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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: 1075660-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh Christine.Cavanaugh@state.mn.us 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA’s) debit card to make Amazon purchases for him/herself. Date of Incident(s): Ongoing prior to September 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): 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 supervisory staff person (P1) the VA’s case manager (CM), the VA’s guardian (G), and the VA. A facility staff person (P2) was also interviewed but P2 did not have information relevant to the Amazon purchases. Attempts were made via phone and email to contact and interview another supervisory staff person (P3), but s/he did not respond to the requests. Attempts were also made via phone, e-mail, and mail to contact and interview the SP, but the SP did not respond to the requests. The VA enjoyed activities such as swimming, mini-golf, parades, and zoos. The VA was diagnosed with “mild” developmental disabilities. The VA’s Individualized Abuse Prevention Plan stated that the VA was susceptible to financial exploitation due to an “inability to handle financial matters.” The VA “might not understand” if s/he had money missing or was being financially exploited. A quarterly financial report was sent to the G and the CM “to ensure the safekeeping” of the VA’s money. The VA stated that s/he heard from an unnamed staff person that the SP “took [the VA’s] money.” The VA did not provide additional information. P1, the Internal Review Report written by P1, facility documentation, and the VA’s bank statement provided the following information: · On August 26, 2025, P3 took the VA to the bank because the VA had concerns about his/her debit card “not working.” At the bank, a statement was reviewed which showed five recent Amazon charges totaling $461.51, that the VA stated s/he did not make. The bank statement showed the following transactions: o August 15, 2025, for $50.47 o August 17, 2025, for $257.52 o August 18, 2025, for $31.09 o August 19, 2025, for $84.95 o August 23, 2025, for $37.48 · On August 27, 2025, an administrative staff person (P4) called Amazon and spoke to a manager, who verified the Amazon charges were associated with the SP’s Amazon account. The CM and the G heard about the incident from P1 but had no additional information to provide regarding the allegations. Law enforcement (LE) information showed that the Amazon purchases were made using the VA’s bank account for purchases on the SP’s Amazon account for a range of items including a leather cross bracelet, a link chain, a ring light, a cellphone case, and various clothing items and all of the items were shipped to the SP’s address. The SP denied the allegations and stated that s/he only used his/her Amazon account for Amazon Prime videos, which s/he had not used for about a month. The SP said, “Unless [s/he] left [his/her] information” at the facility and “they bought stuff” on his/her account. The report was sent to the county attorney’s office for review of possible charges. The facility Employee Code of Conduct policy stated that staff persons were expected to be ethical and responsible when dealing with company clients, finances, products, partnerships, and public image. Theft of inappropriate removal or possession of individual or company property including but not limited to money, valuables, and medication would be considered infractions of the rules of conduct. The Fiscal Policy stated that employees would be expected at times to handle financial transactions for their work location and of the persons receiving services. Staff persons were expected to document the receipt of and disbursement of a person’s funds or other property at the time of receipt of disbursement. Staff persons were not to do the following to persons receiving services: borrow money or items, lend money or items, sell or give items or personal services, co-mingle funds, etc. The SP and P2 were trained on the Reporting of Maltreatment of Vulnerable Adults Act, the VA’s plans, and the facility’s policies and procedures. P1 was trained on the facility’s policies and on the Reporting of Maltreatment of Vulnerable Adults Act. P1’s position did not require him/her to be trained on the VA’s care plans. Conclusion: A. Maltreatment: Although the SP denied to LE that s/he made the Amazon charges with the VA’s account, information obtained showed that between August 15-23, 2025, there were five Amazon charges made using the VA’s bank account that were associated with the SP’s Amazon account and all the items were delivered to the SP’s address. Given that purchases on the SP’s Amazon account were made using the VA’s debit card, that the purchases were delivered to the SP’s address, and that the VA stated s/he did not make purchased via Amazon, there was a preponderance of the evidence that in the absence of legal authority the VA’s funds were willfully used or withheld. 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. The SP was trained on the VA’s plans, the facility’s policies, and on the Reporting of Maltreatment of Vulnerable Adults Act. Purchases on the SP’s Amazon account were made using the VA’s debit card and the purchases were delivered to the SP’s address. Therefore, SP was responsible for the 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 used the VA’s bank account on more than one occasion but it did not meet the definition of serious maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were adequate but not followed. The SP violated facility policies. The SP no longer worked at 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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