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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: 1072301 -H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas 651-431-3970 gessner.rivas@state.mn.us Suspected Maltreatment Reported: It was alleged that a staff person (SP) used a vulnerable adult’s (VA) debit card and withdrew $200 from an ATM on August 10, 2025, at 8:47 p.m. and then unsuccessfully attempted to make another withdrawal at 10:50 p.m. for $400. Date of Incident(s): August 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 was obtained during a site visit conducted on September 4, 2025; from documentation at the facility; and through six interviews conducted with a facility supervisor (P1), facility staff persons (P2 and P3), the VA’s guardians (G1 and G2), and the VA. The SP did not respond to this investigator’s attempts to request an interview with the SP. The VA was diagnosed with a traumatic brain injury with severe memory and cognitive impairments. The VA was employed and liked to keep busy, play mini golf, go fishing, and spend time with her/his dog. The following information was obtained from law enforcement (LE): · LE received a report from the facility of a suspected fraudulent charges on the VA’s debit card. The facility reported that it suspected it was the SP given the time of the transaction and the time that the SP had clocked out on August 10, 2025, and the SP having a partner that lived in the area where the debit card was attempted to be used a second time. · G1 and G2 forwarded emails to LE about the transactions on the VA’s debit card. According to the emails, on August 10, 2025, at 8:48 p.m., at a US Bank ATM at a Circle K, $200 was withdrawn with a remaining balance of $28.45. Later that evening at 10:50 p.m. at a Wells Fargo ATM, an attempt to withdraw $400 was made but was declined. On August 11, 2025, at 10:57 and 10:58 p.m. at a PAI ATM, attempts to withdraw $183.50 were made but were declined and at 11:05 p.m. an attempt to withdraw $84 was made but was declined. · LE reviewed surveillance footage from Wells Fargo Bank which showed that the SP attempted to make a $400 withdrawal with the VA’s debit card on August 10, 2025, at 10:50 p.m. LE confirmed it was the SP in the surveillance footage by comparing that individual to recent booking photos of the SP from August 29, 2025, which matched the SP’s facial tattoos and hair color and style. LE was unable to obtain surveillance footage from US Bank and PAI regarding those ATM transactions. · LE conducted an interview with the SP at the St. Louis County Jail where the SP was in custody on an unrelated matter. The SP stated that P1 always had the VA’s debit card in her/his wallet. The SP denied any involvement in taking or using the VA’s debit card. The SP stated that s/he only used the VA’s debit card to purchase dog food for the VA’s dog. · The SP stated that s/he gave the $200 withdrawn from the VA’s debit card to P1. The SP stated that s/he did not recall how many times s/he had attempted to withdraw money from the VA’s account but after attempting to withdraw $400, s/he threw the VA’s card away near a park. The SP denied being behind the other attempts to withdraw money and that P1 was with the SP when s/he threw the card away. The SP stated that s/he had gotten the VA’s debit card and PIN from P1. · The SP was charged with financial transaction card fraud and financial exploitation of a vulnerable adult. P1 provided the following information: · P1 stated that all residents at the facility had a binder and a money bag where their money was kept in a locked safe; which was where the VA’s debit card was kept; every staff person had access to the safe. Whenever a staff person needed to use the VA’s debit card, P1 would provide that staff person with the PIN for the debit card. Staff persons needed to provide receipts for any transaction which went in the VA’s binder. P1 stated that the PIN was not kept in the safe and s/he would write it on a note for a staff person who needed to use the debit card. · P1 stated that the SP had access to her/his cellphone, and the PIN was noted in the contact information for the VA’s guardian, G2. Or that another staff person may have forgotten to remove any Post-it note with the PIN on it before placing the VA’s debit card back in the safe. · Staff persons were required to count a resident’s cash on hand twice a day. P1 rectified accounts on a monthly basis and uploaded receipts for further review by the facility finance person. · P1 received a screenshot of the VA’s account activity from August 10, 2025, from G2, which showed a $200 withdrawal and later received an email regarding other transactions that same night. P1 believed that the SP was behind the transactions because “it was like a