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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.”
Suspected Maltreatment Reported: Allegation One: It was reported that while being supervised by three staff persons (SP1 - SP3) in a facility gymnasium, an alleged victim (AV1) was able to leave the facility without staff person supervision. Allegation Two: It was reported that SP1 threw a snowball and hit an alleged victim (AV2) in the face causing an injury to AV2. Allegation Three: It was reported that SP1 grabbed AV2 by the collar and pinned him/her to a door; and pushed an alleged victim (AV3) into a door. Allegation Four: It was reported that SP1 grabbed an alleged victim (AV4) by the shirt and pushed AV4 down on a couch. Date of Incident(s): Multiple between November 6 and December 15, 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 January 11, 2023; from documentation at the facility; and through thirteen interviews conducted with four alleged victims (AV1-AV4), another resident of the facility (R), four facility staff persons (P1-P4), two facility supervisory staff persons (P5-P6), and AV1’s and AV4’s guardians (G1 and G4). AV2’s and AV3’s guardians (G2 and G3) were each contacted via voicemail and correspondence, but did respond. SP1 was contacted by phone and a time was scheduled to do a phone interview. At the scheduled time, SP1 did not answer his/her phone and SP1 did not respond to a voicemail left at that time. On the day of the site visit, SP2 and SP3 each declined to be interviewed.
P4-P6 were aware of the allegations but did not have any firsthand knowledge of the allegations. P5 discussed the allegations with the staff persons doing the internal investigations for the facility. The facility was located in a campus style setting with separate buildings housing separate units. According to www.voamnwi.org, the unit of facility that the incidents occurred provided short term residential care for adolescents in crisis and/or transition that need out-of-home placement. 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. At the intersection of the two housing wings were staff offices, classrooms, and a corridor with an exit to right, a gymnasium ahead, and a hallway to the left with another exit. The office walls were made almost entirely of glass allowing increased visibility in and out. There were several cameras located within the facility. The facility’s Restrictive Procedures and Handle with Care Manual provided the following information: • Staff persons were supposed to use the least restrictive method to deescalate a situation. Initially, staff persons should listen to the resident, validate the resident’s feelings, focus on one issue at a time, encourage, offer alternative choices, and persuade the resident to agree on a course of action. • Physical holding was to be 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. Physical holding was immobilizing or limiting a person's movement by using body contact as the only source of restraint. · There was not physical intervention that involved grabbing a youth’s collar and pushing them into door. · “Shame-oriented punitive interventions, retaliation and public humiliation do not constitute limit setting.” Facility documentation showed that the SP1, SP2, SP3, P1, and P2 were each trained on the Reporting of Maltreatment of Minors Act. In addition, SP1-SP3 were trained and the facility’s policy related to supervision of residents and the Restrictive Procedures and Handle with Care Manual. Relevant Rules and/or Statutes: Minnesota Rules part 2960.0050, subpart 1, items N and R, states, in part, the license holder must ensure that a resident’s basic rights are protected, including: the right to courteous and respectful treatment and 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.. Minnesota Rules part 2960.0710, subpart 6, items A and B, states, in part, 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: an immediate intervention is necessary to protect the resident or others from physical harm; and the physical holding or seclusion used is the least intrusive intervention that will effectively react to the emergency. Allegation One: It was reported that while being supervised by SP1 - SP3 in a facility gym, AV1 was able to leave the facility without staff person supervision. The gymnasium was located south of the intersection of the two facility wings through a corridor. In the corridor to the west was an unlocked emergency exit and to the east was a hallway that went to a vestibule that led to an additional exit. In the gymnasium there was a camera above the north door accessing the corridor and an emergency exit in the corner to the west. AV1 was fourteen years old at the time of the incident. AV1 had a good sense of humor, wanted to develop relationships and connections, and enjoyed playing spooky video games and watching movies. AV1 provided the following information: · On November 6, 2022, before lunch, AV1 was in the facility gymnasium with SP1 – SP3 and other