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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”
License Number and Program Type: 1036848-CRF (Children’s Residential Facility) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that staff persons (SP1-SP3) used a physical hold on an alleged victim (AV) that included a “choke hold,” throwing the AV to the floor, and calling the AV “bitch.” Date of Incident(s): December 5, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); subdivision 18, paragraph (a); and subdivision 23, paragraph (a): Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. "Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 19, 2022; from documentation and video footage at the facility; and through ten interviews conducted with the AV, the AV’s family member (FM), facility staff persons (SP1, SP3, and P1-P3), and supervisory staff persons (P4-P6). Facility youth (Y1 and Y2) also provided information, which was included in this report. SP2 initially responded to this investigator’s request for an interview, but then did not respond at the scheduled interview time or to subsequent requests. The AV’s support plans provided the following information: · In October 2022, the AV moved into the facility’s shelter unit where s/he was expected to remain until there was an opening in the facility’s mental health services and treatment unit. · The AV was 15 years old and his/her diagnoses included reactive attachment disorder, attention-deficit hyperactivity disorder, and fetal alcohol syndrome. · The AV had a history of mental health symptoms, including anxiety and anger management difficulties, which created vulnerabilities for him/herself. “Unit staff will be briefed on [the AV’s] history of mental health symptoms and will provide support such as increased supervision or additional check-ins as needed. Unit staff will offer and encourage [the AV] to utilize coping skills when [s/he] is experiencing difficult emotions.” · The AV had a history of being abused by others, and was a trauma survivor. “Unit staff will be made aware of and be sensitive to [the AV’s] trauma history and will work to create a secure and safe environment for [him/her] where [his/her] needs will be met. Staff will monitor [the AV’s] interactions with peers and teach effective interactions with others. Staff will encourage the use of coping skills to manage any symptoms of trauma.” · The AV had a history of aggression towards others. “Unit staff will be briefed on this history and will work to intervene as appropriate. Staff will closely monitor [the AV’s] interactions with others. Staff will offer redirections, breaks, timeouts, or physical escorts in the event that [the AV] is showing signs of aggression or escalation.” According to the facility’s website, www.voamnwi.org, the facility provided temporary shelter care and behavior stabilization services for adolescents ages 12-17. Within the shelter unit, there were youth bedrooms, common areas, and a staff office. The staff office door opened into a short hallway that connected a dayroom area to a dining room. The office walls were made almost entirely of glass allowing increased visibility in and out. There was a camera (camera #1) facing the area that included visuals of the dayroom, hallway, and office. There was a second camera (camera #2) on the other side of the office capturing 360 degrees (°) of the dining room, and portions of the office and hallway. The cameras recorded activity, but not audio. [Note: Camera #2 was not dated or timestamped; camera #1 was. Both cameras were smudged in various areas on the lens making visibility difficult.] The AV stated that on December 5, 2022, s/he had just finished a phone call that was “not good.” The AV asked SP3 if s/he could “take a break,” and SP3 told the AV to ask SP1. (Based on the AV’s description, SP1 was close by and/or within earshot of this conversation.) SP1 responded, “Fuck that. Piece of shit. I’ll kill [the AV] and [the AV’s] whole family.” The AV then “threw something” at SP1. SP1 responded by “tackling” the AV, “choking [the AV’s] face,” punching the AV, and pulling the AV’s hair. SP1 repeatedly stated that s/he was going to “kill” the AV and that the AV was “a piece of shit.” Other than these statements, no other staff were talking or giving any directives to the AV. The AV struggled against SP1’s actions, but did not punch at, or strike, SP1. After about “15 or 20 minutes,” the staff let go of the AV. The AV was not injured during the incident. P1 watched camera footage of the aforementioned incident and had concerns about what s/he observed. “The video was very telling.” P1 stated that SP1 had the AV in a “choke hold,” and “slammed” the AV onto the floor. SP3 then grabbed both of the AV’s legs and “slam[med]” them onto the floor. P2 did not watch the camera footage, but said that about two hours prior to the incident with the AV, s/he saw SP1 yelling and swearing, saying “Fuck this place,” while in the presence of the youth. Y1’s bedroom was near the staff office. During the incident, Y1 poked his/her head out of his/her door and observed about five to six seconds, which included staff holding the AV to the floor. Y1 also heard SP1 call the AV, “bitch,” and might have heard something similar to threatening the AV and the AV’s family. Y2 also observed portions of the incident, and said that s/he saw SP1 put the AV “in a head lock and was punching [the AV] on the back of [his/her] head.” The FM said that the AV had a history of repeatedly “poking” at staff to get a reaction, and then “playing the victim” if the staff reacted; and if the staff did not react, then the AV assaulted them. That said, the FM understood that there might be an exception in any situation. The FM was not present for the aforementioned incident and therefore did not know exactly what happened. The facility’s camera footage showed the following:
