MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

1002621-SUD (Substance Use Disorder)

Investigator(s):

Beth Virden
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
beth.virden@state.mn.us

651-431-6572

Suspected Maltreatment Reported:

It was reported that a staff person (SP) stole six capsules from a vulnerable adult’s (VA) Adderall prescription. There were additional concerns that the VA was missing more than the six capsules of Adderall and that his/her Adderall prescription was not filled in a timely manner resulting in him/her missing doses.

Alleged Licensing Violation:

It was reported that the VA’s privacy was violated.

Date of Incident(s): May 3 and 4, 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 a site visit conducted on May 29, 2025; from documentation and camera footage at the facility, and law enforcement records; and through seven interviews conducted with the VA, facility staff persons (the SP, P1, and P2), and supervisory staff persons (P3, P4, and P5).

The VA’s records, including Medication Intake Form and Medication Administration Record, provided the following information:

· On April 10, 2025, the VA moved into the facility seeking residential substance use disorder treatment.

· The VA’s prescription medications were immediately removed from him/her and “locked up” by staff. The VA was responsible for going to the medication room at his/her scheduled times and taking his/her medications with staff observation. The VA arrived with a prescription bottle containing 40 capsules of Adderall (amphetamine used to treat attention deficit hyperactivity disorder) 30 milligrams (mg) to be taken twice daily. The VA’s first dosage of Adderall 30 mg was administered by staff the morning of April 11, 2025.

· On May 1, 2025, the VA’s Adderall 30 mg was refilled with a 30-day supply, or 60 capsules to be taken twice daily.

· On May 5, 2025, the VA was discharged from the facility. S/he was given his/her belongings and medications, which included 46 capsules of Adderall 30 mg.

Regarding the VA’s six Adderall capsules:

The VA provided the following information:

· The VA had been taking Adderall for some time prior to moving into the facility. This was an amphetamine and so whenever the VA submitted a urinalysis (urine-based drug toxicology screening) in the past, s/he always tested positive for amphetamines due to this prescription. The VA’s urinalyses at the facility also tested positive for amphetamines, as expected.

· However, one day, the VA’s urinalysis at the facility tested negative for amphetamines. The VA had been taking his/her Adderall 30 mg twice daily at the facility and so this test should have tested positive like the prior ones. The VA did not know why s/he tested negative. [Note: Facility documentation showed this happened on April 29, 2025.]

· On May 4, 2025, the VA heard from an unidentified client that the SP was emptying the beads from the VA’s Adderall capsules and then putting [the capsules] back together so it appeared they were whole/filled with medication. [Note: The VA’s Adderall capsules were filled with hundreds of tiny beads or balls of the Adderall compound (medication). The capsule, itself, was a dissolvable shell that held the beads together. The capsule could be opened, twisted apart into two halves, the beads of medication emptied, and the two halves twisted back together so the capsule looked whole but there was no medication inside.]

· After hearing about the SP emptying beads from the VA’s Adderall capsules and unexpectedly testing negative for amphetamines, the VA believed that s/he must have been taking empty Adderall capsules for some time. The VA said that s/he was experiencing symptoms around that time, which might be related to not taking his/her Adderall, this included irritation, hyperfocus, and insomnia.

· On May 5, 2025, the VA was discharged from the facility for unrelated reasons. All of the VA’s belongings were sent home with him/her, including prescriptions. The VA took pictures of his/her Adderall bubble packs and provided the pictures to this investigator. [Note: Bubble packs were monthly cardboard sheets with a set number of capsules contained within separate clear bubbles. Each individual capsule was then popped out of their respective bubble through the back of the card for administration.]

· The pictures showed the VA’s Adderall cardboard sheet with six bubbles popped and pieces of clear tape across the back of each bubble. There were no capsules within those bubbles.

P1-P5, and facility documentation and camera footage provided the following information:

· On the weekend of May 3 and 4, 2025, P2 worked 8 a.m. to 8 p.m.; P1 worked 8 p.m. to 8 a.m.; and the SP worked 4 p.m. to 12 a.m.

