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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: 1093608-HCBS (Home and Community-Based Services) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) obtained a knife while s/he was unsupervised in the community. On October 26, 2023, the AV and a staff person (SP2) got into an argument and the AV stabbed SP2 with the knife. Date of Incident(s): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 6, 2023, and January 10, 2024; from documentation at the facility and law enforcement records; and through ten interviews conducted with an administrative staff persons (P1), two supervisory staff persons (P2 and P3), three facility staff persons (SP1, SP2, and P4), the AV, the AV’s family member (FM1), a community person (CP) who worked at the AV’s school, and the AV’s case manager (CM). The facility provided crisis respite services to alleged victims and vulnerable adults in extended stay hotels. The facility provided around the clock one to one staffing for each alleged victim and vulnerable adult. Consistent information was provided that there were three clients (the AV, C1, and C2) who resided at the extended stay hotel in their own rooms. (Throughout the report, facility was used to reference the hotel and the services provided therein by staff persons. Hotel and facility are used interchangeably.) The AV was diagnosed with fetal alcohol syndrome disorder and anxiety. The AV was 16 years old at the time of the incident and attended an alternative high school. The AV attended school during the weekdays and enjoyed playing basketball at community parks. According to the AV’s Coordinated Services and Supports Plan (CSSP), the AV required 24-hour monitoring and supervision to ensure both his/her health and safety and the safety of other persons. The AV also required “extensive support and supervision” to monitor and address his/her mental health needs. The AV required 1:1 staffing to provide behavioral support and provide him/her with supervision at the facility and in the community. The facility provided a 24-hour care plan including awake overnight staffing. According to the AV’s Support Plan Addendum – Basic Support Services: · When the AV was upset, s/he preferred that staff persons intervened with verbal prompts that assisted the AV with coping skills along with helping the AV “walk away” from a situation. It was important to the AV that staff persons allowed him/her to “vent” his/her frustrations and feelings and that staff persons validated the AV’s feelings and let the AV know s/he was heard. · If the AV had an object used to hurt himself or other persons, staff persons removed the object and placed the item out of reach. Once the AV demonstrated that s/he was able to be safe with him/herself and other persons, staff persons returned the item to the AV. According to the law enforcement report: · On October 26, 2023, at 3:36 p.m., four law enforcement officers (LEO1-LEO4) responded to the hotel on a report of a stabbing. When LEO1 arrived at the hotel, s/he saw the AV and P4 walking along a sidewalk. LEO1 and LEO2 walked over to the AV and P4. LEO2 spoke to the AV who was “agitated” and “upset.” · The AV was placed in handcuffs and LEO1 found a “folding knife” in the AV’s front left pocket. The blade of the knife had “markings/residue” on the end of the blade. The AV was placed in the back of a police vehicle and during that time, the AV said that “someone inside” was “disrespecting” FM1 and the AV stabbed that person. · LEO3 spoke to P4 who said that s/he was inside another hotel room when s/he heard a “commotion” in the main hall. P4 walked out and saw the AV with a knife in his/her hand stabbing SP2 “multiple times.” P4 “tackled” the AV and the knife came out of the AV’s hand. The AV calmed and P4 “let [the AV] back up off the ground to use the least amount of force” with the AV. The AV then ran at SP2 a second time with the knife in his hand so P4 “pinned” the AV against a wall in the standing position. P4 was not certain how the AV obtained the knife. The AV refused to give P4 the knife but agreed to walk outside with P4. · LEO4 went to a hotel room and spoke to SP2. SP2 had a visible stab wound that was about one-half inch long on his/her left calf. LEO4 asked SP2 if s/he had been stabbed anywhere else and SP2 was unsure. Paramedics checked SP2 and said they did not find any other stab wounds. SP2 had a small abrasion across his/her left forearm and said his/her head “hurt.” SP2 had swelling in the center of his/her forehead and a small cut in the corner of his/her left eye. · SP2 told LEO4 that s/he was inside the AV’s room with the AV when s/he was “attacked.” SP2 was not allowed to restrain clients so SP2 placed a chair between him/her and the AV. The AV punched SP2 “several times” in the head. SP2 left the room and “ended up” on the floor with the AV stabbing SP2. SP2 said s/he thought s/he was stabbed more than once. SP2 was then transported to a hospital. · LEO4 then went and spoke to FM1 who had arrived at the hotel. FM1 said that earlier s/he received a phone call from the AV. FM1 said that the AV was “disrespected” by SP2 and FM1 heard the AV and SP2 arguing back and forth. The AV provided the following information: · On approximately one or two previous occasions, SP1 brought the AV to the park and while the AV played basketball with other persons, SP1 went in his/her personal vehicle in the parking lot. SP1 was not able to see the AV from inside his/her vehicle. · On one of those occasions, while SP1 was inside his/her vehicle for “a couple [of] hours,” the AV got into a fight with other persons. They were “slap boxing” for approximately 10 seconds before the AV ran away from the group. The AV was not injured. At one point, the AV went to the parking lot and SP1’s vehicle was not there. The AV went and played basketball and approximately 30 minutes to one hour later, SP1 showed up in his/her vehicle. · The AV did not specify which time, but said on one occasion while at the park, the AV got a pocketknife while SP1 sat inside his/her vehicle. The facility did not allow the AV to have weapons but in the past, the AV was able to obtain a vape pen and a switch blade while residing at the facility. The AV got the switch blade from a friend at school. · On a later date, while SP2 was working at the facility, the AV was on his/her cell phone talking to FM1 when SP2 said “something rude.” The AV did not remember what SP2 said but remembered going over to SP2 who was in a chair, hitting him/her, and telling him/her not to be “rude” to FM1. At one point, SP2 stood up and ran behind a chair and then out of the hotel room into the hall. The AV ran after SP2 and while in the hotel lobby, SP2 “sucker punched” the AV in his/her face, “threw” the AV to the floor, and stood over the AV. The AV pulled out the pocketknife and stabbed SP2 in the ankle. SP2 ran away from the AV and the AV followed. When they got to C1’s door, the AV stabbed SP2 in his/her back and neck area. SP2 went inside C1’s room and the AV then stabbed the door. (Note: The AV did not provide further information regarding this incident.) P4 provided the following information: · A few weeks prior to October 26, 2023, other staff persons messaged on the GroupMe app discussing the AV possibly having a knife but P4 did not recall any details about it. P4 generally worked with another client so was not familiar with the AV’s regular staff persons and was not able to provide information on which staff persons were discussing the knife. · On October 25, 2023, P4 saw the AV for approximately five minutes and did not see bandages on the AV’s hands at that time. · On October 26, 2023, during breakfast, P4 saw bandages on the AV’s hands and asked him/her about them. The AV said s/he was “bored” and cutting him/herself while at school. Otherwise, the AV was “great” and “wonderful” so P4 did not “make an issue” of it. The AV then went to school. · At 3 p.m., after the AV returned from school, P4 clocked out and was waiting in the lobby for his/her ride. P4 heard SP2 say something from the AV’s room about calling FM1 but P4 did not hear clearly because s/he was down the hall. SP2 was “more firm” when the AV did not respond but P4 did not have previous concerns with their interactions. · Approximately 10 to 15 minutes later, P4 saw the AV, with a knife in his/her hand, chasing SP2 down the hall to the lobby. The AV stabbed SP2 “a few times” with the knife as P4 stood up and told the AV to calm. P4 was bigger in stature so s/he stood between the AV and SP2 and continued telling the AV to calm and asking him/her what was going on. The AV still had a knife in his/her hand so P4 “gently bear hug[ged]” the AV while SP2 ran to C1’s room. The AV broke away from P4 and chased SP2 down the hall. The AV yelled at SP2 about not saying things about FM1. SP2 was able to get inside C1’s room. · The AV was trying to get to SP2 and stabbed C1’s door. P4 got between the AV and door and “hugged” the AV to let the AV know that P4 was there and to try to calm the AV. P4 used his/her hand to hold the AV’s hand with the knife it in while telling the AV to calm. Eventually the AV and P4 locked arms together and walked outside until law enforcement arrived. P4 said that at no time did s/he put the AV in a hold on the floor. FM1 provided the following information to this investigator and in a written statement: · Since the prior summer, the AV told FM1 and FM2 that s/he had a knife for “protection” from other persons who attended his/her school and FM1 and FM2 told the AV that was not the best decision. The AV had a history of getting knives and vape pens at school. · A few months