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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: 1110149-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Alice Percy 651-431-3444 Suspected Maltreatment Reported: It was reported that a vulnerable adult’s (VA’s) bank debit card was taken and used for several purchases. A video recording taken at a local business showed a supervisory staff person (SP) using the VA’s debit card to make a purchase. Date of Incident(s): Between August 7 and 11, 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 ten interviews conducted with three facility supervisory staff persons (P1 – P3), three staff persons (P4 – P6), the SP, the VA’s case manager (CM), and the VA’s guardians (G1 and G2). The VA enjoyed participating in Special Olympics, going to church, going to autism camps, and spending time with his/her family members. The VA’s diagnoses included intellectual disabilities, autism spectrum disorder, bipolar disorder, and seizure disorder. According to the VA’s Individual Abuse Prevention Plan, the VA was unable to handle his/her finances and would not recognize if s/he was being financially exploited. The staff persons were to assist the VA with making purchases and receiving proper change and receipts. G1 stated that on August 7, 2024, s/he and G2 were on vacation when they received a text message from P3 saying that they were unable to locate the VA’s debit card and asking G1 to send another debit card for the VA to use. Four days later, G2 was able to access a computer and check the VA’s checking account. G2 saw nine “suspicious” transactions on the bank account and had the bank cancel the VA’s debit card. G2 then let the facility know what s/he found. On August 12, 2024, P1 contacted G1 and G2 and told them that s/he planned to check with the businesses where the transactions occurred and try to get video recordings of the person using the VA’s debit card. Later that day, P1 told G1 and G2 that a staff person used the VA’s debit card and that the facility planned to reimburse the VA for the money that was taken from his/her bank account. G2 stated after receiving a text message from P3 saying that the VA’s debit card was missing, s/he checked the VA’s bank account online and found nine “suspicious” transactions. G2 cancelled the VA’s debit card with the bank and then sent an email to P1, P2, P3, and the SP with a list showing the details of the transactions. P1 later contacted G2 and told him/her that a staff person used the VA’s debit card and the facility was reimbursing the VA for the money that was taken from the VA’s bank account. In the future, the VA’s debit card would be stored in a locked box in the staff office and the staff persons had to sign the card in and out. G2’s name was on the VA’s bank debit card. On August 11, 2024, there was an additional attempt to use the VA’s debit card at a Holiday Station for $45, but the purchase was “declined.” A list of the questionable transactions made on the VA’s bank account was as follows: · On August 8, 2024, a purchase for $14.10 at Value Foods. · On August 8, 2024, a purchase for $15.93 at Value Foods. · On August 8, 2024, a purchase for $34.09 at Moes Smoke Shop. · On August 8, 2024, a purchase for $44.80 at City Liquors. · On August 9, 2024, a purchase for $20.45 at City Liquors. · On August 9, 2024, a purchase for $25.00 at Neighborhood Gas. · On August 9, 2024, a purchase for $30.50 at Quickone African Market. · On August 9, 2024, a purchase for $46.64 at Value Foods. · On August 11, 2024, a purchase for $14.10 at Value Foods. · The total amount of the questionable purchases was $245.61. P1, P2, P3, P4, P5, and P6 provided the following information: · Consistent information was provided that prior to the incident, the VA’s debit card was stored in an unlocked desk drawer in the facility’s staff office but that the office door was typically locked. All of the staff persons had access to the staff office, but not the clients. The VA did not use his/her debit card without the assistance of a staff person. · On August 3, 2024, P3 worked at the facility and used the VA’s debit card when s/he took the VA to lunch. On August 6, 2024, P6 worked at the facility and used the VA’s debit card when s/he took the VA to lunch. P6 stated that s/he returned the debit card and the receipt to the staff office after the outing. P2 stated that s/he typically worked at another program operated by the license holder, but sometimes “stopped by” the facility. P3 stated that s/he did not take the VA on community outings and did not know where the VA’s debit card was stored because s/he never had a reason to use the debit card. P4 stated that the SP was regularly at the facility and often worked in the staff office. P5 stated that the VA had to be with a staff person when the VA’s debit card was used to purchase something for the VA. After using the VA’s debit card, the staff persons were to return the debit card and the receipts for any purchases to the staff office. P5 typically took the VA on a community outing once a week. · P3 stated that on August 7, 2024, s/he and P6 worked at the facility and at approximately 8 a.m., P3 saw the VA’s debit card in the staff office. Later that morning, P3 and P6 ran errands and stopped by the facility’s main office before taking the VA to get lunch and a haircut. P3 entered the main office building while P6 remained in the facility’s van with the VA and another client. P6 did not remember whether s/he took the VA’s debit card when they left to run errands. P3 stated that s/he thought P6 took and had the VA’s debit card with them. At one point, P6 was unable to find the debit card in his/her pockets, so they returned to the facility to look for it but could not find it. P3 then sent a text message to G2 telling him/her that the VA’s debit card was missing and asked G2 to provide them with a replacement debit card. P3 stated that s/he did not know what happened to the VA’s debit card. · On August 11, 2024, G2 sent an email to P1, P2, P3, the SP, and the CM informing them that between August 8 and 11, 