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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: 1069638-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA1’s) debit card and made two withdrawals for his/her personal use totaling $320. There were also concerns that the SP made the withdrawals while working and left two vulnerable adults (VA2 and VA3), who did not have any unsupervised time, unsupervised. Date of Incident(s): February 8, 2025 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 two site visits conducted on February 18 and 19, 2025; from documentation at the facility and law enforcement records; and through eight interviews conducted with VA1, VA3, a facility client (C), two facility supervisory staff persons (P1 and P2), and VA1’s, VA2’s, and VA3’s guardians (G1, G2, and G3 respectively). This investigator met VA2 but did not interview him/her due to his/her diagnoses. An in-person interview was scheduled with a staff person (SP) but at the prearranged time, the SP was not able to meet. Attempts were made via phone and text message to reschedule the interview with the SP, but the SP did not respond to the subsequent attempts. VA1 was diagnosed with a traumatic brain injury, schizophrenia, and bipolar disorder. VA1 enjoyed going out to eat, going on vacation, and spending time with his/her friends and family members. VA1’s Support Plan said that VA1 could be unsupervised for one hour at the facility. VA1’s Individual Abuse Prevention Plan (IAPP) said that VA1 was unable to handle financial matters. VA1’s Funds and Property Authorization said that VA1 had a debit card at the facility that was used to withdraw a weekly allowance. The facility was to ensure the separation of funds from persons served from facility staff persons. Staff persons were also not to “borrow” money from clients including VA1. VA2 was diagnosed with autism disorder and moderate intellectual disability. VA2 was also blind in his/her left eye. VA2 enjoyed spending time with his/her family members and going out to eat. VA2’s Support Plan Addendum Intensive Support Services said that staff persons were to be present with VA2 while at the facility. VA2’s IAPP said that VA2 was unable to recognize dangerous situations due to his/her diagnoses. VA2 was not able to get out of an area or call for assistance if needed. VA2 had no “concept” of harm and staff persons needed to be present to assist VA2. VA2’s Self-Management Assessment said that VA2 was diagnosed with celiac disease and ate a gluten free diet. VA2 may eat “anything” in the cupboards if not supervised. The facility had alarms on exterior doors because VA2 had a history of opening exterior doors and not notifying staff persons prior to leaving. If the alarm sounded, staff persons were to look for VA2 and notify 9-1-1. VA3 was diagnosed with trisomy 16p (a rare genetic disorder of the 16th gene), mild developmental disability, attention deficit hyperactivity disorder, and anxiety. VA3 enjoyed spending time with his/her family members. According to VA3’s Coordinated Service and Support Plan Addendum Intensive Support Services, VA3 “required the presence of staff” while at the facility. The facility was one level and VA1, VA2, VA3, and the C each lived at the facility. [Note: Information showed that the C had unsupervised time at the facility.] The client debit cards were stored in a locked cabinet at the facility that all staff persons had access to. The facility schedule showed that on February 8, 2025, between 10 a.m. and 10 p.m., the SP worked at the facility. G1, P1, P2, the Incident Report and Internal Review completed by P2, the Internal Investigative Authority Report completed by P2, the Police Department report, and VA1’s Transaction History provided the following information: · On February 9, 2025, G1 was reviewing VA1’s bank statement when s/he noticed two withdrawals on February 8, 2025, from VA1’s bank account, totaling $320. VA1 typically had “set amounts” that s/he and staff persons could withdraw and the “transactions” on February 8, 2025, were “not approved.” G1 then notified P1 and P2 and told them that there were two withdrawals, one for $200 and another for $120. P1 and P2 were not aware of VA1 or staff persons withdrawing this money. · On February 10, 2025, law enforcement was notified and requested video footage from a nearby gas station where the ATM withdrawals occurred. Law enforcement “believed” that the person in the video was the SP due to prior law enforcement interactions with the SP. However, law enforcement also provided G1 with a photo and video of the person withdrawing the money. G1 then showed the photo to P1 and P2 who identified the person in the photo as the SP. · VA1 was not aware that s/he was missing money, in part because G1 did not want VA1 to know. · P1 and P2 learned from law enforcement that the withdrawals occurred on February 8, 2025, at 6:38 and 6:39 p.m. At the time the withdrawals were made, the SP was the only staff person working which meant that the SP left VA1, VA2, VA3, and the C unsupervised. VA1 and the C were able to be unsupervised at the facility. However, VA2 and VA3 had no unsupervised time. There were no known impacts to any of the clients, including VA2 and VA3, due to being unsupervised. It was unknown how long the SP was gone from the facility but P1 and P2 said that it took about 15 to 30 minutes to drive from the facility to the gas station and back. P2 also spoke to a staff person (P3) who worked the shift after the SP’s, starting at 10 p.m., and P3 told P2 that the SP was present when s/he arrived and that VA1, VA2, VA3, and the C were in bed and there were no concerns. · At some point, P2 spoke to the SP who denied leaving the facility or using VA1’s debit card. Law enforcement also spoke to the SP who denied using VA1’s debit card and said that s/he “never” left the facility at the time of the incident and “did not know why [s/he] would be on the video footage because [s/he] was not allowed to leave [the facility].” · P2 also spoke to VA1-VA3, and the C. The C was not aware that the SP left. VA3 said that “after dinner,” the SP left to get a medication from his/her nearby home and then told VA3 that s/he went to a gas station. The SP asked VA3 to “watch” VA2 while s/he was gone. VA1 said that the SP went outside to smoke “every once in a while” during his/her shift. VA2 was not able to provide information due to his/her diagnoses. · P1 did not have any other concerns with the SP. P1 felt “sick” about the incident and could “not believe” that the SP would use VA1’s debit card or leave the clients unsupervised. · VA1’s debit card was kept in a locked cupboard that all staff persons had access to. VA2’s debit card was also at the facility at the time of the incident but there was no money missing from VA2’s debit card. · G1 reviewed VA1’s bank statement for other concerning withdrawals but did not see any. G1 did not have any other concerns with the facility. · Law enforcement sent the report to the county attorney’s office for “charges of financial transaction card fraud” which was pending upon the completion of this investigation. VA1 did not have any concerns with staff persons, including the SP. VA1 was not aware of the SP leaving the facility but said that at times, staff persons including the SP, went outside to smoke. VA1 did not have any concerns with his/her finances. VA3 and the C had no concerns with the facility and VA3 enjoyed working with the SP. VA3 and the C were not aware of any times that a staff person left the facility. G2 said that the facility notified him/her of the incident. G2 did not have any concerns with the facility but said that VA2 did not have any unsupervised time at the facility and if a staff person left VA2 unsupervised, the “potential for harm was great.” G3 said the facility notified him/her that VA3 was unsupervised for approximately 20 minutes. VA3 did not have any unsupervised time and could be “unpredictable” if unsupervised. However, there were no known impacts to VA3 being unsupervised. G3 did not have any concerns with the facility. The Employee Handbook said that staff persons were not to borrow money from a client. The Service Recipient Rights said that clients were to be free from financial exploitation. Facility documentation showed that P1, P2, and the SP were trained on VA1’s, VA2’s, and VA3’s plans, client rights, and on the Maltreatment of Vulnerable Adult’s Act, prior to the incident. Conclusion: A. Maltreatment: On February 9, 2025, G1 was reviewing VA1’s bank statement when s/he noticed two withdrawals totaling $320 from VA1’s bank account on February 8, 2025. G1 then notified P1 and P2 and told them that there were two withdrawals, one for $200 and another for $120. The withdrawals occurred during the time that the SP was the only staff person working at the facility. Regarding VA1’s missing money: Information from G1 and VA1’s Transaction History showed that on February 8, 2025, two withdrawals were made from VA1’s account totaling $320. VA1 was not aware of the money being withdrawn and G1 said that the transactions were “not approved.” Although the SP did not provide information for this report and denied to P2 and law enforcement that s/he withdrew the money, law enforcement, P1, and P2 each identified the SP as the person in video/photos at the ATM withdrawing the money. Therefore, there was a preponderance of the evidence that without legal authority, a person willfully used or disposed of 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). Regarding leaving VA2 and VA3 at the facility without staff supervision: Information showed that at the time the withdrawals were made, the SP was the only staff person working at the facility with VA1, VA2, VA3, and the C. VA1 and the C each had unsupervised time at the facility. However, information from VA2’s and VA3’s plans in addition to P1, P2, G2, and G3 each showed that VA2 and VA3 did not have any unsupervised time at the facility, required staff persons in the facility at all times, and each faced risks when left unsupervised. Although the SP did not provide information for this report and denied to P2 and law enforcement that s/he left the facility, the SP was working and identified in video/photos by P1, P2, and law enforcement as being at the gas station ATM during the time s/he was working. Additionally, following the incident, VA3 told P2 that “after dinner,” the SP left to get a medication from his/her nearby home and then told VA3 that s/he went to a gas station. While it was unknown how long the SP was gone from the facility, P1 and P2 each estimated between 15 and 30 minutes, based on the time it took to get to and from the gas station where the withdrawals were made. Although VA2 and VA3 were not harmed during the time they were unsupervised, leaving VA2 and VA3 unsupervised was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, a violation of their plans, and was not accidental or therapeutic conduct. In addition, leaving VA2 and VA3 unsupervised at the facility between 15 and 30 minutes exposed each to dangers and would not allow for the SP to intervene in the event of an emergency. Therefore, there was a preponderance of the evidence that there was a failure to supply VA2 and VA3 with care or services which was reasonable and necessary to obtain or maintain VA2’s and VA3’s physical or mental health or safety.
It was determined that 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). 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, VA1’s, VA2’s, and VA3’s plans, and the facility policies prior to the incident. The SP was also identified by P1, P2, and law enforcement in video/photos as the person withdrawing money from the ATM. The SP was responsible for the maltreatment of VA1, VA2, and VA3. 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 financial exploitation and neglect for which the SP was responsible was recurring because there were two transactions made from VA1’s account and the SP was responsible for financial exploitation of VA1 and neglect of VA2 and VA3. However, it did not meet the definition of serious because neither VA2 nor VA3 sustained an injury that required the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed, including because the SP took money from VA1’s account “without consent.” Staff persons were retrained on the client’s supervision levels. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.
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