On December 5, 2022, following the aforementioned incident, the AV submitted an Official Grievance Form to the facility, and included the following: “[SP1] told me [s/he] would kill me and my family and when [SP1] brot [sic] me to the growund [sic] [SP3 and SP1] repetle [sic] cald [sic] me names and screamd [sic] obsides [sic] at me [Y1] winessed [sic] them and heard them call me names. [SP1] also puld [sic] my hiar [sic]. i was scaryd [sic] for my life” On December 8, 2022, P4 documented the “Disposition of the Grievance” on the AV’s Official Grievance Form, and included the following: “[SP1, SP2, and SP3] explained that [the AV] was not following expectations that afternoon into the evening. [The AV] was calling staff names and threatening them. [The AV] threw objects … and hit staff. [The AV] was placed in a hold so [s/he] would not throw any more objects or hurt anyone. There was a lot of yelling at each other.” “[SP1, SP2, and SP3 were] talked to on how not to let what residents say effect [sic] them. They should ignore negative comments. Yes, they need to protect themselves but remain calm. Staff will be using de-escalation more.” SP1 provided the following information: · Immediately prior to the incident, the AV had asked to take a “break” or a walk with staff. SP1 declined, citing the AV’s prior maladaptive behavior (i.e. throwing the unit telephone in a garbage can). The AV responded by picking up the garbage can and dumping the contents on the office floor. The AV then walked away towards his/her bedroom. · Shortly after, the AV returned to the office carrying a hairbrush and a flower pot. The AV threw both items at SP1 striking SP1’s back. SP1 said, “I just went out there (into the hallway) and there was another staff (SP2) and we just went out there and we was like trying to grab [the AV] but like it was two staff so like we both didn’t really know what like hold we was trying to put [him/her] in and then so I just kinda like grabbed [him/her] like this and we fell.” SP1 demonstrated wrapping his/her arms around in a hugging motion and described the action as “like a bear hug.” · “I fell on top of [the AV] and then probably 10-15 seconds after, we finally turned [him/her] around and then I just had [his/her] hands like this.” SP1 demonstrated having the AV’s hands resting on the AV’s lower back, palms up, with one on top of the other. SP1 believed they remained in this position for about two minutes. · When this investigator referred to SP1’s conduct as being a “hold,” SP1 said, “It wasn’t a hold cause I didn’t like actually put [him/her] in a hold. I was just holding [his/her] hands like this while talking to [him/her] … I didn’t put [him/her] in a hold.” SP1 demonstrated having the AV’s hands resting on the AV’s lower back, palms up, with one on top of the other. · When this investigator asked for clarification on why SP1 did not believe his/her conduct was a “hold,” SP1 said, “I mean like. I wasn’t like mad, like I wasn’t like. I didn’t put [him/her] in a hold cause [s/he] was calm. After like I had [him/her] on. Like after we fell, and I had [him/her] like this, and we finally flipped [him/her] over, [s/he] was calm and so I didn’t see no reason to put [him/her] in like a hold so we just had [his/her] hand on [his/her] back like this and [s/he] was just resting and laying down.” · SP1 said that s/he initiated physical contact with the AV because the AV had just thrown a hairbrush and a flowerpot at him/her. “I don’t know about you, but that’s a hold. At Bar None or anywhere else that I’ve worked at, that’s a hold if someone is throwing stuff at you. So, that’s what prompted it.” · SP1 said s/he did not say anything to the AV during the incident and that no other staff persons said anything to the AV either. · SP1 said that s/he was trained to provide redirection prior to implementing a hold and, “Yeah, [the AV] had. The whole. This is like a whole weeks of verbal redirection. It’s not like we just put [him/her] in a hold. [S/he] already threw apples at our cars. [S/he] already cursed us out every single day. [S/he] already [unintelligible] every single day we come in. It wasn’t like. I ain’t never even put a kid in a hold since probably seven months. Since that. But, it wasn’t like this just happened. It was like a daily thing where like redirection, redirection, redirection, and that same day when [s/he] threw the phone in the trash, it wasn’t like, ‘Oh you’re going to get put in a hold.’ I was wiping it. I didn’t even talk to [his/her] ass and then [s/he] threw the trash all over the office. Nobody said nothing. Nobody put [him/her] in a hold. Nothing. It’s just the fact that [s/he] came back with a brush and flower pot and threw it at me. That’s physical abuse. So I have a right to put [him/her] in a hold at that point. So [s/he] got put in a hold.” · SP1 denied having done and did not witness others, place the AV in a choke hold, call the AV names, or threaten the AV. · SP1 said that s/he received training on the facility’s restrictive procedures, including physical holds. SP3 provided the following information · SP3 left the unit prior to the start of the incident. When s/he returned, SP1 and SP2 had the AV in a physical hold and the AV was “Just laying [sic] there.” “I grabbed [the AV’s] legs until [s/he] was ready to get up.” · The