· P1 and P2 each said that on May 3, 2025, at 8 p.m., they and the SP completed a scheduled count of the clients’ narcotic medications including the VA’s Adderall 30 mg bubble packs. The count added up with no discrepancies or concerns. P2 recalled physically handling the bubble packs and did notice tampering or anything out of the ordinary. Once this count was complete, P2 left for the day.

· P1 said that around 11 p.m., s/he and the SP completed another narcotics count. [Note: This count was scheduled for 12 a.m., but the SP asked to leave his/her shift early and so they were completing the SP’s end-of-shift tasks earlier.] P1 said that during this count, the SP physically handled all of the bubble packs. The SP held each bubble pack out faceup so that P1 could see the capsules through the bubbles and count them. P1 recalled that the SP held the VA’s Adderall bubble pack in his/her hand and once it was counted, the SP placed it on the table faceup and stacked the other clients’ bubble packs on top of the VA’s. P1 never saw the bottom side of the VA’s Adderall bubble pack but, at that time, “Didn’t think anything of it.” P1 and the SP had completed medications counts together “many times.” The count did not show anything missing and once the end-of-shift tasks were complete, the SP left for the night.

· P1 and P2 each said that the next morning, May 4, 2025, at 8 a.m., they completed a scheduled narcotics count. At that time, P1 and P2 noticed the VA’s Adderall bubble pack had six capsules popped but with a piece of clear tape across the back of each bubble so that the capsule remained as though someone mistakenly popped the six capsules and tried putting them back in their respective bubbles. P2 said that this was not the case when s/he handled the bubble pack at 8 p.m., the day prior. P1 and P2 shone a flashlight on the capsules and could see that they were empty or just shells with no “beads” inside. There were no staff initials next to each bubble or other documentation to explain what happened. P1 and P2 called P5.

· P1, P2, and P3 each said that if a staff person accidentally popped a wrong medication and needed to put it back into the bubble pack, it was acceptable to tape the capsule back in; however, the staff should then initial near the bubble and document in the staff logs. This was not done regarding the VA’s six Adderall capsules.

· P2 said that s/he did not have any conversations with the SP about putting tape on a bubble pack or what to do with a bubble that was compromised.

· P1 and P2 each said that they did not take/steal the VA’s Adderall.

· The facility provided camera footage for this investigation, which showed the following:

[Note: The camera was motion-activated and so when there was no movement, the camera did not record. The camera showed the staff office interior. It did not show the medication storage area, which was connected to the back of the office.]

o On May 3, 2025, at 10:03:14 p.m., the SP closed the office door, grabbed keys from the staff desk, and walked out of frame toward the medication room. There was no one else in the office.

o At 10:03:25 p.m., the SP walked back into frame, grabbed his/her backpack, and then walked back out of frame toward the medication room at 10:03:42 p.m.

o At 10:08:42 p.m., the SP walked back into frame, took a piece of clear tape from the tape dispenser, and then again walked off camera toward the medication room at 10:08:51 p.m. [Note: The piece of tape appeared to be a continuous piece about four inches long.]

o At 10:09:45 p.m., the SP walked back into frame carrying his/her backpack and setting it down on the floor. The SP then reopened the office door.

· P4 and P5 reviewed the facility’s camera footage. P4 said, “It did look suspicious. [The SP] was doing something [s/he] wasn’t supposed to do.” P5 said that after watching the footage, “[The SP] seemed to walk into the med room with a backpack, grab a roll of scotch tape, which [s/he] attempted to conceal from the cameras, and then come out of the med room with [his/her] backpack. [The SP] then requested to leave [his/her] shift early and left for the day after medication counts.”

· P3 and P5 each said that there were other clients with Adderall prescriptions during this same timeframe but there was no information they were stolen or tampered with.

· P1-P5 each said that the VA’s tampered (emptied) capsules were future dosages of Adderall. There was no information the VA took any tampered capsules; however, there was also no way to know whether the VA’s previous, already taken, capsules were tampered or not.

