|
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.” Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1036848-CRF (Children’s Residential Facility) Investigator(s): Kimberly Huettl Anderson kimberly.huett.anderson@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) allowed two alleged victims (AV1 and AV2) and one vulnerable adult (VA) use his/her nicotine vape pen on more than one occasion. Date of Incident(s): September 22, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): 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. 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 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 27, 2023; from documentation at the facility; and through eleven interviews conducted with AV1, AV2, and the VA; facility staff persons, AV1’s guardian (G1), AV2’s guardian (G2), and the VA’s family member (FM), and the SP. The facility provided residential care for adolescents in need of out-of-home placement. AV1’s Client Info stated that AV1 was sixteen years old at the time of the incident and diagnosed with oppositional defiant disorder, attention-deficit hyperactivity disorder, cannabis dependence disorder, and alcohol dependence disorder. AV1’s Person Centered Treatment Plan stated that s/he was admitted to the facility for substance abuse and mental health concerns. Staff persons were to provide AV1 with coping skills to manage his/her mental health and substance abuse. AV2’s Client Info stated that AV2 was fifteen years old at the time of the incident and diagnosed with Cannabis dependence, post-traumatic stress disorder, attention deficit hyperactivity disorder, and reactive attachment disorder. AV2’s Person Centered Treatment Plan stated that AV2 was admitted to the facility to address his/her nicotine, vaping, marijuana usage and to develop effective coping skills to manage his/her substance abuse and mental health concerns. The VA’s Client Info stated that the VA was eighteen years old at the time of the incident and diagnosed with cannabis and nicotine dependence disorder, major depressive disorder, attention deficit hyperactivity disorder, and anxiety disorder. The VA’s Person Centered Treatment Plan stated that the VA was admitted to the facility for substance abuse and mental health concerns. The facility’s Critical Incident Reporting Form stated that on September 22, 2023, the SP took AV1, AV2, and the VA on a walk and let AV1, AV2, and the VA use the SP’s nicotine vape pen. AV1 told this investigator that on the day of the incident, AV1, AV2, and the VA went on a walk around the facility with the SP. When the SP pulled a nicotine vape pen out of his/her pocket, AV1, AV2, and the VA asked the SP if s/he would let them use it. The SP gave the nicotine vape pen to AV2 first and then AV2 gave it to AV1 and the VA. AV1 stated that s/he did not want to use the nicotine vape pen, but s/he did because s/he felt peer pressured. AV2 did not want to talk to this investigator about the incident. The VA told this investigator that s/he saw the SP share the nicotine vape pen with AV1 and AV2 but that s/he did not use it because s/he was discharging from the facility soon. Two facility management persons (P1 and P2) and one staff person (P3) provided the following information: · P1, P2, and P3 each stated that on the day of the incident, P3 brought a fourth resident on a walk to meet up with the SP, AV1, AV2, and the VA. When P3 and the other resident approached the SP, AV1, AV2, and the VA they smelled a blueberry scent. P3 did not recognize the smell but the other resident told P3 that it was a vape.
