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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: 1070927-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA) money to make purchases for him/herself. Date of Incident(s): Multiple dates from December 5, 2023, through January 31, 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; and through four interviews conducted with two supervisory staff persons (P1 and P2), a facility staff person (SP), and the VA’s legal guardian (G). The VA was diagnosed with autism. According to the VA’s Financial Authorization, the VA had a checking account with a check card. The facility assisted the VA with bank transactions. According to the facility’s Individual Abuse Prevention Plan (IAPP), the VA was unable to handle financial matters because s/he had “minimal understanding” of his/her finances. The VA did not understand the value of money and would not recognize mismanagement of his/her funds. The VA’s finances were audited monthly by the facility and staff persons reported any suspected exploitation per facility policies. P2 provided the following information: · On February 20, 2024, P2 reviewed the VA’s finances and balanced the VA’s checkbook with receipts that were provided by staff persons. P2 saw food items on some of the receipts that the facility purchased for clients, including multiple pints of blueberries; multiple bags of cheesy puff corn; and items that the VA did not eat because s/he wore dentures, including peanuts. P2 had not seen the items at the facility but previously saw the SP eating multiple pints of blueberries and multiple bags of cheesy puff corn while s/he worked. The SP’s initials were on the receipts submitted for the purchases. · P2 texted the SP about the items and the SP said that s/he “accidently” took some of the items to the SP’s house, including protein bites. The SP said s/he would bring the protein bites back the next time s/he worked. Later that day, the SP was admitted to a hospital so was not able to return the protein bites. P2 then notified a supervisory staff person (P3) about the purchases. · On February 26, 2024, P2 texted the SP to meet him/her at the main office the following day. Later that day, the SP went to the main office and dropped off his/her resignation letter at the front desk. P2 had not spoken to the SP since. P1 stated on February 22, 2024, P3 contacted P1 and said that while P2 was doing the VA’s finances, s/he noticed some questionable purchases. Some of the items included blueberries, popcorn, and peanuts. The VA would not have purchased with his/her own money because the facility purchased the VA’s groceries and the VA did not enjoy eating popcorn or peanuts. Receipts from December 5, 2023, to January 31, 2024, showed multiple purchases with the VA’s bank card of items such as puffcorn, blueberries, and other grocery items that totaled $144.12. Each receipt included the SP’s initials as the staff person who assisted with the purchases. The SP stated that P2 made a list of items and the SP took the VA to stores and purchased items from the list. The SP then said that s/he “rarely” brought the VA shopping and that P2 generally did. The SP got receipts for purchases and then documented them in the VA’s ledger. The SP stated on one occasion, the VA asked the SP if s/he could buy blueberries with the VA’s money and the SP told the VA blueberries were purchased with the facility money but the SP went ahead and purchased the blueberries with the VA because possibly another staff person (P4) said it was allowed. The SP was not able to provide additional information about the conversation with P4. The SP denied that P2 asked the SP about buying blueberries and other food items purchased. The SP denied using the VA’s money to purchase items for him/herself. The G was made aware of the purchases by P2 and said they were not typical items that the VA purchased. The G did not have concerns with the facility. Facility documentation showed that staff persons, including the SP, were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Information showed that there were multiple purchases made with the VA’s bank card of grocery items that the VA did not enjoy eating, and that the facility was responsible to purchase for the VA, totaling $144.12. During his/her interview the SP denied using the VA’s money to purchase the items for him/herself. However, P2 said s/he saw the SP eating some of the items at the facility, the receipts for the purchases were initialed by the SP, and the SP acknowledged to P2 that s/he “accidentally” took some of the items home with him/her. Therefore, there was a preponderance of the evidence that in the absence of legal authority the SP willfully used the VA’s funds. 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 626.556, subdivision 10e, paragraph (i): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the VA’s plans and The Reporting of Maltreatment of Vulnerable Adults Act. 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 s/he used the VA’s funds on multiple dates. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at the facility. 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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