residents. AV1 was sitting in a chair watching as SP1 – SP3 and others were playing basketball. AV1 saw that SP2 left his/her keys under a chair and AV1 took the keys. AV1 then left the gymnasium, went into the hallway, and exited a door. · While AV1 was away from the building, s/he went to the parking lot and used the keys to unlock a car door. As AV1 was doing this, another resident, who was out on a walk, looked at AV1, so AV1 ran to the back of the building and into the woods. While in the woods, AV1 received cuts on his/her legs from sharp vines, fell, and believed “maybe broke one rib.” AV1 then walked towards the end of the facility’s driveway where it met a road. · Near the street entrance to the grounds, AV1 was then stopped by law enforcement and SP2 arrived in his/her personal vehicle. AV1 got into the law enforcement vehicle and was returned to the facility. When AV1 returned to the facility s/he was bandaged up by a staff person The facility Internal Review provided the following information: · On the date of the incident, SP1 – SP3 were in the gymnasium playing basketball with the residents. SP2 left his/her facility keys either under a chair or in a coat pocket. AV1 took the keys and camera footage reviewed by the facility showed that at 12:25 p.m., AV1 left the gymnasium unnoticed by SP1 – SP3 and exited the building through a door to the right of the gymnasium. · SP1 – SP3 were told by two other residents that AV1 had taken SP2’s keys and left. SP3 received a text message from another staff person stating that a resident was seen outside the building. Camera footage reviewed by the facility showed that at 12:36 p.m. SP1 and SP2 and two other staff persons exited the building to look for AV1. · SP1 called law enforcement regarding AV1 leaving. SP2 got into his/her personal vehicle and drove around the facility grounds and attempted to locate AV1. SP2 then saw AV1 with the law enforcement who were bringing him/her back to the facility. SP1 said s/he was called by law enforcement 15 minutes after the initial call and told that they found AV1 and were bringing him/her back to the facility. Camera footage reviewed by the facility showed that at 1:14 p.m. AV1 was returned to the building by law enforcement. AV1 was out of the building for 49 minutes. · AV1 told the law enforcement that s/he was injured by SP2 and SP3, but they believed the injuries to AV1 were done by him/herself and not by staff persons. After returning, SP1 attended to the cuts on AV1’s legs, discussed the incident, and AV1 went into their personal space for quiet time. (Note: In the Internal Review there is no mention of a rib injury to AV1.) Conclusion Allegation One: On November 6, 2022, while in the gymnasium, SP2’s unattended keys were taken by AV1 who then left the building at 12:25 p.m. without staff persons’ knowledge. AV1 was able to open a vehicle but then ran into the woods. SP1 - SP3 were alerted to AV1's departure by other residents, then searched the outside area, and SP1 telephoned law enforcement. AV1 was found by law enforcement near the entrance to the grounds and brought AV1 back to the building at 1:14 p.m. While out of the facility, AV1 said that while in the woods, s/he received some cuts on his legs, fell, and “maybe broke a rib.” There was no additional information that there were any concerns with AV1’s ribs. Although AV1 was able to leave without staff persons knowledge and with a set of keys, without additional information from SP1, SP2, and SP3, it was unclear what activities they were engaged in at the time AV1 left or the reason why SP2’s keys were not with SP2. In addition, AV1 never left the grounds and sustained minor scratches from being in the woods. Therefore, there was not a preponderance of the evidence that there was a failure to supply AV1 with necessary care or a failure to protect AV1 from conditions or actions that seriously endangered AV1’s physical or mental health. It was not 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 and/or 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). Allegation Two: It was reported that SP1 threw a snowball and hit AV2 in the face causing an injury to AV2. Surrounding the facility was a walking loop. AV2 was sixteen years old at the time of the incident. AV2’s was creative, smart, had a good sense of humor, and enjoyed playing video games, watching movies, and playing guitar. AV2 provided the following information to investigators and in the Internal Review: · On the date of the incident, AV2 was on the walking loop with staff and other residents. AV2 was throwing snowballs at them and was asked to stop and did not. SP1 “[got] mad at [AV3]” who was also throwing snowballs. SP1 then began packing snowballs. P1 and P2 were ahead of SP1 and AV2 during the walk. · AV2 said that SP1 “walked up to me with this packed, really packed ice snowball, and slammed it into my face, like hard.” AV2 said SP1 was about two feet away from him/her and that SP1’s hand was open when the snow hit AV2’s face. AV2 said