prior to October 26, 2023, the facility changed from a regular Community Residential Setting (CRS) facility to Crisis Respite Care facility. Since then, things had been deteriorating so FM1 and FM2 were in the process of finding the AV another facility to reside when the incident took place. · Approximately one week prior to October 26, 2023, a little after 5 p.m., the AV called FM1 and said s/he was “robbed” at a park. FM1 asked the AV where a staff person was and the AV responded, “Why does that matter?” After 7 p.m., the AV called and asked if FM1 could come get the AV from the park. FM1 asked the AV where the park was located and why a staff person was not with the AV. The AV responded that s/he did not know where the staff person was and that s/he left the AV alone at the park. FM1 did not go to the park to get the AV.
· At some point, FM1 spoke to P2 who said the AV bought a knife from someone at the park while s/he was without a staff person. The staff person who was with the AV sat in his/her vehicle for a while and then left the park. P2 also said s/he was going to contact the licensing agency and file a report. On October 24, 2023, the AV visited FM1 and FM2 at their house and did not have cuts on his/her hands. · On October 26, 2023, at 2:46 p.m., FM1 received a phone call from the CP saying s/he was concerned because earlier that day and the previous day, the AV had “deep cuts” on his/her hand, possibly from a piece of glass. The CP said s/he asked the AV about the cuts and the AV “brushed off” the CP and said s/he fell off a bike. The CP found out from another community person who worked at the school that the AV had been “cutting” his/her hand while at the facility because s/he felt like staff persons “ignored” him/her. · FM1 hung up and “immediately” called P3 and told him/her what the CP said. P3 was “alarmed” that staff persons did not notice cuts on the AV’s hand and/or notify P3. P3 said s/he was going to contact staff persons and follow up. · After P3 and FM1 hung up the phone, the AV called FM1 and said s/he wanted to go to a park and asked FM1 if s/he would pay for a taxi service. The AV had a history of using taxi services if staff persons were unable to drive the AV. FM1 reminded the AV s/he was not allowed to go to a park without a staff person and the AV “complained” that the staff person working would not take the AV to a park. · FM1 heard a staff person later to be determined to be SP2 yell in the background, “Of course I will not let you go to the park.” The AV asked SP2 about visiting another client at the hotel and SP2 responded, “Of course I will not let you go to someone else’s room.” SP2 did not provide reasons why the AV was not allowed to go to either place. · The AV told SP2 s/he was “disrespectful” and SP2 said something along the lines of, “You are just a [boy/girl].” FM1, who was on speaker phone, responded that the AV was sixteen years old and a teenager. SP2 got “mad” and yelled, “You always let [the AV] disrespect you.” FM1 was “upset” by the comment so s/he told the AV s/he was hanging up and coming to the facility to get the AV. · FM1 called P3 and told P3 about SP2’s interaction with the AV and said s/he was going to the facility. While they were talking, P3 said s/he got a text from SP2 that the AV stabbed him/her. P3 then hung up the phone to find out what was happening at the facility. · FM1 and FM2 drove to the facility and spoke to P4 and then law enforcement who said they were transporting the AV to a detention center. FM1 spoke to P3 and told P3 that P2 previously said that the AV had got a knife at the park. P3 said s/he was unaware of the knife because P2 had not told P3. FM1 also told P3 that s/he told P2 that s/he could search the AV’s belongings and did not know if they had found the knife. · Later on at the detention center, FM1 and FM2 asked the AV about the cuts on his/her hands. The AV said s/he was “bored” at the facility and “frustrated” with staff persons. FM1 did not remember the names of the staff persons the AV was frustrated with. The AV said the knife s/he used to cut his/her hands was the one s/he got at the park, but later threw out in a garbage can. The AV did not tell FM1 where s/he got the knife that s/he used to stab SP2. FM1 was unsure if it was the same knife or two different knives. SP1 provided the following information: · SP1 generally worked with another client at the facility. SP1 asked P2 “multiple times” if s/he could read the AV’s plans and P2 responded that s/he would bring the AV’s plans the next time s/he worked since they were not at the hotel. SP1 said s/he was not trained on the AV’s plans so s/he did not know the AV’s supervision requirements, so s/he provided the same supervision as s/he did with another client. P2 was aware that SP1 brought the AV out in the community but did not discuss