” and “frantic.” Additionally, the SP started looking for the money immediately and denied doing “anything.” P3 provided the following information: · On May 7, 2024, the SP assisted the VA with taking money out of the VA’s bank for rent. The SP said s/he placed the money in a “pink bag” and put it in the medication cabinet. On May 8, 2024, P2 arrived at the facility and looked for the pink bag with the money, but it was not found. P2 then contacted P3 regarding the missing money. P3 added that P1 was at the facility during the overnight from May 7 to May 8, 2024, however P1 was not aware of the money at the facility during that shift. · The SP denied taking the money, but was acting abnormal while searching for the pink bag, which included “scurrying around, looking here, looking there, looking under the desk, [and] looking in the cabinet several times.” · Approximately a year prior, the facility had a similar issue with money going missing, but they were unable to determine if staff persons were involved in the incident. The SP was present at the facility when the previous incident occurred. · P2 informed P3 the staff office and medication cabinet were unlocked upon his/her arriving to the facility on May 8, 2024, which was abnormal. P3 said the SP did not follow his/her training by not securing the VA’s money, not locking the office and medication cabinet, and not providing the VA with a receipt. The SP provided the following information: · The VA gave the SP $1,000 cash for rent on May 6, 2024, around 2 or 3 p.m. (Note: based on other information, the SP likely misspoke and received the $1,000 from the VA on May 7, 2024.) The VA was present when the SP placed the money into an empty pink zipper bag and then into the medication cabinet. · The SP and P1 did not complete money counts at shift change on May 7, 2024, at 8 p.m., or May 8, 2024, at 8 a.m. The SP said s/he did not know that counts were supposed to be completed at shift change, and s/he did not tell P1 the VA’s $1,000 was in the pink bag. · On the morning of May 8, 2024, the SP had the keys to the staff office and medication cabinet, and believed the door to the office and the medication cabinet were each locked when P2 arrived at the facility on May 8, 2024. · The SP denied taking the VA’s $1,000. Law enforcement was contacted during the investigation. However, a criminal investigation was not completed. P1-P3 and the SP were all trained on Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s client specific programming. The training included the facility’s Resident House Guidelines, the VA’s Individual Resident Placement Agreement, and the facility’s policies on handling of vulnerable adults’ funds, property, and petty cash. Conclusion: It was reported the SP stole the VA’s $1,000 cash. Information was consistent that on May 7, 2024, the VA took $1,000 cash out of his/her bank account to pay his/her rent. Around 2 or 3 p.m., after returning to the facility, the VA gave the cash to the SP. The SP placed the cash into a pink zipper bag, then put the bag into the medication cabinet, which was inside of the staff office. P1 arrived at the facility around 8 p.m., on May 7, 2024, and relieved the SP from his/her shift. However, according to P1 and the SP, the SP did not inform P1 of the rent money, and they did not count the money together, or complete any documentation related to the amount of cash present. The SP returned to the facility on May 8, 2024, at 8 a.m., and P1 and the SP did not count or document the amount of cash present at that time. P1 left the facility around 8 a.m., and P2 arrived at the facility around 9:15 a.m. P2 was unable to locate the VA’s rent money and requested the SP’s assistance. P2 and the SP searched the office for the money, however the money was not found. P2 said when s/he arrived at the facility the staff office door and the medication cabinet were each unlocked. However, the SP said s/he believed the door to the office and medication cabinet were each locked when P2 arrived at the facility, and the SP was upstairs in a common area when P2 arrived. The SP acknowledged that s/he did not complete money counts with P1, but denied stealing the money. Multiple persons (P1, P2, the SP, the VA, and the VA’s housemates) all potentially had unsupervised access to the staff office and unlocked medication cabinet while the VA’s money was inside the staff office. Therefore, there was not a preponderance of the evidence as to whether the VA’s funds were acquired by anyone other than the VA. It was not determined whether financial exploitation occurred (in the absence of legal authority a person acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud). Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but not followed. A similar incident involving a different vulnerable adult occurred 1-2 years prior while the SP was working, however the facility was unable to determine what happened to that money. The facility credited the VA $1,000 toward his/her rent payment and changed their cash policy and process of rent payment. The facility completed staff training and completed corrective action to protect the persons that received services. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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