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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: 1072188-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) opened capsules of a vulnerable adult’s (VA’s) medication, removed the contents of the capsules, and replaced the contents with an unknown substance. Date of Incident(s): Prior to May 28, 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 June 25, 2024; from documentation at the facility and law enforcement records; and through interviews conducted with facility staff persons (P1, P2, and the SP), and the VA. Facility documentation showed that the VA was diagnosed with attention deficit hyperactivity disorder (ADHD), high blood pressure, post-traumatic stress disorder, mood disorder, reactive attachment disorder, and borderline personality disorder. The VA took methylphenidate, a medication which was a central nervous system stimulant that came in several forms including capsules, often used to treat ADHD. The VA wanted to be more independent and live in his/her own apartment someday, but s/he might decline to regularly clean his/her bedroom. Staff persons assisted the VA with medications and were responsible for managing his/her medications, but the VA could self-administer his/her medications when s/he was away from the facility and s/he had eight hours of unsupervised time in the community. The VA enjoyed using electronic devices and liked listening to music. Facility documentation, the facility’s Internal Review, records from the law enforcement agency, and interviews with this investigator provided the following: · P1, a supervisory staff person, said that the VA’s prescribed methylphenidate was stored in a locked safe in a locked closet and staff persons had the keys for both the safe and the closet with them when they worked shifts. The last week of April 2024, P1 noticed that several bubble packages of medications for the VA and other residents that came from a pharmacy to the facility were not sealed as well as they had been previously. P1 contacted the pharmacy and learned that the pharmacy obtained medications from a different company and the way they sealed the packages was different. Staff persons taped the packages together to prevent medications from falling out of the packages. A day or two later, P1 noticed that there was more tape than there had been on the bubble pack that contained the VA’s methylphenidate, but no capsules were missing so P1 did not “think anything of it.” · However, on May 10, 2024, when P1 pushed a capsule through the bubble pack of methylphenidate to give to the VA, s/he noticed that there were “cuts” on the side of the blister that contained the capsule. P1 was alarmed and contacted P2, an administrative staff person, and a facility health care professional (HCP) for guidance. The VA’s bubble pack of methylphenidate was replaced and when the HCP came to the facility on May 12, 2024, and examined the bubble pack of methylphenidate, s/he agreed that the pack had been altered. P1 contacted a law enforcement agency, and a law enforcement officer (LEO) came to the facility, then began an investigation. P1 planned to check the VA’s medications before and after each shift when possible, to “narrow down” the time frame in which someone might be altering the medication packaging. On May 12, 2024, there were 17 capsules that appeared altered from the methylphenidate package that was taped together, and 4 that appeared altered from the bubble pack that P1 closely monitored by examining or photographing the pack between staff person shifts, which replaced the taped together pack. · Records from the law enforcement agency showed that the agency had contact with the facility on May 13, 2024, when an LEO met with P1 and the HCP. The LEO saw the VA’s methylphenidate bubble pack, which was filled on April 22, 2024, with 30 doses of the medication. The pack was taped together, and when the tape was removed from the package, the blisters for 17 capsules were “punctured” or “damaged.” The LEO removed 5 unaltered capsules of medication and left those at the facility to be administered to the VA but took the bubble pack with the remaining capsules in blisters that were punctured/damaged with him/her to the police department. At the police department, the LEO removed two capsules (one from an unaltered blister in the bubble pack and one from a blister that appeared to be altered) then opened the capsules and compared the contents of the capsules. The LEO noted that the contents of the two capsules were “drastically different,” and s/he thought that someone had removed the contents of the capsules then replaced the contents with an unknown substance. The substance in the capsule from the unaltered blister was powdery, but the substance from the capsule in the blister that appeared altered was granulated. · On May 24, 2024, the LEO talked with P1 at the facility and learned that additional blisters/capsules of the VA’s methylphenidate had been cut or punctured, and it was thought that the capsules were tampered with. The LEO returned to the facility and interviewed P1, and a staff person (P3) who had worked the previous overnight shift. When P1 left the facility on the morning of May 22, 2024, the methylphenidate packaging was intact, but when P1 returned to the facility later that day, some of the plastic blisters holding the capsules had been cut and the capsules looked “manipulated” according to the records. · At 3 p.m., on May 24, 2024, P1 saw the VA’s methylphenidate and it was “not manipulated” in its package, but when P1 saw the methylphenidate later that day at 11 p.m. when s/he returned to the facility, the medication looked manipulated. The SP had the keys to the safe and the closet between 3 p.m. and 11 p.m., and according to P1, the SP was the only staff person who worked each shift after which the methylphenidate capsules and their packaging looked manipulated. The LEO observed multiple capsules of methylphenidate and noted that they were filled with a “clear crystal substance, similar to that of granulated sugar.” The amounts of the granulated substance varied between each capsule, but the manipulations of the methylphenidate packaging were similar and there were small slits in the plastic backing of several capsule blisters, which were large enough for a capsule to pass through. Photos were taken of the packages and the facility discussed installing cameras at the facility to monitor medications. · The next day, the LEO returned to the facility shortly after 5 a.m., and observed an unmanipulated package of methylphenidate that belonged to the VA. The LEO removed a capsule of methylphenidate from the unmanipulated package and carefully opened the capsule to visually compare its contents to the contents of capsules from the manipulated packages. The contents of the capsules looked different, and the LEO asked the SP for