AV was “not really” struggling or fighting back against the hold, but SP3 grabbed the AV’s legs because, “It’s part of our procedure,” even when a youth was not doing anything. · SP3 did not know if SP1 and/or SP2 were giving the AV any instructions or redirection, because SP3 was wearing “air pods” at the time and could not hear. · SP3 said that s/he did not, and did not witness others, place the AV in a choke hold, call the AV names, or threaten the AV. · SP3 said that s/he received training on the facility’s restrictive procedures, including physical holds. P3 provided the following information: · P3 told this investigator that the AV had a history of being “disrespectful towards the staff” and “curses 24/7.” Staff gave the AV “paperwork” as a consequence for his/her maladaptive behaviors, but then the AV would go to a supervisor and they would “overturn” the paperwork giving the AV “power.” P3 said, “There’s nothing we can do … If we can’t give [the AV] paperwork, we have to put [him/her] in a hold.” · P3 was not present when the hold was initiated, but stated that s/he did not have concerns regarding the portion of the hold that s/he did witness. P3 said that if a youth threw something at staff it would “not necessarily warrant a hold,” but “it depends … everyone is different.” P3 did not witness any staff place the AV in a chokehold, call the AV names, or threaten the AV. P4-P6 provided the following information: · P5 watched the aforementioned camera footage, and said, “The technique [used to hold the AV] did not align with what we train on … No hold is ever going to be just like the manual.” P5 had been working in his/her position for many years, and had reviewed several incidents involving physical holds. P5 reiterated that most physical holds did not look like they did in the training. “Doesn’t always happen the way they are trained.” · P6 said that the physical hold “was not the way we train on a hold.” In watching the aforementioned camera footage, P6 said that it looked like SP1 had initially been attempting to escort the AV to the calming room; however, the AV got turned around and when SP1 “bear-hugged” the AV to get him/her turned back around, they both fell to the floor. · P4 said, “The hold was very sloppy.” · P4-P6 each did not observe any staff use a choke hold on the AV, and the AV did not disclose such information during subsequent, separate, interviews with P4 and P6. · P4 interviewed the AV for the facility’s internal investigation, and, “[The AV] kept changing [his/her] story.” At one point, the AV said that SP1 called him/her, “bitch,” and that SP1 threatened to hurt the AV; however, the AV then “changed [his/her] story” so that SP1 did not threaten him/her. · P6 said that s/he was not initially told about any name-calling, but that a few days after the incident, the AV told him/her that SP1 had been calling him/her names and threatened him/her. · P5 said that if a youth threw an object at staff, it might warrant a physical hold if lesser methods of de-escalation were unsuccessful. The AV had a potential to assault other staff persons and/or other youth, and because of this, intervention was necessary. A hold was used if de-escalation was not successful. P5 believed that, regarding the incident herein, SP2 tried using verbal redirection following the AV’s “bad” phone call; however, was unsuccessful. P5 added that throwing objects had a potential to be charged as an assault by a law enforcement agency, and that this might also require physical intervention by staff. · P6 said that the AV had a history of being “impulsive,” and knowing that the AV had just thrown a flower pot at staff, P6 believed the staff were warranted in implementing a physical hold. There were other flower pots on the unit, which the AV could have continued to throw at staff. · P4 said that throwing an object at a staff person might warrant a hold, but it “depends on how extreme.” However, the AV’s conduct of throwing a flower pot at SP1 would “definitely” warrant an escort to the calming room, which, according to P4’s observations of the camera footage, was what it looked like SP1 was attempting to do. · P6 said that regarding SP3’s conduct of grabbing the AV’s legs, P6 heard that the AV’s pants had fallen down and that SP3 was helping to pull them back up by grabbing the AV’s legs. [Note: P6 was the sole one to mention anything about the AV’s pants. For the facility’s internal investigation, SP3 told P4 and P6 regarding his/her conduct, “[SP1] was struggling with the hold and [the AV] was kicking [his/her] legs, so I grabbed them and kept them secure.” · Regarding the length of the hold, P6 said that “a release can take some time.” Staff were trained to “process [the youth] out of the hold.” Staff were not supposed to immediately release the hold, but instead to encourage breathing, and then to release one body part at a time. · Following the incident, SP1-SP3 were retrained on restrictive procedures/physical holds. · P4, P5, and P6 each did not have, and were not aware of, previous concerns with SP1’s-SP3’s conduct. For the facility’s internal investigation, SP1 told P4 and P6 that s/he called the AV, “bitch,” during the incident, but denied calling the AV any other names. In addition, although P4 and P6 each told this investigator that it appeared SP1 had initially been trying to physically escort the AV to the calming room, SP1 did not provide this information to this investigator or during the facility’s internal investigation. However, in SP1’s incident report stated, “When writer approached [the AV] and was getting in position to possibly