· Regarding the VA testing negative for amphetamines on April 29, 2025, the facility’s urinalysis records showed that the VA submitted urinalyses on April 11, 23, 24, 26, 29, and May 3, 2025. All, but April 29, tested positive for amphetamines, which were attributed to his/her prescription for Adderall. The test completed on April 29 tested negative for amphetamines. However, the facility submitted all urinalyses to a forensic toxicology laboratory for additional specimen screening. The test, which tested negative at the facility on April 29, 2025, tested positive for amphetamines at the laboratory. The laboratory concluded that the positive amphetamine result on April 29, 2025, was “consistent” with the VA’s prescription for “Amphetamine” (aka, Adderall).

The SP provided the following information:

· The SP only worked weekends, 4 p.m. to midnight. The SP’s interactions with the VA were “generic.” “I didn’t know [the VA] at all.”

· On May 3, 2025, at 12:55 p.m., the VA messaged the SP on social media asking for another staff person’s last name. The SP knew this was not allowed and told a supervisor. When the SP saw the VA later that same day, s/he told the VA that s/he could not contact staff on social media. The VA responded, “Oh yeah. I know. Sorry.” [Note: The SP recorded this incident in the facility’s communication log.]

· The VA’s prescriptions included Adderall, which was prescribed for attention deficit hyperactivity disorder. There was one other client prescribed Adderall, and another client prescribed a similar medication with a different name.

· When the VA first arrived at the facility, his/her medications were in bottles. To administer the VA’s bottled medications, the SP handed the bottle to the VA and watched the VA take his/her capsule out and then hand the bottle back to the SP. When the VA’s medications were refilled while s/he was at the facility, they came packaged in bubble packs. To administer the VA’s bubble-packed medications, the SP handed the bubble pack to the VA and watched the VA pop his/her capsule out and then hand the bubble pack to the SP. The SP “never had any problems” administering medications to the VA and the VA never handled his/her medications without the SP watching.

· Also on May 3, 2025, maybe at the scheduled 4 p.m. narcotic count, the SP noticed that one Adderall capsule was about to fall out of the VA’s bubble pack. The SP asked P2 what to do about this and P2 told the SP to place a piece of tape across the bubble to hold it in. The SP asked if s/he should document this anywhere and P2 said no. The SP set the bubble pack down to tape later.

· Around midnight, the SP and P2 completed a scheduled narcotics count, which added up with no discrepancies. The SP did not notice any tampering or anything odd with the bubble packs. The SP then left the facility but received a phone call from a supervisor around 11 a.m., the next day, stating that there were medications missing and that the SP should not show up for work that day.

· The SP said that s/he did not take the VA’s Adderall capsules and did not unscrew the capsules to take the beads out. The SP believed s/he was being “set up” by either staff or the VA, or both. The SP did not know why staff would want to set him/her up but said that the VA was mad at the SP for not giving him/her the staff person’s name on social media.

· The SP provided a screenshot of a social media message, dated May 6, 2025, from an unknown person, but whom the SP believed was affiliated with the VA. The SP believed the message was from the VA. The message said, “Gotcha hahahaha [laughing emoji] hope you get fired. You like being set up your [sic] a piece of shit. Should have gave me names…. Now look we did that whole RX thing to get you”

· Regarding the camera footage, the SP said that staff were allowed to shut the office door for many reasons, including to eat or have time alone. The SP believed that s/he grabbed his/her backpack to get a snack or take a vitamin. “I have no idea.” The SP grabbed the piece of tape to tape the bubble on the VA’s bubble pack, which s/he had previously asked P2 about. P2 was in the living room with clients at the time and not in the office with the SP.

· The SP was “heartbroken and disappointed” by the allegations.

This incident was reported to law enforcement, whose case was pending at the completion of this investigation.