it was “not playful,” but like SP1 was “trying to hurt [AV2] hard . . . really aggressive.” AV2 sustained a scratch as a result of this. AV2 provided different information regarding what happened next. AV2 told investigators that s/he thought SP1 put him/her into a hold, and “threw” AV2 into snow but in the Internal Review AV2 said the force of the impact of the snowball pushed him/her to the ground. · SP1 then stood over AV2 with a leg on either side of AV2 and kneeled down with another snowball in his/her hand. SP1 asked, “Are we going to stop?” and AV2 said, “No” and stood. AV2 saw SP1 pack another snowball, throw it at AV3, and “hit [AV3] with it in the face and tried throwing [AV3] to the ground.” · When initially interviewed by the facility on December 13, 2022, AV2 said that as s/he walked back towards the unit s/he “lightly” threw another snowball at SP1. SP1 then packed another snowball and threw it over AV2’s head. In subsequent interviews with investigators and the facility (January 11 and 18, 2023), AV2 stated SP1 hit him/her on top of the head with the snowball which resulted in a “migraine” and brief swelling on AV2’s head. · Once inside the building, P2 offered to assist AV2 with cleaning the injury on his/her face but AV2 declined apart from getting a cloth to clean his/her face. · AV2 said s/he later sustained a nosebleed after being hit on the head with the snowball from SP1, but also said it might have been from earlier when s/he was ill and blowing his/her nose a lot. AV2 said P2 saw the nosebleed. · AV2 said s/he was assessed by a facility health care professional (HCP) about three to four days later. (Note: The Internal Review stated that according to the camera footage at 11:41 a.m., AV2 came out of his/her room and was seen holding what appeared to be a napkin, toilet paper, or similar item with blood on it.) An undated Incident Report completed by the HCP said that AV2 received a “minor scratch on the left underside of [his/her] chin.” The scratch was “extremely superficial” and “3 inches long and ‘hairline’ in width.” The documentation stated there was “no active bleeding, bruising, or swelling. [AV2] report[ed] no pain or discomfort. No medical attention necessary.” AV3 provided the following information to investigators and in the Internal Review: · On the day of the incident, while on a walk, AV3 and AV2 threw snowballs at staff persons and other residents. AV3 saw SP1 take “a snowball chunk, put it on [AV2’s] face, and slam [AV2] into the snow.” AV3 heard AV2 call SP1 a “douchebag,” that SP1 “was not supposed to do that to kids,” and that AV2 wanted to press charges. AV3 turned around and started to walk back towards the facility. · SP1 then came up behind AV3, “took a snow chunk and put it on [AV3’s] face, and slammed [AV3] into the snow.” AV3 said AV1, another resident who was no longer at the program, and the R saw this occur. AV3 stood and walked the next “minute or two” back to the facility and inside. (In the Internal Review, AV3 was not interviewed about the incident, but in an interview by the facility about a subsequent incident that day, AV3 said that s/he “was already mad because of being pushed in the snow.” There was no additional information regarding the incident.) P1 provided the following information to investigators and in the Internal Review: · On December 11, 2022, in the late morning, AV2, SP1, P1, P2, and other residents were outside the facility walking the loop as part of a fitness program. AV2 threw snowballs at the others present including staff persons and residents. AV2 was asked by other residents and staff persons to stop but AV2 continued to do so. · P1 saw SP1 make a snowball and SP1 said it was for AV2, but P1 was unsure what SP1 was going to do with the snowball. SP1 told P1 s/he was going to do it, but P1 “didn’t know [SP1] was going to do all that.” P1 was ahead of AV2 and SP1 and said that from his/her “peripheral” and “quick glances,” s/he saw SP1 throw the snowball at AV2, push AV2 in the snow, and stand over AV2. P1 was not able hear the conversation between SP1 and AV2. (In the Internal Review P1 stated that s/he did not remember seeing SP1 throw the snowball at AV2, but from P1’s “peripheral” saw SP1 push AV2 into the snow. When SP1 was standing over AV2, P1 thought s/he heard AV2 say, “None of you guys see this?” and that s/he wanted to press charges.) P1 continued to walk with the other residents back into the building to keep them away from the situation. P1 and P2 were the last persons to enter the facility. · P1 did not see SP1 throw snowballs at any other resident or push any other resident into the snow. After returning, P1 saw that AV2 had a cut on his/her chin that was bleeding and AV2 declined first aid. P2 provided the following information to investigators and in the Internal Review: · P2 was outside with P1, SP1, and several residents. AV2 threw snowballs at peers and staff and was asked to stop by staff persons. SP1 told P2 s/he “would take care of it” and “handle it.” P2 