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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: 1108772-SUD (substance use disorder) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a staff person (SP) took gabapentin belonging to a vulnerable adult (VA). Date of Incident(s): prior to October 10, 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): 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 two interviews conducted with a facility management staff person (P) and the VA. Although this investigator contacted the SP and a facility health care professional (HCP), each did not respond to requests to be interviewed. The facility provided residential services to persons with substance use concerns. Medications for the VA and other clients were stored in a locked medication cart in a locked office. When medications were administered, clients went to a medication room. There was one key to the medication cart and another key for the office that was maintained by the staff person administering the medications. Medications were to be dispensed to a client when the client was present in the office. The office was equipped with a video surveillance camera. The VA’s Diagnostic Assessment showed that s/he was diagnosed with generalized anxiety disorder and post-traumatic stress disorder. According to the P, the VA enjoyed spending time with family and friends and accessing the community. The facility’s Incident Report and an interview with the P provided the following information: · At about 3 p.m. on October 10, 2025, the P was notified that one of the VA’s medication, gabapentin, was “low.” As a result, the HCP did a medication count and determined that 43 pills were missing. Because the medication was not a narcotic medication, it was not counted daily. · The P and the HCP reviewed surveillance footage and saw the SP “dispensing the medication without client present” and taking some of the medication. The SP also put some of the medication in his/her bag. · When the P and the HCP talked to the SP, the SP “admitted” to taking the VA’s gabapentin. The SP also said that s/he took some of the VA’s medications on previous days, but did not remember how many s/he took. The P was going to send the surveillance footage of the incident to the investigator however the P was unable to do so because the system was new, so the P did not know video only saved for 14 days rather than 30 days which the old system did. The VA stated that that s/he “never expected” a staff person to take his/her medications. The facility’s internal review provided information that was consistent with the information provided by the P. The facility’s training records showed that the P and the SP were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to October 10, 2025. Conclusion: A. Maltreatment: On October 10, 2025, the P learned that the VA’s gabapentin was low. As a result, the HCP counted the gabapentin and determined that 43 pills belonging to the VA were unaccounted for. When the P and the HCP reviewed surveillance footage, they saw the SP consume some of the VA’s medication and put some of it in his/her bag. When the P and the HCP talked to the SP, the SP admitted to taking the medications and on previous days, but the SP did not remember how many s/he took. Given that the SP stated s/he took the VA’s gabapentin, there was a preponderance of the evidence that the SP willfully took property belonging to the VA in the absence of 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. Given that the SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act, the SP was responsible for the financial exploitation 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 took the VA’s gabapentin on more than one occasion. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that although policies and procedures were adequate, they were not followed by the SP. The SP was no longer employed by 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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