an interview. · In an interview with the LEO, the SP stated that s/he had access to the VA’s medications on May 24, 2024, but did not observe manipulation to the methylphenidate packaging on that date. The SP was the only staff person on shift between 3 and 11 p.m. on May 24, 2024, and added that s/he would have likely seen the VA or another resident if they had attempted to access to the medications. The SP knew that methylphenidate was a controlled substance and a narcotic, and knew what it was prescribed for, but denied that s/he had handled the medication inside the capsules. However, the SP saw the contents of a “pill” on the bottom of the safe “one day” when s/he counted the medications and thought another staff person was responsible for the incidents described in the records from the law enforcement agency and said that s/he did not tamper with or remove/replace the active ingredients in the VA’s medication. · The SP told this investigator that s/he did not know whether s/he should complete an interview with this investigator, and s/he was unsure what the concerns were about his/her work at the facility. However, the SP denied that s/he was responsible for maltreatment. · The LEO put a capsule of methylphenidate from an unmanipulated medication package, a capsule of the unknown substance that looked like granulated sugar from a manipulated medication package, and a third capsule that was thought to be prazosin hydrochloride, which was found in a facility trash can, into evidence. Prazosin hydrochloride was often used to treat high blood pressure. The LEO submitted his/her report to the county attorney’s office for possible charges related to irregularities with the VA’s medication. · Medication Administration Records (MARs) for the VA in April and May of 2024 showed that the VA was administered methylphenidate each morning and prazosin hydrochloride each evening, with no missed medications noted. No information or documentation from P1, P2, the HCP, or records from the law enforcement agency showed that the VA had an increase in symptoms or concerns from missing doses of medications or ingesting capsules from which the prescribed medications had been removed or replaced with an unknown substance. No information showed whether packages of medications prior to April of 2024 had been tampered with. · The VA completed an interview with this investigator and said that s/he learned of the concerns with his/her medications from P1 and P2 and did not previously know that his/her medications or their packaging had been manipulated. The VA noticed that his/her medications tasted sugary but did not notice any changes or issues from taking medications with active ingredients that might have been replaced with an unknown substance. The VA had no concerns regarding his/her care at the facility. The facility’s personnel and training records showed that staff persons interviewed for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: A. Maltreatment: Information was consistent from P1, P2, and records from the law enforcement agency that P1 noticed medication packages containing methylphenidate which was prescribed for the VA between late April of 2024, and May 24, 2024, were manipulated and had slits cut into the packages. On May 10, 2024, P1 noticed cuts in the packaging for the VA’s methylphenidate and asked the HCP to examine the medication/packaging. The HCP agreed that the medication/packaging had been altered and P1 contacted the LEO, then began monitoring the packages of methylphenidate for tampering and taking photos of them before and after shifts. On May 12, 2024, there were 17 capsules that appeared altered from the methylphenidate package that was taped together, and 4 that appeared altered from the bubble pack that P1 was monitoring/photographing. At 3 p.m., on May 24, 2024, prior to the SP’s shift, P1 observed that the VA’s methylphenidate package was not manipulated or tampered with, but at 11 p.m., but after the SP’s shift, the packages were manipulated, and the contents of the capsules looked different when compared to the contents of capsules from packages that were not manipulated. In addition, a capsule of prazosin hydrochloride was found in the trash at the facility. P1 said that the SP was the sole staff person who worked between 3 and 11 p.m. and was the only staff person who worked shifts after which the packages of medications appeared manipulated after P1 began monitoring the medications. In an interview with this investigation, the SP denied that s/he was responsible for maltreatment. In addition, the SP told the LEO that s/he did not take the VA’s medication, manipulate it, or tamper with its packaging. Regarding neglect: Although some of the methylphenidate that was likely tampered with was administered to the VA, given that the VA said that s/he did not notice any changes or issues from taking the medication and P1 stated no changes in the VA’s behaviors were observed, there was a not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to obtain or maintain the VA’s health or safety. It was not determined whether neglect occurred (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). Regarding financial exploitation: Although the SP denied that s/he altered the VA’s medications, given that information and photographs from P1 showed the VA’s methylphenidate was not manipulated prior to the SP’s shifts but had been altered after several of the SP’s shifts, and that the law enforcement agency investigated the incidents and thought the SP was responsible for replacing the contents of some capsules of the VA’s medication with an unknown substance on multiple occasions, there was a preponderance of the evidence that the VA’s medication was removed from some of the capsules and replaced with an unknown substance in the absence of legal authority. 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 the only staff person who had the keys to the medication safe and the closet in which it was stored during shifts where the VA’s medications were altered. In addition, the SP was trained on 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. The financial exploitation for which the SP was responsible was not “serious” because the VA was not injured but was “recurring” because the SP tampered with and replaced the contents of multiple capsules of the VA’s medications on several dates. Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but were not followed. The SP was no longer employed at the facility when this report was written. 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 facilities licensed by the Department of Human Services, the Department of Health, facilities serving children or youth licensed by the Department of Corrections, and unlicensed Personal Care Provider Organizations. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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