escort ….” The facility’s Restrictive Procedures and Handle with Care Manual provided the following information: · Staff were supposed to use the least restrictive method to deescalate a situation. Initially, staff should listen to the youth, validate the youth’s feelings, focus on one issue at a time, encourage, offer alternative choices, and persuade the youth to agree on a course of action. · The facility only uses restrictive procedures when necessary and in a manner that takes into consideration the youth's history of trauma to avoid causing the resident additional trauma. · Physical holding is to be used in emergency situations as a response to imminent danger to the youth or others, and when less restrictive interventions are determined to be ineffective. Physical holding is immobilizing or limiting a person's movement by using body contact as the only source of restraint. · The emergency use of physical holding must meet the following conditions: o An immediate intervention is necessary to protect the youth or others from physical harm. o The physical holding used is the least intrusive intervention that will effectively react to the emergency. Every attempt should be made to assist a resident in gaining appropriate control to avoid the need for physical holding. o The use of physical holding must end when the threat of harm ends. o Staff must treat the youth respectfully throughout the procedure. · The facility trained on various holds, including escort and takedown. Escorts included holding a resident’s arms by one staff person or two. A two-person takedown included one staff person holding a resident’s knees while the second staff person lowered the resident into a sitting position. · Regarding the “letting go” process: o “Even though we have regained physical control over the resident, we are still in the middle of an incredibly physically and emotionally charged experience both for ourselves and the resident. In order to assist the resident in regaining his/her internal controls, we must first regain controls over ourselves - including our breathing, tension level and adrenaline rush. Often the resident will respond to a restraint by screaming, swearing, yelling, insulting, accusing and threatening. Our best response to most of these actions is to simply maintain our hold and not respond verbally even though instinctually we want to verbally respond by increasing the volume of our voice. In terms of de-escalating by reducing stimulation, silence in this situation is golden.” o “The resident's tension begins to de-escalate and you can feel him/her calming down.” o “The letting go process is a gradual test of how in control the resident is. Just as we moved quickly to gain control, now that we have it we move slowly and gradually in relinquishing control while helping the resident regain it.” o The staff person then communicates instructions to the resident, including “We are going to let go of one arm and we want you to keep it right where it is.” If the resident complies, then other body parts can be slowly released in the same manner. Facility documentation stated that the staff persons interviewed and SP2, received training on the facility’s handle with care, including Restrictive Procedures and De-escalation, and on the Reporting of Maltreatment of Minors Act. [Note: Information was also provided that there was not specific training for each specific youth; rather the training was more general. However, the facility required staff to attend staff meetings in which the various youth, including the AV, were discussed.] Relevant Minnesota Statutes and Rules: Minnesota Rules part 2960.0050, subpart 1, item R, states, in relevant parts, the license holder must ensure that a resident’s basic rights are protected, including the right to be free from restraint or seclusion used for a purpose other than to protect the resident from imminent danger to self or others, except for the use of disciplinary room time as it is allowed in the correctional facility's discipline plan.. Minnesota Rules part 2960.0710, subpart 6, items A and B, states, in relevant parts, physical holding and seclusion are behavior management techniques which are used in emergency situations as a response to imminent danger to the resident or others and when less restrictive interventions are determined to be ineffective. The emergency use of physical holding or seclusion must meet conditions, including: A. an immediate intervention is necessary to protect the resident or others from physical harm; and B. the physical holding or seclusion used is the least intrusive intervention that will effectively react to the emergency;
Conclusion: A. Maltreatment: Camera footage showed that on December 5, 2022, the AV threw a flower pot at SP1. SP1 responded by grabbing the AV and eventually ending up on the floor with the AV underneath him/her. SP2 was present, and SP3 arrived later and grabbed the AV’s legs. The AV was not injured. Although SP1 did not believe his/her conduct was a “hold,” the facility’s policies defined a physical holding as “immobilizing or limiting a person's movement by using body contact as the only source of restraint.” Therefore, SP1’s conduct was a physical hold. SP1 said that prior to the hold, staff had been providing “a whole weeks of verbal redirection” to the AV. SP1 gave examples of the AV’s maladaptive behaviors from the days prior that were not related to the incident resulting in the physical hold. The AV said that no one gave him/her any directives or instructions, and SP1 and SP3 provided similar information. Although the camera footage