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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: 1070499-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth/Alice Percy Minnesota Department of Human Services 651-431-6537 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) gave unused incontinence supplies to a staff person (SP) because the VA did not use them. The VA also gave used continuous positive airway pressure (CPAP) supplies to the SP. Date of Incident(s): Ongoing, prior to September 22, 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 law enforcement records; and through five interviews conducted with a facility supervisory staff person (P1), the SP, the VA, the VA’s guardian (G), and the VA’s case manager (CM). Attempts were made by telephone and email to contact and interview a former supervisory staff person (P2), but P2 did not respond to the requests. The VA enjoyed going on walks, watching television, playing video games, going on community outings, and spending time with his/her friends. The VA’s diagnoses included borderline intellectual disability, pervasive developmental disorder, attention-deficit disorder, lymphedema, and a history of seizures. The VA used a continuous positive airway pressure (CPAP) machine while sleeping. The VA worked at a community job each weekday. The VA’s Coordinated Service and Support Plan Addendum stated that the facility would offer activities in the areas of leisure, community, social, financial, medical, coping and modeling appropriate behavior skills and self-care skills training. The staff persons were to assist the VA with medication administration, scheduling medical appointments, and providing transportation to the medical appointments. The VA’s Individual Abuse Prevention Plan (IAPP) stated that the VA was “historically impulsive with money” and was dependent on others to handle his/her money. In the past, the VA gave others “large amounts of money” and did not have sufficient money to make necessary purchases. The VA did not understand what constituted financial exploitation. The facility did not allow the clients to buy, sell, trade, or give away personal items to others. The VA provided the following information: · In 2022, the VA was prescribed incontinence products by his/her doctor and the products were delivered to the facility every month as an “auto order.” At some point, the products did not fit the VA correctly, but s/he did not cancel the order and s/he continued to receive the products each month. The VA tried different styles and sizes, but none of them worked for the VA so s/he quit using them. P2 told the VA to “get rid of them” so the VA gave the items to the SP. The VA believed that the SP gave the incontinence products to his/her family member (FM), who in turn gave the products to others who could not afford to buy the products. · The FM sometimes gave gift cards or $20 to the VA “as compensation” for the supplies. The VA did not know the cost of the incontinence supplies. When P1 began working at the facility, s/he asked the VA about the incontinence supplies. The VA believed it was his/her “fault” for giving the items to the SP and s/he did not want the SP “to get in trouble.” · The VA ordered his/her CPAP supplies on an app. The VA said s/he never gave any of his/her CPAP supplies to anyone because s/he routinely used them. A review of five Durable Medical Equipment Orders provided the following information: · On April 4, 2022, the VA was prescribed adult disposable briefs and chux (pads for bed). · On September 14, 2022, the VA was prescribed daytime adult disposable underwear. · On October 20, 2022, the VA was prescribed adult disposable briefs. · On October 27, 2022, the VA was prescribed disposable underpads. · On November 23, 2022, the VA was prescribed adult disposable briefs. A review of 36 Invoices from a medical supply store dated between April 13, 2022, and August 8, 2025, showed that on 36 occasions, underwear, briefs, mattress pads, underpads, and panty liners were delivered to the facility. The total amount paid for the purchases was $6,958.12. P1 provided the following information: · P1 recently began working at the facility. While P1, the SP, and the VA were driving to the VA’s doctor appointment, the VA mentioned that s/he received his/her monthly supply of incontinence products. P1 asked the VA why s/he received them since s/he did not use them. The VA told P1 that s/he liked to donate the items to “people who were less fortunate.” The SP then stated that s/he took the incontinence products from the VA and gave them to the FM who worked as a home health aide and who in turn gave the products to the people s/he worked with. The FM then gave the VA $20 for the products. The VA told P1 that P2 knew that the VA gave the incontinence products to the SP. P1 did not believe that the SP received any compensation for the items s/he gave to the FM. · P1 stated that after learning about the VA giving away the incontinence products, P1 contacted the medical supply store and discontinued the order. Each month, the VA received four or five boxes of adult briefs, protecting pads, and liners. P1 did not believe the VA ever used the products and did not know why s/he was prescribed them. P1 did not believe that the CM or the G were aware that the VA received the products. · P1 believed that the VA used all of his/her CPAP equipment and s/he did not believe that there were any extra CPAP supplies available for the VA to give away. The SP provided the following information: · Each month, the