2024, the VA’s bank debit card account had “suspicious transactions” and that s/he “shut down” the card. There were nine transactions totaling $245.61 on the VA’s debit card that G2 believed were not made by the VA. P1 then talked to the SP and asked him/her if s/he knew anything about the transactions. The SP denied knowing what occurred. G2 sent details about the transactions to P1, who then went to the businesses where the transactions occurred and asked to see any video recordings showing who made the purchases with the VA’s debit card. One of the video recordings at Moe’s Smoke Shop showed the SP in the store on August 8, 2024, at 4:17 p.m., when the VA’s debit card was used. · P1 stated that s/he asked the SP about using the VA’s debit card and the SP told P1 that s/he found a debit card on the ground outside the facility’s main office and s/he started using the card to make purchases. The SP told P1 that s/he did not see the name printed on the card and “didn’t steal” from the VA. After making several purchases, the SP threw the debit card away. P1 stated that the SP knew G1 and G2, had met them at the VA’s team meetings, and had “fairly regular” communications with them via telephone and email. · After the incident, the VA’s debit card was stored in a locked box in the staff office and there was a sign-out sheet that was to be completed each time the debit card was taken out of the locked box. The SP provided the following information: · On August 7, 2024, at approximately 10 a.m., the SP went to the facility’s main office building and saw the facility’s van parked in the parking lot. A staff person, the VA, and another client were sitting in the van and the SP saw P3 in the main office. When the SP left the main office and drove out of the parking lot, s/he saw a debit card lying in the driveway. The SP stopped his/her car, picked up the debit card, and put it in his/her pocket without looking at it. When the SP went home at the end of the day, s/he placed the debit card in his/her wallet without looking at the name on the debit card. A day or two later, the SP used the debit card to purchase gas and then used it at “two or three” other businesses before throwing the debit card away. The SP threw the debit card away because s/he realized it was “inappropriate” to use the card to make purchases for him/herself. The SP did not think that the debit card belonged to anyone associated with the facility. · The SP did not realize that it was the VA’s debit card until s/he received an email from G2 saying that the VA’s debit card was missing. P1 initially talked to the SP about the VA’s debit card being missing and the SP “did not think” about the debit card s/he found. Later, P1 told the SP that s/he saw a video recording of the SP using the VA’s debit card. The SP told P1 that s/he found the debit card in the parking lot and s/he knew it was wrong to use debit card, but did not know that it was the VA’s debit card. The SP stated that s/he did not know why s/he used the debit card to make purchases. The SP did not know why the VA’s debit card was left in the parking lot, but thought P3 might have dropped it when s/he stopped at the main office. · In the past, the SP did not take the VA on community outings and did not use the VA’s debit card. The SP did not recall G2’s name and did not believe s/he met G2. The CM stated that after G2 sent an email to the facility regarding the suspicious transactions on the VA’s debit card, the facility responded quickly and determined who was responsible for making the transactions. The VA had “no concept of money” and would not be able to determine if someone used his/her debit card. Facility documentation showed that the SP and P1 – P6 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: A. Maltreatment: On August 7, 2024, P3 and P6 planned to take the VA to get a haircut and have lunch after stopping at the facility’s main office building. P3 went into the main office building while P6 waited in the facility’s van with the VA. A short time later, the SP arrived and then as s/he left the office building’s parking lot, s/he said s/he saw a debit card lying on the ground. The SP stopped, picked up the debit card, and placed it in his/her pocket without looking at the name on the debit card. Between August 8 and 11, 2024, the SP used the VA’s debit card at several business. The SP said s/he threw the debit card away because s/he realized it was “inappropriate” to use the card to make purchases for him/herself. The SP did not think that the debit card belonged to anyone associated with the facility and did not realize it was the VA’s debit card until s/he was questioned about it by P1. While it was unclear how or when the VA’s debit card was left in the parking lot, given that P3 said s/he saw the debit card at the facility prior to the errands and that it was not there upon their return to look for it, it was more likely than not that it was dropped by either P3 or P6 when they were at main office that morning. Although the SP stated that s/he was not aware the debit card was the VA’s, given that the SP stated s/he found the card and used the debit card (nine times between August 8 and 11, 2024) to make purchases totaling $245.61 for his/her own use, there was a preponderance of the evidence that in the absence of legal authority the SP willfully used the VA’s debit card. 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. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Although the SP stated that s/he did not know the card was the VA’s, the SP stated s/he found the card and made the decision to use a card for his/her personal use. 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 the SP used the VA’s debit card nine times between August 8 and 11, 2024. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate, but were not followed by the SP. After the incident, the staff persons were trained on the facility’s financial safety protocol. The facility reimbursed the VA for $245.61. 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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