Regarding the VA’s additional missing Adderall capsules:

The VA said that when s/he discharged home on May 5, 2025, the facility gave him/her one cardboard sheet of Adderall, which had 23 capsules remaining. The VA believed s/he was not given the full amount of his/her Adderall prescription. On May 1, 2025, the VA’s Adderall prescription was refilled with 60 capsules and so the VA should have had more than 23 capsules on May 5, 2025.

P5 and facility documentation provided the following information:

· The VA’s discharge medication list showed that the VA was sent home with 46 capsules of Adderall 30 mg. This form was signed by three staff persons and the VA.

· P5 said that three staff persons and the VA counted the VA’s medications and then signed the form verifying what was present when the VA left the facility. The facility was not aware of any missing bubble pack cards of Adderall or the VA reaching out about missing any of his/her Adderall upon arriving home.

Regarding the VA’s Adderall refill:

The VA provided the following information:

· Prior to discharge, around the end of April 2025, the VA’s Adderall prescription was not refilled in a timely manner and as a result, s/he missed doses.

· When the VA asked staff about this, P4 said that the VA was responsible for refilling his/her own prescriptions. The VA said that s/he was not made aware of this prior to running out of his/her prescription. The VA contacted his/her doctor requesting a refill but missed a few Adderall doses while awaiting the refill.

P4 and facility documentation provided the following information:

· P4 said that when the VA moved into the facility, his/her prescriptions were at a Walmart pharmacy in a different city. The facility submitted a request for the VA’s prescriptions be transferred to the local pharmacy. Typically, for narcotics like Adderall, the pharmacy would not transfer it and instead the client needed to ask their provider for a new prescription. The Walmart pharmacy, as expected, declined to transfer the VA’s Adderall prescription. P4 told the VA that s/he was “running low” on his/her Adderall 30 mg and that the VA needed to contact his/her provider to get a new prescription. The VA tried to do so but was unable to get ahold of the provider. After about two days of waiting, P4 again told the VA to call the provider and if the provider did not respond, P4 would call with the VA. Later that day, the VA was able to get ahold of his/her provider and his/her Adderall prescription was refilled and arrived that evening around 5 or 6 p.m. However, this prescription was written stating that the Adderall should be administered at 1 p.m. daily. Given that 1 p.m. had already passed, staff were unable to administer the medication that night and so the VA missed one dose of Adderall due to the way the new prescription was written. P4 was not aware of any other doses missed by the VA as a result of this refill situation.

· The facility’s Individual Progress Note, completed by P4, stated:

On 4/30 this writer observed the staff talking to [the VA] about [his/her] medication and trying to get ahold of [his/her] medication management provider. This writer told [the VA] that if they do not get a hold of [his/her] provider within the next day that we can call the provider together.

· The VA’s medication administration records and staff Medication Error Forms stated that the VA was out of, and did not receive, his/her Adderall 30 mg on April 30 or May 1, 2025. “Client stated [s/he] contacted doctor 4/29.” On May 1, 2025, the VA’s Adderall 30 mg was ready at the pharmacy for pick up.

Facility documentation stated that P1-P5 and the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act.

Conclusion:

A. Maltreatment:

Regarding the VA’s six Adderall capsules:

The VA and P1-P5 provided consistent information that the VA’s Adderall 30 mg bubble pack had tape across the back of six bubbles and that the capsules inside each bubble were tampered and did not have medication inside. P1, P2, and the SP were working during the timeframe when the incident occurred, and each denied taking the VA’s Adderall.

Although the SP provided social media messages, which s/he believed were from the VA and indicated the VA set the SP up to get fired for his/her “RX,” the messages were sent from an unknown person and did not state why or how the sender believed they got the SP fired.

In addition, facility camera footage showed the SP in the staff office with the door closed during the timeframe the medications went missing. The SP was seen taking his/her backpack and a piece of tape to the medication room. Although the SP said that s/he was taping a bubble pack, which s/he had previously asked P2 about, P2 stated that this conversation never occurred. Given that only staff persons had access to the VA’s medications aside from when the VA was taking his/her medications while supervised by a staff person, there was a preponderance of the evidence that a staff person took the contents of six of the VA’s Adderall 30 mg capsules.