then saw SP1 pick up snow and pack it down for “half the loop” making the snowball “really hard.” As they walked, P1 and P2 were with the other residents while SP1 and AV2 were behind them. · P2 said that s/he turned around and saw AV2 on the ground and SP1 standing over him/her. (In the Internal Review, P2 said that when s/he looked back, s/he saw that SP1 did not have the snowball and “[SP1] and [AV2] were going to the ground.”) P2 heard AV2 yelling at SP1 saying that s/he was “going to press charges” against SP1. SP1 then helped AV2 up from the ground. P2 walked with P1 and the other residents back to the building because s/he did not want the residents to “witness more.” P2 and AV2 were the last two to enter the facility behind SP1 and the other residents. P2 did not recall SP1 having any contact with AV2 outside the door. · After coming into the building, AV2 told P2 that s/he was bleeding from his/her cheek from the snowball. Later in the shift, P1 told P2 that AV2 said that the SP1 “hit [him/her] in the face with the snow.” P2 saw a cut on the left side of AV2’s jawline. P2 offered AV2 medical attention and a grievance form and provided AV2 with a warm washcloth. · While in the building, P1 informed P2 of AV2 getting a nosebleed and that AV2 gave P1 a “thumbs up, indicating that it was from the snowball.” P2 did not see AV2 with a bloody nose as AV2 came into the building or when s/he provided care to AV2’s chin. · Later in the shift, P2 was told by SP1 that s/he “smashed, like crushed, the snowball on [AV2’s] face.” · P2 said that s/he did not see SP1 throw snowballs at any other residents, did not see SP1 push any other residents down, and did not see any other residents on the ground, but P2 was not with SP1 the entire time. The R started an interview with investigators, but asked to end it prior to pertinent information being shared. SP1 provided the following information to the facility Internal Review: · AV2 and AV3 were throwing snowballs at peers and staff persons so SP1 told them to stop and they laughed in response. SP1 then “got escalated,” told AV2 and AV3 this was a “form of bullying,” and that SP1 “[did] not tolerate that.” AV2 then again threw a snowball at SP1’s chest. · SP1 “got escalated again and [SP1] decided to teach [AV2] a lesson.” SP1 made a snowball and “smashed the snowball in [AV2’s] face.” SP1 said that “with the force of [his/her] smashing [AV2] with the snowball [AV2] fell into the snow.” · SP1 “was still escalated,” told AV2 “that is what it feels like to be bullied,” and asked AV2 if s/he “liked that.” SP1 was “tired of [AV2] being a bully, and [SP1] wanted to teach [AV2] a lesson.” · SP1 did not say anything about hitting AV2 on the top of the head or throwing a snowball at AV3 or pushing AV3 to the ground. Because of the location of the incident, there was no camera footage available. Conclusion Allegation Two: A. Maltreatment: On December 11, 2022, staff persons and residents walked around the facility loop. AV2 and AV3 threw snowballs at others despite requests from staff persons to stop. P2 said that SP1 told him/her s/he “would take care of it” and “handle it.” SP1 provided information in the Internal Review that s/he became “escalated” and wanted to “teach [AV2] lesson” about bullying. SP1 then packed a snowball and approached AV2. SP1 smashed the snowball into AV2’s face causing AV2 to fall to the ground. P1, P2, and AV3 each saw SP1 hit AV2 with the snowball, push AV2 to the ground, and/or stand over AV2 while s/he was on the ground. As a result of the incident, AV2 sustained a three inch long and hairline cut to the left underside of his/her face that bled. AV2 gave inconsistent information regarding whether SP1 hit him/her on the head with snowball when walking into the facility and no staff persons witnessed SP1 hit the AV with another snowball. AV3 stated that SP1 hit him/her with a snowball and pushed him/her into the snow, but no one else besides AV2 saw this happen. Therefore, there was not a preponderance of the evidence that those incidents occurred. However, SP1’s actions of smashing a snowball into the face of AV2 was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, was purposeful and caused an injury to AV2. Therefore, there was a preponderance of the evidence that an injury was inflicted on AV2 other than by accidental means. 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. SP1 was trained on the Reporting Maltreatment of Minors Act and the facility’s policy related to Crisis Management/Physical & Non-Physical Intervention Techniques/De-escalation Techniques. SP1 was responsible for the care and supervision of AV2 at the time of the incident. SP1 was responsible for the maltreatment of AV2. C. Recurring and/or Serious Maltreatment: See Conclusion Allegation Four. Allegation Three: It was reported that SP1 grabbed AV2 by the collar and pinned him/her to a door; and pushed AV3 into a door. Allegation Three occurred on the same day shortly after the incident in Allegation Two. AV3 was fourteen years old at the time of the incident. AV3 had a history of property destruction. AV3 had a good sense of humor and enjoyed playing video games and spending time with his/her friends and family. 