VA received four to six cases of incontinence products, but did not use them, so P2 initially told the SP “to get rid of them” and told the SP to take the products to a landfill. The SP did not want to throw all of the products away, so s/he gave them to the FM, who then gave them to others who could not afford to purchase incontinence products. · The FM wanted to give the VA money for the products, but P2 initially told the SP that the VA could not take money. P2 then told the SP that the FM could give a maximum of $20 for the products. For two years, the FM gave $20 to the SP to give to the VA each month. Then the VA asked if the FM could give him/her a $20 McDonald’s gift card instead and P2 agreed so the FM gave the VA $20 gift cards for another “year or two.” · The SP called the medical supply store “a couple times” in the past five years and was told that they could not return the products once they were delivered to the facility so the SP should donate the products, which the SP continued to do each month. The SP believed that P2 also tried to cancel the orders for the incontinence products, but the SP believed that the VA then reordered the incontinence products because s/he wanted to receive $20 each month. · P1 recently began working at the facility and asked the VA and the SP about why there were incontinence supplies delivered to the facility that the VA did not use. The SP told P1 that the FM was no longer going to be able to take the incontinence products, so P1 told the SP and the VA that s/he would “find a new home for them.” · The VA also had outdated CPAP supplies in his/her closet which did not work with the VA’s current CPAP machine so the SP gave the items to the FM to give away. The CM stated that s/he was unaware if the VA used incontinence supplies. The VA did not provide any information to the CM about donating his/her incontinence supplies. The VA had a CPAP machine in his/her bedroom. The G stated that s/he had no information about the VA donating his/her incontinence products. The facility’s Financial Exploitation policy defined financial exploitation as occurring when a person willfully used, withheld, or disposed of funds or property of a vulnerable adult. Facility documentation showed that the SP and P1 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: In 2022, the VA was prescribed adult disposable briefs, underwear, underpads, and chux and on 36 occasions between April 13, 2022, and August 8, 2025, each month several boxes of the supplies were delivered to the VA at the facility that totaled $6,958.12 during the time period. The SP stated that P2 told the SP to “get rid of” the products so the SP gave the products to the FM, who in turn gave the VA $20 each month for the products. The VA stated that s/he never used the products and was aware that the SP gave the products to the FM. The SP stated s/he also gave some of the VA’s CPAP supplies to the FM, however, the VA stated that his/her CPAP supplies were not given away because s/he used them. P2 did not provide information for this report so it was unclear if or when P2 tried to cancel the deliveries or what conversations s/he had with the SP. The SP stated that s/he tried to cancel the deliveries “a couple of times,” but the SP believed the VA reordered the incontinence products so that the deliveries continued for over three years. P1 stated that when s/he learned that the VA was not using the supplies s/he called and the deliveries were cancelled. Although the SP stated that P2 gave him/her permission to take and/or dispose of the products, the VA was subject to guardianship and the VA’s IAPP stated that the VA did not understand what constituted financial exploitation and the facility did not allow the clients to buy, sell, trade, or give away personal items to others. In addition, the facility’s Financial Exploitation policy defined financial exploitation as occurring when a person willfully used, withheld, or disposed of funds or property of a vulnerable adult. Given that the SP, P2, nor any other staff person had the authority to give approval for and/or take and/or dispose of the VA’s items; that the VA’s incontinence products that totaled $6,958.12 were taken and given away by the SP, yet the VA received at most $20 a month or about $800, there was a preponderance of the evidence that in the absence of legal authority a person willfully disposed of property belonging to the VA. 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. Although the SP stated that s/he received permission from P2, P2 did not provide information for this report and did not have the legal authority to give approval for any person to take and/or dispose of the VA’s items and the facility did not allow the clients to buy, sell, trade, or give away personal items to others. In addition, the facility’s Financial Exploitation policy defined financial exploitation as occurring when a person willfully used, withheld, or disposed of funds or property of a vulnerable adult and facility documentation showed that the SP received training on the on the facility’s policies, Reporting of Maltreatment of Vulnerable Adults Act, and on the VA’s plans prior to the incidents. The SP took the VA’s items that totaled $6,958.12 and gave them to his/her family member. 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 took items from the VA on 36 occasions. 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 staff persons. 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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