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 the VA’s Adderall refill:

Although there was concern that the VA’s Adderall was not refilled in a manner necessary to avoid lapses, there was also information to show that the VA was informed of the need to contact his/her provider for the refill and that the VA attempted to contact his/her provider on April 29 and 30, 2025; and that staff told him/her if s/he did not reach his/her provider within the next day, they would help. By May 1, 2025, the VA had reached his/her provider, and his/her Adderall was ready at the pharmacy for pick up and staff picked it up that same day. Given that the provider’s response time was not within the staffs’ control, there was not a preponderance of the evidence whether staff should have or could have done more to prevent the lapse in the VA’s prescription.

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 the VA’s additional missing Adderall capsules:

Although the VA said that s/he only received 23 Adderall capsules when s/he was discharged from the facility, the VA’s discharge medication list showed the VA was sent home with 46 capsules, which was counted and verified by three staff persons and the VA at the time of the VA’s discharge. Therefore, there was a preponderance of the evidence that staff persons did not take the VA’s additional Adderall.

It was determined that financial exploitation did not occur (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 responsible for the VA care and supervision and 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. The SP took the medications at a single time, and it did not meet the definition of serious.

Alleged Licensing Violation: It was reported that the VA’s privacy was violated.

The VA provided the following information:

· On May 4, 2025, a client, whom the VA declined to identify, told the VA, “I can’t believe what’s going on … [The SP’s first name] has been taking your pills, emptying the beads and putting [the capsule] back so it appeared you were taking them, but you weren’t getting it.” The client said that s/he heard this from P2.

· Around this same timeframe, an unidentified community person told the VA that they heard about the VA’s missing medications from a person, who was later identified as P2’s significant other (SO). The SO worked at a different substance use disorder treatment facility and had no affiliation to the VA. The VA said, “Why does everyone know this but me? What the hell?”

· The VA said that s/he did not sign a release of information for anyone to share or receive information about his/her care at the facility.

P3 and P4 each said that the VA told them that two unidentified clients or community persons knew about the VA’s missing medications and said they were told about this by P2 or the SO. P3 said that the facility did not know what to believe regarding this aspect of the situation and were waiting to address this with P2 after the completion of the maltreatment investigation.

P2 told this investigator that s/he did not tell the SO about the VA’s missing medications or share the VA’s name with the SO. P2 said that s/he did not tell any clients about the situation either. P2 said that it was possible clients overheard staff talking about it at the facility.

The facility’s communication book included an entry on May 4, 2025, which was the last entry of that day with no timestamp. P1 documented that the VA came up to the medication window and asked to get a list of his/her medications and the current count of each. P1 told the VA that s/he would do so when s/he had time later that day. P1 asked the VA if s/he wanted the information for any specific reason and the VA said to P1, “You know what this is about.” The VA did not elaborate and left. P1 called P5, “because if [the VA] sees that [his/her] Adderall is off [s/he] is going to come at me for it and I wouldn’t know exactly how to say why they’re (the Adderall is) off (count)….”

Minnesota Statutes 245G.09, subdivision 1, states in part, client records must be protected against loss, tampering, or unauthorized disclosure according to section 254A.09, chapter 13, and Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67, and title 45, parts 160 to 164.

Given that the VA told more than one person, including this investigator, that other people knew about the VA’s tampered Adderall capsules before the facility told the VA; that P1 recorded in the communication book the VA asked about his/her medication counts; and that P1’s documentation implied the facility had not yet told the VA about his/her tampered medications, although it appeared the VA already knew, a licensing violation was determined.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate but not followed. Although the camera footage did not show the SP taking the VA’s medications, “[The SP] was seen taking a long piece of tape back into the medication room during [his/her] shift when the medication was tampered with.” The incident was not similar to past incidents. In response to this incident, the facility planned to add additional cameras. 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.

On July 10, 2025, the facility was issued a Correction Order for the violation outlined in this report.

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/