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 and allowed visibility in and out. There was a camera that faced the area that included visuals of the dayroom, hallway, and office. The camera recorded activity, but not audio. AV3 provided the following information to investigators and in the Internal Review: · The R stared at AV3, so AV3 pushed the R. SP1 saw this and pushed AV3 into a mirror and told AV3 to go to his/her room. SP1 pushed AV3 with both hands from the back again two more time into walls and doors and told AV3 to go to his/her room. SP1 told AV3 not to push the R and called AV3 “a bitch.” · During the Internal Review AV3 said s/he “was already mad because of being pushed in the snow” so when the R stared at him/her s/he pushed the R. SP1 then pushed AV3 into the mirror on the unit, into one of the bedroom doors, and again at his/her bedroom door. SP1 told AV3, “That’s what you get,” and AV3 believed it was regarding the earlier incident involving the snowballs. The R started an interview with investigators, but asked to end it prior to pertinent information being shared. P1 and P2 provided the following information to investigators and in the Internal Review: · P1 saw AV3 push the R into a metal door and then saw SP1 use both hands and push AV3 either by his/her front or side, towards the hallway. SP1 told AV3 to go to his/her room and AV3 went. P1 directed SP1 to go to another unit in the program or to take a break · P2 walked onto the unit with AV2. P2 heard the calming room door slam. P2 heard the R screaming and saw the R “cupping” his/her ear. P2 attended to the R and did not see the events between AV3 and SP1. P1 told P2 that SP1 “like charged after [AV3]” and P2 called “A Five Second Rule.” (Note: This is called to get all residents into their rooms in five seconds so staff persons can address a situation.) The facility Internal Review stated that at 11:30 a.m. residents along with SP1, P1, and P2 came onto the unit. AV3 pushed the R into the doorframe of the calming room. SP1 approached AV3 and pushed AV3 from the back into wall in front of AV3. (Note: No camera footage of this push/shove was provided to investigations.) Camera footage showed that as AV3 walked towards his/her door and SP1 followed behind. AV3 went into his/her room and SP1 pushed (a second time) AV3’s back from behind into the room by extending his/her arm behind AV3. AV2 was then seen coming out of his/her room while SP1 walked down the hall towards AV2. AV2 provided the following information to investigators and in the Internal Review: · AV2 said s/he was in his/her room during quiet time. AV2 opened the door and looked out of his/her room. SP1 came over, pushed the door closed, and “smash[ed] [AV2’s] hand a little bit.” (Note: No camera footage of this was provided to investigations.) · AV2 opened the door again and SP1 said to go back in for quiet time. AV2 opened the door fully and called SP1 an “idiot” or something. SP1 “then pinned [AV2] against the door with his/her forearm on [AV’s] chest.” SP1 said s/he was “crazy . . . didn’t care . . . wasn’t afraid” and would “kick [AV2’s] ass.” P1 walked over and told SP1 to stop. SP1 stopped and AV2 returned to his/her room. There were no other interactions between AV2 and SP1 that day. (Note: In the Internal Review AV2 said his/her nose started bleeding “a little after [the SP] pinned me up against the door.”) P1 and P2 provided the following information to investigators and in the Internal Review: · P1 saw AV2 come out of his/her room, SP1 grabbed AV2 by his/her shirt with one hand, and “put [him/her] against the door or the wall” for about five seconds. P1 guided SP1 away from AV2. P1 saw that SP1 was “escalated” so P1 told SP1 to go to the office, take a break, or leave. SP1 then left the unit. After the incident, P1 was not aware of any injuries to AV2. · P2 saw AV2 opened his/her door and SP1 was in front of it. SP1 yelled at AV2 and “grabbed” him/her by the front of his/her shirt with his/her two hands, pushed AV2 against the bedroom door. P2 intervened and told SP1 to remove him/herself from the situation and go to the office to calm. P2 then processed the situation with AV2. The facility Internal Review stated and the camera footage provided information that AV2 was standing in his/her doorway, talking to others around him/her. SP1 approached AV2 and appeared to use his/her body to push AV2 backwards into the room door. SP1 appeared to place his/her hands on AV2’s clothing near the collar and pushed forward that caused the door to open further. P1 and P2 approach them from two different hallways. P1 got in between SP1 and AV2 and P2 placed his/her hands on SP1’s back and guided him/her to leave the area. SP1 provided the following information in the Internal Review: · When staff persons and residents returned