the AV’s supervision requirements with SP1. · On approximately three or four occasions, SP1 and the AV went to the park where the AV mostly played basketball. On two of those occasions, for approximately five minutes, SP1 sat inside his/her vehicle to warm up while s/he watched the AV play basketball. SP1 denied leaving the park. · One time while at the park, the AV called FM1 and asked if it would be “okay” to bring a knife to school. FM1 told the AV that it would not be okay. The AV said s/he previously saw a friend at school with a knife and the AV needed one for “security.” FM1 again said, “No,” and they changed topics. The AV did not have pockets so SP1 did not think the AV had a knife. · On a later unknown date, P2 called SP1 who said that the CP called and said the AV had a knife that s/he got from the park. SP1 was not aware of the AV getting a knife while at the park. The CP provided the following information: · On October 12 or 13, 2023, another community person at the AV’s school told the CP that the AV had cuts on his/her hands. The CP went to the AV and saw “pretty deep” cuts on the AV’s hands and the AV said they were from falling off a bike. The AV showed the CP a video from a park where s/he was slap boxing other persons. The CP asked the AV about a staff person while at the park. The AV said the staff person was inside his/her vehicle, often stayed in his/her vehicle, and the AV was allowed to “do what [s/he] wants.” The AV did not provide the CP with the staff person’s name. The AV told the CP s/he purchased a knife while at the park. The CP asked the AV why and the AV said to “protect” him/herself. · The CP texted P2 and at 3:30 p.m., P2 called the CP. The CP told P2 that s/he was concerned because the AV had cuts on his/her hand, the AV was at parks alone, and got a pocketknife while at a park. P2 said s/he would look into the situation and follow up with the CP but did not follow up. · On October 26, 2023, the CP spoke to FM1 and/or FM2 and possibly discussed the AV having a knife. The CP did not recall any additional information about this phone call. P2 provided contradictory information during his/her interview which included the following information: · P2 knew the AV since the AV was approximately 12 years old. In 2020, P2 worked in a direct support role with the AV and had “built rapport” with FM1 and FM2. P2 worked as an independent contractor for the facility for approximately six months until October 13, 2023, as a supervisory staff person who oversaw compliance. · After the AV moved to the most recent extended stay hotel, and because of a transition with supervisory staff persons, the facility had P2 provide oversight to the AV and problem solve ways to deescalate the AV. The AV previously verbally threatened staff persons about getting staff persons terminated or harming them but the AV “never followed through” so P2 did not see it as a “real concern.” · The AV was able to get pocketknives and vape pens and P2’s understanding was that FM1 and FM2 were aware of the items so when an incident occurred, P2 called FM1 and FM2 and notified them. FM1 and FM2 then took the items from the AV. On a previous occasion during the summer of 2023, the AV traded another client a pocketknife and it was later found on the other client. P2 confiscated the knife, locked it in the main office, and notified FM1 and FM2 about it.
· At the end of September 2023, FM1 and FM2 called P2 and said that the AV was alone at a park. P2 asked SP1 about it and SP1 said s/he did not leave the park but had been sitting inside his/her personal vehicle in the parking lot. SP1 was still able to see the basketball hoop and the AV from inside his/her personal vehicle. P2 had a “corrective conversation” with SP1 that s/he was required to be where the AV was able to visually see SP1. P2 possibly wrote up a corrective action plan for SP1 and notified P1 about the incident. (Note: When requested, the facility was unable to find any corrective action plan for SP1.) P2 could not recall if s/he contacted the licensing agency about the incident with SP1. This investigator asked P2 if SP1’s actions were in line with his/her training from the facility and P2 said it was not because if an incident took place and SP1 was inside his/her vehicle, s/he was not able to get to the AV “quick enough.” P2 denied knowing that the AV got a knife during this incident. · On October 12, 2023, the CP called P2 and said there was a video showing that the AV was in a fight at a park and threatening other persons with a pocketknife. P2 “immediately” called FM1 and told him/her that the school said that the AV possibly had a pocketknife but P2 had not confirmed. FM1 was unsure how the AV got a pocketknife but said s/he would “look into it.” FM1 agreed to talk to the AV that night about the pocketknife and it was P2’s “understanding” that FM1 and FM2 would get the pocketknife from the AV and “keep [P2] in the loop.” P1 and P4 were also aware of the concerns about a possible knife and P3 was “transitioned into the loop” and that they were waiting to hear back from FM1 and FM2. · Later that day while at the facility, P2 talked to the AV about getting into a fight at the park but did not “press” the issue of staff persons supervision since the AV “shrugged off” the incident and P2 did not want to escalate the AV. P2 did not follow up on the incident because s/he ended his/her contract at the facility on October 13, 2023. · While in the detention center, the AV called P2 because although P2 was no longer employed at the facility, s/he had rapport with the AV. The AV said that s/he did not mean to stab SP2 and that s/he was “so angry.” P2 “encouraged” the AV to “follow the rules.” P1 stated that during the internal review process, P2 told P1 that s/he responded to a call from the school about a possible knife. P2 also said on October 12, 2023, FM1 and FM2 told P2 that they were going to get the knife from the AV’s school. P2 did not tell P1 about any other follow up with FM1 or FM2 after the conversation. No staff persons saw a knife between October 12 to 26, 2023. P3 provided the following information: · P3 replaced P2 at the facility and had worked with the AV approximately one to two times prior to October 26, 2023. On one occasion, P2 told P3 about the AV being alone at a park but it was more of a discussion of how P2 dealt with SP1. P2 said s/he conducted a room search but did not find any weapons, but the AV had a backpack on him/her that was not searched. P2 told P3 that s/he was going to file a report with the licensing agency. P2 did not mention that the AV possibly had a pocketknife. · On October 26, 2023, FM1 called and told P3 about cuts on the AV’s hand. FM1 told P3 about the incident where SP1 left the AV alone at the park and that the AV possibly got a knife. P3 sent out a GroupMe message to staff persons saying that the AV possibly had a knife. A few staff persons responded saying that the AV got the knife from school and other staff persons said it was from the park. SP2 responded saying s/he was working at that time and would talk to the AV. P3 called FM1 and FM2 to update them and as they were talking, P3 got a text from SP2 that the AV was stabbing SP2. P3 told FM1 and FM2 about the text, hung up the phone, and drove to the facility. · When P3 got to the facility, s/he saw P4 outside so spoke to him/her first. P4 said s/he was done with his/her shift and waiting in the lobby when s/he saw SP2 running down the hall with the AV chasing him/her with a knife. P4 tried calming and redirecting the AV. SP2 ran away and the AV followed so P4 grabbed the back of the AV’s shirt and held it so SP2 was able to run into another room. P4 waited for the AV to calm and then they walked outside. · The AV was inside a police vehicle so P3 did not talk to him/her but spoke to a law enforcement officer and P3 told him/her that FM1 and FM2 were on their way to the hotel. SP2 was escorted to an ambulance so P3 did not talk to him/her. · After the AV stabbed SP2, multiple staff persons came to P3 and told P3 about the AV possibly having a pocketknife s/he obtained because s/he was alone at a park. Staff persons, including SP2, and another staff person (P5) were aware that the AV had a pocketknife but no one was able to take it from him/her and it was not located during a room search. SP2 provided the following information: · SP2 only worked with the AV approximately five or six times. On a previous occasion, two staff persons (P6 and P7) told SP2 about previously hearing the AV discussing “stabbing” staff persons while play video games. On another occasion, the AV gave C1 a pocketknife that was later taken away from C1. · SP2 remembered either a GroupMe message or heard from another staff person that P2 searched the AV’s room and did not find a knife. The AV possibly hid the knife or got rid of that one and later got another one. SP2 was unaware if supervisory staff persons took additional action regarding the possibility that the AV had a knife. · Prior to October 26, 2023, SP2 had not seen cuts on the AV’s hands. Approximately two days prior to the incident, P3 came out and searched the AV’s hotel room for possible drugs and the AV was still “mad” about the search. The AV told SP2 that staff persons were “always in [his/her] business.” · On October 26, 2023, SP2 agreed to cover another staff persons shift that started at 3 p.m. Shortly after, P3 sent out a GroupMe message that said that the CP reached out to him/her because the AV had cuts on his/her hands. SP2 spoke to the AV who had bandages on his/her hands and asked the AV what happened with his/her hands. The AV responded that s/he got into a fight at school