did not contain audio, about one second passed between the AV throwing the flower pot and SP1 initiating a physical hold on the AV, which supported the fact that there was no verbal redirection, de-escalation attempt, and/or lesser restrictive method prior to the hold. The conduct of not providing lesser restrictive methods to deescalate the AV prior to initiating a hold was inconsistent with the facility’s policies, which stated, “Every attempt should be made to assist a resident in gaining appropriate control to avoid the need for physical holding,” and violations of Minnesota Rules part 2960.0050, subpart 1, item R and 2960.0710, subpart 6, items A and B. P3-P6 each stated that throwing an object at a staff person had a potential to warrant a hold. SP1 believed this was an “assault” and that s/he “had a right” to put the AV in a hold. However, the facility’s policies stated that the emergency use of physical holding was only warranted as a response to imminent danger to the resident or others. The camera footage showed that the AV had turned to leave the area after throwing the flower pot, and therefore, there was no longer a threat of imminent danger; the “assault” had ended. Although SP1 believed that the AV might continue to throw other flower pots or hurt others, the AV had not done so; and as a result, the physical hold was initiated out of SP1’s belief of what the AV might do and not what was actually happening. The conduct of implementing a physical hold that was not in response to imminent danger was inconsistent with the facility’s policies and violations of Minnesota Rules part 2960.0050, subpart 1, item R and 2960.0710, subpart 6, items A and B. Given that the AV was not causing harm to him/herself or others, that SP1’s actions were inconsistent with the facility’s policies and did not include lesser restrictive methods, and that SP1’s conduct likely escalated the AV, there was a preponderance of evidence that there was a failure to provide the AV with necessary care required and a failure to protect the AV from conditions or actions that seriously endangered the AVs physical or mental health when reasonably able to do so. It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so; failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). Furthermore, although SP1 denied placing the AV in a “choke hold,” Y2 saw SP1 with the AV in “a head lock” and based on review of the camera footage, this investigator also saw conduct that appeared consistent with this account. In addition, although SP1 denied calling the AV names when speaking to this investigator, the SP acknowledged to calling the AV “bitch” during the facility’s internal investigation. In addition, wrapping an arm around the AV’s neck had a potential to limit the AV’s ability to breathe. Therefore, there was a preponderance of evidence that the AV was subjected to actions that represented a substantial risk of physical injury. It was determined that physical abuse occurred ("physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. At the time of the incident, SP1-SP3 were working at the facility and therefore, were responsible for the AV’s care and supervision. Facility documentation stated that SP1-SP3 each received training on the facility’s handle with care, including Restrictive Procedures and De-escalation, and on the Reporting of Maltreatment of Minors Act. Regarding SP2 and SP3: Although SP2 did not provide information for this investigation, the camera footage showed SP2 reacting to what was happening and not initiating what was happening. Therefore, SP2’s responsibility was mitigated. Although SP3 grabbed the AV’s legs, which did not appear to be moving, SP3 arrived in the midst of the physical hold, and therefore had limited information about what transpired prior. SP3’s immediate reaction to take control of the AV’s legs was in response to the immediate situation. Therefore, SP3’s responsibility was mitigated. Regarding SP1: SP1’s conduct towards the AV, including initiating the hold, wrapping his/her arm around the AV’s head, and knocking the AV to the floor, was inconsistent with the facility’s policies and had a potential to cause injury to the AV. SP1 was responsible for maltreatment of the AV. 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 neglect and physical abuse for which SP1 was responsible was not “recurring” maltreatment because it was a single incident that met two definitions of maltreatment; and it did not meet the definition of being “serious” maltreatment. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review, and determined that policies and procedures were adequate, but not followed. “The physical and non-physical interventions used by staff were not executed in a manner consistent with the program’s restrictive procedure training (Handle with Care) including policies and procedures governing verbal de-escalation strategies. [SP1] admitted to using a profanity when speaking to a resident, which is not consistent with facility policy, mission, values, expectations, or training, specifically regarding resident rights and trauma-informed-care.” The facility provided additional training to SP1-SP3 regarding “Handle with Care including verbal de-escalation strategies and physical restrictive procedures, as well as trauma-informed care and review of resident rights.” Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. On February 15, 2023, the facility was issued a Correction Order for the violations outlined in this report. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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