to the unit from their walk, SP1 saw AV3 push the R into the calming room door. SP1 “slightly pushed [AV3] and told [AV3] to go to [his/her] room.” SP1 followed behind AV3 and “put” him/her in his/her room. · A “Five Second Rule” was called and AV2 came out of his/her room and did not return. SP1 then grabbed AV2 by his/her shirt to try to get AV2 into his/her room. P1 and P2 told SP1 to “take a break” so s/he went into the office and then left the facility. Conclusion Allegation Three: A. Maltreatment: Information was consistent on December 11, 2022, after staff persons and residents returned inside from a walk, AV3 pushed the R into the calming room door. SP1 responded and pushed AV3 twice, once into a wall or doorframe and towards his/her bedroom. P2 called a “Five Second” but AV2 came out of his/her room. SP1 grabbed AV2 by the shirt, pushed him/her backwards, and pinned AV2 to his/her door. P1 and P2 approached SP1 and intervened. P1 got between SP1 and AV2, and SP1 was asked to leave the area. SP1 did so and AV2 returned to his/her room. AV2 reported a bloody nose, but it was unclear when it occurred and whether it was a result of this incident. Although AV3’s interaction with the R likely might have required intervention, when AV2 opened his/her bedroom door after a five second was called, AV2 was not a danger to him/herself or others and would not have required physical intervention. Therefore, pushing AV3 into a doorframe and then into his/her room and pinning AV2 up against the door and telling AV2 s/he was “crazy . . . didn’t care . . . wasn’t afraid” and would “kick [AV2’s] ass,” was not consistent with the facility policy and were a violation of Minnesota Rules, part 2960.0050, subpart 1, items N and R, and part 2960.0710, subpart 6, items A and B. Although there was no information that AV3 sustained an injury and that it was unknown whether AV2’s bloody nose occurred as a result of the incident, there was a preponderance of the evidence that shoving, pushing, and pinning residents was a failure to supply AV2 and AV3 with necessary care and failure to protect them from conditions or actions that seriously endangered their physical or mental health or safety. 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 and/or 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). 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. SP1 was trained on the Reporting Maltreatment of Minors Act and the facility’s policy related to Crisis Management/Physical & Non-Physical Intervention Techniques/De-escalation Techniques. SP1 was responsible for the maltreatment of AV2 and AV3. C. Recurring and/or Serious Maltreatment: See Conclusion Allegation Four. Allegation Four: It was reported that SP1 grabbed AV4 by the shirt and pushed AV4 down on a couch. The dayroom of the facility had resident bedroom doors along two sides across from each other and were connected by two hallways and staff offices. In the middle of the dayroom were four couches. The couches were wooden with three cushion seats and backs. As a result of Allegation Three, SP1 was reassigned to work in a different unit which was in a different building. P5 was uncertain why SP1 was on the unit at the time of this incident. AV4 was fifteen years old at the time of the incident. AV4 had a history aggression towards others and anger management difficulties. AV4 enjoyed going fishing, swimming, and using jet skis and four wheelers. AV4 provided the following information to investigators and in the Internal Review: · On December 15, 2022, while in the dayroom AV2 was upset and yelled at others. AV4 heard SP1 call AV2 “dumbass” and AV2 walked towards his/her bedroom as SP1 continued to talk to him/her. At that point, AV4 also attempted to get AV2 to go to his/her room. SP1 then grabbed AV4 by his/her shirt collar and “was in [AV4’s] face.” P3 told SP1 to let go of AV4. SP1 raised his/her fist at AV4 and SP1 said, “Don’t fucking play with me,” and then released AV4. SP1 returned to AV2’s doorway. · AV4 then threw a deck of cards towards SP1 and AV2 and SP1 “grabbed” AV4 by the front of the neck with one hand. SP1 faced AV4 as AV4 backed away from SP1 who continued to grasp AV4’s neck. SP1 then pushed AV4 over the side edge of the couch and slammed” him/her onto the couch. AV4 received a scratch on his/her neck from SP1’s nails. SP1 told AV4 not to “fucking play” with SP1. · SP3 came over and “pulled” SP1 off AV4 and then took AV4 to the calming room. P3 told SP1 to take a break off of the unit. P3 provided the following information to investigators and in the Internal Review: · At the time of the incident in the common area, AV4 was swearing at staff persons and other residents and calling them names. Staff persons told the other residents not to interact with AV4. AV2 got upset with staff persons because they did not intervene when AV4 called SP3 an “idiot.” SP1 then called AV2 “a dumbass” and AV2 began to yell. AV4 went to AV2’s bedroom doorway, gave AV2 “positives” and attempted to get AV2 to stop and