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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: 1120847-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) stole a vulnerable adult’s (VA’s) discontinued medications. Date of Incident(s): June 23, 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/or law enforcement records; and through three interviews conducted with facility staff persons (P1 and P2) and a guardian (G). The VA was not aware that medications were taken and was not interviewed due to his/her diagnoses. The SP did not respond to this investigator’s attempts to interview him/her. The VA enjoyed bike riding, walking around in town, and window shopping. The VA also enjoyed people watching at a local mall. The VA’s diagnoses included schizoaffective disorder, bipolar disorder, persistent mood disorder, anxiety disorder, attention deficit hyperactivity disorder, and intellectual disabilities. The facility was a split-level home where the VA resided on the upper level and another client (C) resided on the lower level. Only the VA’s medications were kept in a locked medication cabinet in an upstairs office. Overflow/expired/discontinued medications were stored in the bottom drawer of the medication cabinet until they were destroyed. Live stream video surveillance was used in all common areas inside the facility and around the outside front door. Two managerial staff persons (P1 and P2) and/or the facility’s Investigation Report and Summary provided the following information: · On the evening and overnight hours of June 22-23, 2024, the SP was scheduled to work with the C in the lower level of the facility so there was no reason for the SP to be upstairs at the facility. · P1, P2, and a facility supervisor (P3) each reviewed camera footage of June 23, 2024, between 12:25 a.m. and 12:38 a.m. The SP was seen in the upstairs office opening the medication box and looking through “bubble packs” of the VA’s medications using a flashlight on a phone. While still in the office, the SP was seen tucking a bubble pack into the front of his/her pants and covering it with his/her shirt, leaving the office, then returning to the office and putting the top part of the medication package/label into a shredder before going into the living room and putting the bubble pack into his/her backpack. The SP was observed putting something (believed to be medication) into his/her mouth and swallowing it with something in a drinking cup. (During this time, a staff person, P4, was working with the VA and was in the VA’s room watching television with the VA.) · P3 believed that a “full pack” of Clonidine was missing from the medications set aside to be destroyed. · P1 believed there should have been two, or possibly three bubble packs of Clonidine 0.3 milligrams but now there was only one set aside to be destroyed. · After reviewing the video, P1 and P2 called the SP and first asked about seeing the SP set out a pillow and blanket for him/herself because the SP was supposed to be awake for his/her scheduled shift on the lower level with the C. The SP denied sleeping and replied, “No comment,” and hung up. There was no opportunity to ask the SP about the VA’s missing medications before the SP hung up. · Together, P1 and another staff person (P5) went through the VA’s current and overflow/expired/discontinued medications to determine what medication was missing. All of the VA’s currently prescribed medications were accounted for. However, since overflow/expired/discontinued medications were not documented until they were destroyed, it was not determined what bubble pack of medication the SP took. Information showed it was likely Clonidine 0.3 milligrams (prescribed for the VA’s attention deficit hyperactivity disorder) that was taken from the area where medications were stored until they were destroyed. The G was informed of the incident but had no information specific to the incident. This investigator talked to a law enforcement officer (LEO) who said the SP did not respond to calls requesting an interview. In addition, given the facility was not able to confirm what medication was taken, how much, and the value, there was not enough information to charge the SP with theft. Facility documents showed the SP was trained regarding the Reporting of Maltreatment of Vulnerable Adult Act, Conclusion: A. Maltreatment: Information showed that the VA’s current medications as well as overflow/expired/discontinued medications were stored in an upstairs office in a medication box. There was no list of the overflow/expired/discontinued medications until they were destroyed; however, P1 and P3 believed Clonidine was in the box and needed to be destroyed. Camera footage showed that on June 23, 2024, the SP was seen looking through the medication box with a flashlight, taking an unidentified bubble pack of the VA’s medications, tucking it into his/her pants, putting the top part of the bubble pack/label in a shredder, and putting the bubble pack into his/her backpack. P1 and P2 attempted to interview the SP; however, the SP hung up on them before they were able to ask the SP about the VA’s medications. The SP did not respond to this investigator’s attempts to contact him/her via telephone or mail. Although the SP did not respond to interview requests from the LEO or this investigator, and it was unknown what medication the SP had in his/her possession and put into his/her backpack, because the camera showed the SP taking a bubble pack of medications from the medication box where the VA’s medication were stored and putting it in his/her backpack, there was a preponderance of the evidence that in the absence of legal authority the SP willfully used, withheld, or disposed of property of the VA.
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 received training 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. It was determined that the substantiated financial exploitation for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was single incident, and the VA did not sustain an injury. Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but were not followed when the policy and procedure regarding prevention of fraud, financial abuse, and wasteful financial practices was not followed. There was no need for additional staff person training because the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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