· P3 did not see the vape pen and did not talk to the SP about the incident but talked to P1 about it. · P1 and P2 were not at the facility at the time of the incident, but P1 received a message from P3 about the incident that evening. The next morning P1 and P2 spoke to AV1, AV2, and the VA individually and asked them if the SP allowed them to smoke his/her vape pen. At that time, AV1, AV2, and the VA all denied smoking the vape pen. · After talking to AV1, AV2, and the VA, P1 and P2 asked them to submit a urine analysis which came back positive for nicotine. · P1 and P2 spoke to the SP on the day after the incident. The SP told P1 and P2 that s/he gave his/her vape pen to AV1, AV2, and the VA and allowed them to use it when they were on a nature walk. P2 stated that the SP also said that s/he allowed AV1, AV2, and the VA to use his/her vape on one other occasion but did not provide any details about when the other incident occurred. · P1 and P2 did not know how many times that AV1, AV2, and the VA used the SP’s vape pen. P2 stated that many of the youth tested positive for nicotine because vape pens were easily accessible to them. P1 and P2 each stated that it was not uncommon for the VA’s urine tests to be positive for nicotine because the VA admitted to using nicotine when s/he was on home visits. · The facility prohibited all drugs and alcohol on the premises except for nicotine for staff persons. However, staff persons were to keep their cigarettes or vape pens in their car and use them off site if they required a “smoke” break. · P1 and P2 each stated that the SP was trained on the facility’s drug and alcohol policies, on professional boundaries, and on AV1’s, AV2’s, and the VA’s treatment plans prior to the incident. The SP provided the following information: · On September 22, 2023, the SP went on a nature walk around the facility with AV1, AV2, and the VA. When they entered a wooded area, AV1, AV2, and the VA asked if they could use the SP’s vape pen. The SP stated that s/he felt “ganged up on” so s/he let them take “several hits” of the vape pen. · AV1, AV2, and the VA each knew that the SP carried his/her vape pen in his/her pocket because they saw the SP carrying it in his/her hand. The SP stated that s/he was trained to keep the vape pen in his/her vehicle, but that s/he felt that keeping the vape pen in his/her pocket was “safer.” · When P1 and P2 asked the SP if s/he allowed AV1, AV2, and the VA to use his/her vape pen, s/he acknowledged that s/he had let them use it on more than one occasion. The SP told this investigator that AV1, AV2, and the VA each used the SP’s vape pen on three separate occasions. · The SP was aware that AV1, AV2, and the VA struggled with substance abuse and that they were at the facility to receive substance abuse treatment, but the SP did not consider nicotine a drug. G1 stated that s/he was aware of the incident involving the nicotine vape pen but did not have any other concerns about the facility. G2 was concerned about the incident involving AV2 using the SP’s nicotine vape pen as well as being concerned about the lack of communication from facility management persons regarding AV2’s progress at the facility. The FM was concerned that the SP allowed the VA to use his/her nicotine vape pen when the VA was at the facility for substance abuse. The facility’s Cumulative Reports for AV1, AV2, and the VA’s urine analysis dated September 3 and October 22, 2023, provided the following information: · AV1 was positive for nicotine on September 5, 15, 22, and 23, 2023. · AV2 was positive for nicotine on September 5, 15, and 22, 2023. · The VA was positive for nicotine on September 3, 5, 10, 15, 18, 22, 24, and 29, 2023. The facility’s Smoking/Tobacco Use policy stated that residents and staff persons were “never” allowed to use tobacco on the facility’s property or during facility activities. Facility staff persons were to keep tobacco concealed within a vehicle or the back office and not within a residents’ access. Facility staff persons were prohibited from providing the tobacco products to residents. The facility’s personnel files showed that the SP was trained on the facility’s Smoking/Tobacco Use policy on July 17, 2023. The SP, P1, P2, and P3 were each trained on the Reporting of Maltreatment of Minors Act and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident.
Relevant Rules and/or Statutes: Minnesota Statute, section 609.685 states in part that persons under the age of 21 can not be sold, given, or otherwise furnished tobacco, tobacco-related devices, or electronic delivery devices. Conclusion: A. Maltreatment: On September 22, 2023, the SP, AV1, AV2, and the VA went on a walk and AV1, AV2, and the VA took “several hits” off of the SP’s vape pen. The SP also told P1 and P2 that s/he allowed AV1, AV2, and the VA to use his/her vape pen on more than one occasion and told this investigator that s/he allowed them to use it on three separate occasions. AV1, AV2, and the VA each had a history of substance use and were at the facility in part to develop coping skills to address their substance use. Although the SP did not consider nicotine a drug, providing nicotine to AV1 and AV2 who were minors, and to the VA who was considered underage constituted an illegal act and encouraged each to engage in illegal activities, therefore there was a preponderance of the evidence that there was a failure to provide AV1 and AV2 with necessary care and that there was a failure to provide the VA with care that was reasonable and necessary. 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 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). It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). 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. The SP was responsible for the care of AV1, AV2, and the VA. The SP was trained the facility’s Tobacco/Smoking policy, the Reporting of Maltreatment of Minors Act, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The SP was responsible for maltreatment of AV1, AV2, and the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was not serious because AV1, AV2, and the VA did not sustain an injury requiring medical care, but was considered recurring maltreatment because s/he stated that s/he allowed AV1, AV2, and the VA to use his/her vape pen on three occasions. The SP was disqualified from providing direct contact services. 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 their policies and procedures were adequate but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. 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.
|