go into his/her room. P3 stood in front of AV4 and told him/her to go to his/her bedroom. · P3’s back was to SP1 and AV4 so P3 did not see the initial interactions between SP1 and AV4. P3 looked behind him/her and saw SP1 put AV4 into a “normal hold.” P3 saw SP1 reach under AV4’s arms, “pull” AV4 away from AV2’s doorway, and then let AV4 go from the hold. (Note: After the incident, AV4 told P3 that SP1 “grabbed” him/her by the neck and “ripped” him/her away from the door.) · During the incident, AV4 was “very escalated, very verbally abusive” towards staff persons. At one point after SP1 let AV4 go, AV4 threw a deck of cards at SP1. SP1 “grabbed” AV4 again and pushed him/her onto the couch. SP3 “pulled” SP1 off of AV4 and then escorted AV4 to the calming room to get him/her away from SP1. P3 then told SP1 to leave the unit. · P3 talked with AV4 afterwards. AV4 said that s/he got a scratch on the neck and P3 documented it on an incident report (investigators requested the incident report, but the facility was not able to provide one). P3 said the scratch was “very minimal” about “the length of a fingernail,” and was not bleeding. SP3 provided the following information in the Internal Review: · AV2 called SP3 an “idiot,” picked up a hair gel container, and “made it seem like [s/he] was going to throw it at someone.” AV2 went back into his/her room and called SP3 “a piece of shit, unintelligent, and a dumb ass.” · A "Five Second” was called and AV4 went to AV2’s room. Staff persons told AV4 to go to his/her room and s/he did not. SP1 “moved” AV4 away from AV2’s door. AV4 threw a deck of cards at SP1’s face and SP1 grabbed AV4, but SP3 could not recall how. SP1 “put” AV4 onto the couch. SP3 “grabbed” AV4 and escorted him/her to the calming room. According to the Internal Review, SP1 told P5 that after AV4 threw cards at him/her, s/he “grabbed” AV4 by the shirt and then pushed him/her down on the couch. The Internal Review stated camera footage showed that at 7:37 p.m. AV2 was outside his/her door and talking with AV1. AV4 approached AV2 and pushed him/her into his/her room. (Note: This footage was not shared with investigations). The camera footage showed the following: · AV2 was in his/her bedroom doorway facing the common area. AV4 was in the common area and faced AV2. P3 was next to the door and then moved behind AV4 and faced AV2. SP1 and SP3 were in the common area and walked towards AV2’s door. · SP1 approached AV4 from behind, wrapped his/her left arm under AV4’s arm and grabbed towards the middle of AV4’s sweatshirt. SP1’s right hand was on AV4’s right shoulder. SP1 spun AV4 away from AV2’s door but AV4 resisted and got away from SP1’s right hand but SP1’s left hand remained gripped on AV4’s sweatshirt. At this point, SP1’s body was turned away from the camera. · SP3 walked over to SP1 and AV4 and attempted to separate them, but SP1 remained gripping AV4’s sweatshirt with his/her left hand. SP1 moved toward AV4 as AV4 moved backwards several steps. SP1 released AV4 from his/her grip. SP1 and SP2 returned to AV2’s doorway. AV4 then took a deck of cards and threw them at SP1 and AV2. · SP1 went behind SP3, approached AV4, and with his/her left hand, grabbed the front of AV4’s sweatshirt. SP1 continued to walk forward and then extended his/her right hand and pushed AV4 backwards approximately three feet to the couch in the middle of the room. SP1 continued to hold AV4 as SP1 pushed AV4 over the wooden arm of the couch. The couch moved and AV4 landed on the couch back and then lower cushions lying flat down. SP1 continued to hold AV4’s sweatshirt and leaned over AV4 while s/he moved around to the back of the couch. SP1’s hands were near AV4’s upper chest around the sweatshirt collar area. · SP3 approached AV4 and SP1 from the front of the couch and placed his/her hands on AV4, but SP1 blocked the view of where SP3’s hands were. SP3 attempted to pull AV4 away from SP1 as SP1 continued to hold AV4 which appeared to jostle AV4. SP3 again pulled AV4 and SP1’s grip released. SP3 pulled AV4 from the couch and guided AV4 away from SP1 when the footage ended. P3 stood with AV2 at his/her door during the incident. Conclusion Allegation Four: A. Maltreatment: Camera footage showed that on December 15, 2022, AV4 stood in AV2’s doorway. SP1 grabbed AV4 gripping the chest of AV4’s sweatshirt from behind and spun/moved AV4 away from AV2. SP3 separated AV4 from SP1. AV4 then threw a deck of cards towards AV2 and SP1. SP1 then again grabbed AV4’s sweatshirt at the neck and walked forward while pushing AV4 backwards, eventually pushing AV4 over the wooden arm of the couch and onto the cushions. SP3 approached them, placed his/her hands on AV4, and removed AV4 from the situation. AV4 said that after the incident, s/he had a scratch on his/her neck from where the SP grabbed him/her. P3 said that after the incident, s/he saw a small scratch, that was not bleeding, on AV4’s neck. At the time of the incident, SP1 was assigned to work in a different unit and it was unknown why SP1 