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INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information
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.”
Report Number: 20154252
Date Issued: September 24, 2015
Name and Address of Facility Investigated:
Lakes Homes Lake Forest Granger
914 Lake Forest Circle
Attn Reiffenberger Thomas
Detroit Lakes, MN 565601
Lakes Homes and Program Development, Inc.
847 Highway 10 E
PO Box 1355
Detroit Lakes, MN 56501-4218
Disposition: Substantiated as to financial exploitation of a vulnerable adult, inconclusive as to responsibility
License Number and Program Type:
1070532-H_CRS (Home and Community Based Services-Community Residential Setting)
1070520-HCBS (Home and Community-Based Services)
Investigator(s):
Dee McNama/Marie E. Tierney
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
(651) 431-6573
Suspected Maltreatment Reported:
It was reported that a bottle of a vulnerable adult’s (VA’s) liquid Lorazepam was missing. A staff person (SP) was
suspected of taking the VA’s Lorazepam.
Date of Incident(s): Unknown date between July 6 and 31, 2015
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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 August 25, 2015; from documentation at the
facility and law enforcement records; and through six interviews conducted with facility staff persons (P1 – P6),
including supervisory and administrative staff persons.
The following information was obtained from facility documentation and interviews with P1 – P6:

According to facility documentation, the VA was a “very friendly” and “pleasant” person who enjoyed
watching television and attending movies and concerts. The VA communicated using gestures and facial
expressions, and his/her diagnoses included profound intellectual disability, hydrocephaly, encephalopathy,
and spastic quadriparesis. Staff persons were to administer the VA’s medications to him/her. The DHS
investigator met the VA during the site visit, but did not interview the VA due to his/her inability to
communicate.

Facility documentation showed that the VA was prescribed liquid lorazepam (an anti-anxiety medication)
to be administered in 0.3 milliliter (mL) doses on an as needed basis. On April 3, 2015, the VA’s
prescription was filled with 30 mL of liquid lorazepam. It was documented that 6.2 mL was either dosed to
the VA or otherwise accounted for as used in facility documentation. The last documented date the liquid
lorazepam was administered to the VA was June 19, 2015.

According to P1 – P6, the VA’s liquid lorazepam required refrigeration and was stored in a cardboard box
in an unlocked refrigerator in the facility’s locked staff office. All facility staff persons (P1 – P6 and the
SP) had access to the office.

On July 31, 2015, when P1 was training a new staff person, s/he opened the refrigerator and picked up the
VA’s lorazepam box to show the new staff person. Upon picking up the box, s/he felt that it was empty.
The VA’s lorazepam bottle was not found at the facility.

Facility policies and procedures required staff persons to “count” certain medications (including
lorazepam) at the beginning of each shift, at the end of each shift, and each time the medication was
administered. Facility records documented that staff persons accounted for the VA’s liquid lorazepam at
required times. However, P1 – P6 provided consistent information that when staff persons accounted for
the VA’s liquid lorazepam, they looked inside the refrigerator and, upon seeing the lorazepam box was
present, marked the lorazepam accounted for, without looking inside the box to see whether the bottle was
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present, nor what (if any) amount of lorazepam was in the bottle.


There was conflicting information regarding the last time the VA’s lorazepam bottle was seen at the
facility. Facility documentation stated that the last time staff persons knew the bottle was present was July
6, 2015, but P2 told the DHS investigator that s/he saw it on July 11, 2015. According to facility records,
the bottle contained 23.8 mL of lorazepam on both dates.
P1 – P6 each denied taking the VA’s missing lorazepam, and P1 – P5 each said they suspected the SP took
the bottle because the SP was a newer staff person, the SP stopped working at the facility during the time
the lorazepam was taken, and the SP recently had legal problems related to drug and alcohol abuse. In
addition, P5 said that when a law enforcement officer (LEO) was at the facility investigating the VA’s
missing lorazepam, the LEO told P5 that the SP was “on their radar.”

The DHS investigator scheduled a telephone interview with the SP on September 8, 2015, but the SP did
not answer the telephone at the prearranged time. The DHS investigator subsequently made attempts to
contact the SP by mail to schedule an interview, and the SP did not respond. Therefore, the SP was not
interviewed.

The facility’s personnel files and training records documented that P1 – P5 and the SP were each trained on
the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. P1 – P5 were each trained on
medication administration. The SP was not trained on medication administration. However, there was no
evidence that the SP administered medications at the facility.
Conclusion:
A. Maltreatment:
Information was consistent that the VA’s bottle containing 23.8 mL of liquid lorazepam was taken from the facility
sometime between July 6 and 31, 2015. Given that the bottle was kept in the locked staff office which was only
assessable to staff persons, there was a preponderance of the evidence that a staff person willfully used, withheld, or
disposed of the VA’s property.
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
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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 VA’s bottle of liquid lorazepam was stored in a cardboard box in an unlocked refrigerator in the facility’s
locked staff office, and all staff persons (P1 – P6 and the SP) had access to the bottle between July 6 and 31, 2015.
However, P1 – P6 each denied taking the lorazepam and the SP did not provide information. Given the above, it
could not be determined who was responsible for the maltreatment of the VA.
Action Taken by Facility:
The facility completed an internal review and determined that policies and procedures were adequate but were not
followed. The facility retrained all staff persons on the facility’s medication counting policies and procedures. The
facility also determined that the incident was not similar to past events with the vulnerable adults or services
involved, and that additional corrective action was necessary to protect the health and safety of vulnerable adults.
Action Taken by Department of Human Services, Office of Inspector General:
A licensing violation was determined because facility staff persons failed to follow facility policies and procedures
regarding medication counts. The facility retrained all staff persons on medication counting policies and
procedures. Because the facility self-corrected the violation prior to the completion of the investigation, no
correction order was issued.