|
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: 1070852-H_CRS (Home and Community-Based Services-Community Residential Setting) 1070806HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-6553 Suspected Maltreatment Reported: It was reported a staff person (SP) made an unauthorized withdrawal of $400 from a vulnerable adult’s (VA) bank account. Date of Incident(s): August 1, 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 law enforcement (LE) records; and through three interviews conducted with a facility supervisor (P2), the VA’s guardian (G), and the SP. LE completed an interview with the VA and the VA expressed frustration by the situation. An additional interview with a DHS investigator was determined not to be needed due to the VA’s lack of relevant information and emotional well-being. The G did not have a firsthand relevant information related to the alleged incident. Facility documentation showed the VA was described as friendly and hard working. The VA enjoyed listening to music, going fishing, and sports. The VA was very close with his family, and it was important for the VA to have a sense of independence. The VA was diagnosed with developmental disabilities, microcephaly, and intermittent explosive disorder. The VA’s Individual Abuse Prevention Plan (IAPP) stated the VA was unable to add or subtract money and was unable to balance his/her checkbook. Staff persons assisted the VA with budgeting, paying bills, and balancing his/her bank account. P2 said on August 1, 2024, the VA’s bank account transactions included a balance inquiry and a withdrawal of $400. The SP was the only staff person working during the timeframe the alleged incident occurred. P2 said a facility supervisor (P1) was assisting the VA was the alleged incident was discovered. The facility’s Internal Review (IR) provided the following information: · On August 1, 2024, $400 was withdrawn from the VA’s account without the VA’s knowledge. The SP was working during the time the withdrawal occurred. · The VA said on August 1, 2024, s/he asked the SP to purchase a soda from the store, and the SP used the VA’s debit card which was in a locked cabinet. The VA said P1 found out a $400 withdrawal from the VA’s bank account occurred. The VA said s/he was not provided the cash that was withdrawn. · On August 4, 2024, P1 attempted to make a purchase for the VA, however the VA did not have enough money in his/her account. P1 and the VA contacted the bank and reviewed recent transactions and learned of a $400 cash withdrawal on August 1, 2024. P1 confirmed the facility did not have a receipt of the $400 withdrawal. P1 spoke with the SP, who stated the VA requested $40 be withdrawn. There was no receipt that $40 had been withdrawn. · P1 contacted P2 and informed him/her of the alleged incident. A bank transaction statement reviewed showed a person completed a balance check at an ATM on August 1, 2024, at 1:30 p.m. Thereafter $400 was withdrawn from the bank account. P1 and P2 confirmed the SP worked on August 1, 2024, and was the only staff person working during the time the money was withdrawn. · The SP said s/he went to an ATM on August 1, 2024, and withdrew $40 for the VA. The SP said s/he returned to the facility after the transaction and put the money and transaction slip into the VA’s money pouch. The SP said s/he did not document the withdrawal. · The faciality did not find a withdrawal receipt or cash that matched the withdrawal of for $40 or $400 in the VA’s money pouch. LE records provided the following information: · The VA’s debit card and personal pin code was kept in a locked cabinet inside the staff office. · On August 4, 2024, the VA attempted to purchase an item, but did not have enough money and P1 assisted the VA in obtaining a bank statement. Thereafter, it was discovered a withdrawal of $400 occurred on August 1, 2024. The VA denied making the withdrawal. The facility schedule was reviewed, and it showed the SP worked on August 1, 2024. · LE obtained a video recording from the automatic tell machine (ATM). The video showed a person at the ATM who made a transaction. The person was later identified as the SP, and LE arrested the SP. While interacting with LE during the arrest the SP said the arrest was “about work,” but there was no information whether the SP admitted or denied withdrawing money from the ATM. On October 31, 2024, the SP was convicted of 609.821.2 (1) Financial Transaction Card Fraud-Use-No Consent. The SP said all information in LE records was accurate and confirmed s/he used an ATM to withdrawal $400 from the VA’s account. P2 and the SP completed training on Reporting of Maltreatment of Vulnerable Adults Act and on the facility’s policies and procedures. The facility was unable to provide a training record for P2 and the SP regarding the VA’s client specific information. Conclusion: A. Maltreatment: Information showed that on August 1, 2024, an ATM withdrawal was made from the VA’s bank account for $400. The facility schedule showed the SP was the person working at the time of the withdrawal, and SP told the facility s/he had withdrawn $40 for the VA. However, there was no information that supported the SP’s claim as there was no withdrawal of $40 from the VA’s bank account. LE completed an investigation, including obtaining a video recording which identified the SP as the person who made the withdrawal. The SP was arrested and charged by LE for criminal financial transaction card fraud for use of the VA’s debit card without consent. The SP was convicted of the crime on October 31, 2024. The SP confirmed s/he used an ATM to make the withdrawal from the VA’s bank account. Given that the SP used the VA’s debit card to withdraw $400, and that the funds were not used for or by the VA, there was a preponderance of the evidence the VA’s funds were willfully used without 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. LE obtained video footage that showed that the SP made an ATM withdrawal of $400 using the VA’s debit card. The SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, and the facility’s policies and procedures. 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 not recurring maltreatment because it was a single incident. Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate but not followed. The facility retrained all staff persons at the facility on documenting finances. The report was not similar to past events. The SP no longer worked for 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 August 1, 2025, the facility was issued a Correction Order for not maintaining personnel records as required.
|