was present. In addition, AV4 was not a danger to him/herself or others and did not require physical intervention. SP1’s actions were not consistent with the facility policy and were a violation of Minnesota Rules, part 2960.0050, subpart 1, items N and R, and part 2960.0710, subpart 6, items A and B. In addition, given that the camera footage showed AV4’s body connecting with the couch with enough force to move the couch, the SP’s actions of pushing AV4 across the floor over the arm of a wooden couch posed a serious risk of harm to AV4. Therefore, there was a preponderance of the evidence that there was a failure to supply AV4 with necessary care and a failure to protect AV4 from conditions or actions that seriously endangered AV4’s physical health. 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 and/or 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). In addition, because during the incident SP1 was not engaged in any intervention approved for use by the facility, and that SP1’s actions caused a scratch on AV4’s neck, there was a preponderance of the evidence that an injury was inflicted on AV4 other than by accidental means. 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. SP1 was trained on the Reporting of Maltreatment of Minors Act and Crisis Management/Physical & Non-Physical Intervention Techniques/De-escalation Techniques. SP1 was responsible for the maltreatment of AV4. 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 physical abuse and neglect for which SP1 was responsible was recurring maltreatment because SP1 was responsible for the maltreatment of AV2 in Allegation Two, AV2 and AV3 in Allegation Three, and AV4 in Allegation Four. In addition, it was determined that the substantiated physical abuse for which SP1 was responsible was serious maltreatment as it resulted in a cut on AV2's head that bled in Allegation Two, and a scratch on AV4’s neck in Allegation Four. SP1 was disqualified from providing direct contact services. Action Taken by Facility: Allegation One: The Internal Review stated the facility determined policies and procedures were adequate related to the incident, but not followed. SP1, SP2, and SP3 each received corrective action for not following policy related to supervision of residents. This included the requirement to complete a retraining on the policies, procedures, and expectations involving supervision of residents. SP2 also received corrective action for not maintaining possession of his/her facility keys. Allegation Two: The Internal Review stated the facility’s policies and procedures were not adequate and were not followed. The facility stated, “Current procedures for grievances meet requirements and should be reviewed to determine if modifications are appropriate for quality assurance purposes. Current procedures for internal reviews meet requirements and should be reviewed to determine if modifications are appropriate for quality assurance purposes.” SP1 was reassigned to another unit. A quality assurance review was to be completed by the administrative team and may result in additional corrective actions and/or additional training plans if deemed appropriate. P1 and P2 were given additional training on related to documentation of incident reports and incident notifications. Allegation Three: The Internal Review stated the facility’s policies and procedures were not adequate and were not followed. The facility stated, “Current procedures for grievances meet requirements and should be reviewed to determine if modifications are appropriate for quality assurance purposes. Current procedures for internal reviews meet requirements and should be reviewed to determine if modifications are appropriate for quality assurance purposes.” SP1 was reassigned to a different unit. A quality assurance review was to be completed by the administrative team and may result in additional corrective actions and/or additional training plans if deemed appropriate. P1 and P2 were given additional training related to documentation of incident reports and incident notifications. Allegation Four: The Internal Review stated the facility’s policies and procedures were not adequate and were not followed. The facility stated, “Current procedures for grievances meet requirements and should be reviewed to determine if modifications are appropriate for quality assurance purposes. Current procedures for internal reviews meet requirements and should be reviewed to determine if modifications are appropriate for quality assurance purposes.” A quality assurance review was to be completed by the administrative team and may result in additional corrective actions and/or additional training plans if deemed appropriate. SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 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 SP1 was responsible for maltreatment and the disqualification of SP1 are each subject to appeal. On August 2, 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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