crumb trail right to [the SP],” because of the locations where the debit card was used having a connection to the SP. G2 had called the facility and asked if the VA’s debit card was still in the safe, and it was not, and a staff person called P1 and asked if P1 had it her/his wallet; it was not. · The last time prior to August 10, 2025, that a staff person used the VA’s debit card was on or about August 6, 2025, when the VA was taken out for a haircut and a meal. · The SP worked on the evening of August 10, 2025, but did not show up for work the following day. The SP lived with P1 while the SP was working at the facility and got along great with the residents. P1 stated that after the incident, the SP reached out to P1 on August 10, 2025, asking to borrow money but P1 ignored the SP. · P1 denied the SP’s allegations that s/he gave the SP the VA’s debit card or PIN and that the SP gave her/him the $200 that was withdrawn using the VA’s debit card. P2 provided the following information: · P2 worked the morning of August 11, 2025, and received a call from the one of the VA’s guardians (G2) asking about a transaction that appeared on the VA’s account. G2 asked who had worked the evening before. After that phone call, P2 notified others including P1. · While P2 did not handle client funds, P2 recalled that when a staff person handled a client’s funds, a staff person was supposed to file receipts and document in the client’s ledger how much money was spent and how much was left. · P2 stated that there were no red flags with the SP. The SP would do the things that were asked of her/him such as cooking, and the SP was upbeat and good natured . P3 provided the following information: · P3 stated that staff persons had to count a client’s cash on hand at the beginning of their shift and verify that debit cards were accounted for. · On August 6, 2025, P3 and another staff person accompanied the VA to Noodles and Company where they used the VA’s debit card for the VA’s food. P3 took the VA’s debit card which had the PIN on a note that was wrapped around the debit card. After the outing, P3 placed the debit card back along with the receipt and entered where it was used on the VA’s money log and informed P1. P3 worked on August 8, 2025, but did not recall seeing the VA’s debit card in the safe. · P3 recalled that the SP was a good worker but that the SP had a couple of no call, no shows and was allowed to return to work. G1 Provided the following information: · G2 got a text notification regarding a transaction on the VA’s debit card on August 10, 2025. A withdrawal of $200 was made along with multiple other attempts thereafter at other locations. · G1 stated that the facility did not notify them in advance when the VA debit card would be used and that the facility did not know the amount of money in the VA’s account. Facility documentation showed that P1, P2, P3, and the SP 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: Information showed that on August 10, 2025, the SP took the VA’s debit card and withdrew $200 at an ATM from the VA’s account. Later that evening the SP tried to withdraw $400 at an ATM from the VA’s account, but that transaction was declined. On August 11, 2025, there were three more attempts to withdraw money from the VA’s account, each attempt was declined. LE was able to obtain surveillance footage from the second ATM and confirmed that it was the SP that made that attempted withdrawal. The SP stated that s/he gave the $200 withdrawn from the VA’s debit card to P1 but P1 stated that the SP did not give him/her $200. The SP stated that s/he did not recall how many times s/he had attempted to withdraw money from the VA’s account but after attempting to withdraw $400, s/he threw the VA’s card away near a park. The SP denied being behind the other attempts to withdraw money. Given that the SP had access to the VA’s debit card, that the SP was recorded on surveillance footage attempting to make a withdrawal from the VA’s account after the successful $200 withdrawal and before other unsuccessful withdrawal attempts, and that the SP stated that s/he made the $200 withdrawal and other unsuccessful withdrawal attempts, therefore was a preponderance of the evidence that the SP willful used and withheld the VA’s funds 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. The SP was trained in 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 was not “recurring” maltreatment because the SP successfully withdrew money from the VA’s account on one occasion and was not “serious” maltreatment because it did not meet the statutory definition. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP was no longer employed 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.
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