and was injured. SP2 asked the AV if s/he felt “suicidal” and “what made [the AV] want to cut [his/her] hands?” The AV responded that s/he did not cut his/her hands. · Later, the AV said s/he got the knife from someone at school and cut his/her hands while at school because another staff person was “getting on [the AV’s] nerves.” SP2 was aware of the amount of security at the AV’s school because s/he had been there prior to this but did not ask the AV any additional questions about where s/he got the knife although SP2 did not think it was at school. · The AV became “antsy” and paced around his/her room. SP2 asked the AV what was wrong, and the AV said s/he wanted to go to a specific mall. SP2 told the AV that s/he did not want to bring the AV to that specific mall but offered to take him/her to any other mall. In the past it was difficult to supervise the AV at the specific busy mall because the AV walked away from SP2. · SP2 then left the AV’s room and went to the living room to document the incident. The AV called FM1 and asked about ordering a taxi service so that s/he could go into the community and SP2 said s/he spoke from the other room and reminded the AV that s/he was not allowed to use a taxi service alone. The AV responded that s/he was “not talking to [SP2].” FM1 was on speaker phone and asked SP2 about taking the AV to the mall. Because SP2 was sitting in another room at the time working on documentation, it could have sounded like SP2 was yelling at the AV. SP2 responded that s/he did not tell the AV s/he could not go to a mall just that certain one. The AV then told FM1 that SP2 would not allow the AV to see C1. SP2 responded that the AV had not asked SP2 that, but that SP2 would contact C1’s staff person to see if they were at the hotel.
· The AV began swearing at and calling FM1 names so SP2 asked, “Why [FM1] was letting [the AV] talk to [FM1] like that?” SP2 told the AV because of his/her interactions with FM1 and swearing, SP2 would not take the AV out in public. FM1 asked what SP2 had said to the AV. SP2 responded, “It [was] crazy how [FM1] was sitting on the phone letting [the AV] disrespect [FM1].” FM1 responded that s/he was on his/her way to the facility and hung up the phone. · SP2 continued to work on documentation in the other room where s/he could not see into the AV’s bedroom but heard the AV putting on his/her backpack and saying things such as “I am going to beat this bitch ass.” The AV then came out of his/her bedroom to SP2, grabbed SP2’s hair, and punched SP2 in the head and face. SP2 covered his/her face and told the AV to “get off me.” SP2 was able to push the AV off him/her and get away. The AV “charged” at SP2 so SP2 grabbed a chair to put between them. SP2 told the AV that they needed “space” and told the AV to “stay over there” and SP2 would “stay over here.” · At one point, SP2 was able to get to the door to the hall and open the door and ran out. The AV then “chased” SP2 into the hall. SP2 knocked on the door to the hotel staff room but no one answered. The AV caught up to SP2 and punched him/her. A community person told the AV to “stop hitting” SP2. SP2 ran to the lobby and that was when SP2 saw that the AV had a knife. P4 was sitting in the lobby and SP2 “pushed” the AV away from him/her who fell and grabbed SP2’s leg and stabbed SP2 on the left calf. SP2 “pushed” the AV across the floor and SP2 ran to C1’s room. That staff person let SP2 inside and they closed the door. When the AV got to the door, s/he stabbed the hotel room door threatening s/he was going to “get a gun” and if s/he saw SP2 “on the street, [the AV] will shoot [SP2].” At one point during the incident, the AV cut SP2 on his/her left forearm with the knife. P4 spoke to the AV outside in the hall while SP2 stayed in the hotel room waiting for law enforcement. GroupMe texts between staff persons showed the following: · On September 7, 2023, P2 sent out a GroupMe message to all staff persons that the AV threatened to stab staff persons. P2 was unsure where the information came from but after P2’s “research” s/he “assured” staff persons that the AV threatened to harm him/herself and not a staff person. In the over three years that P2 knew the AV, the AV did not attack staff persons. The AV possibly threatened in a “moment of anger” but “never followed through EVER.” Apart from damage to property, the AV was a “safe client to work with.” · On October 12, 2023, P2 sent out a GroupMe message to all staff persons that said s/he was on the phone with the CP and it was brought to P2’s attention that the AV bought a pocketknife from “someone” at a park recently. There was also a video on the AV’s cell phone of him/her slap boxing. This took place when the AV said that SP1 sat in his/her vehicle and the AV was unsupervised. P2 asked if any staff persons had information on the situation. No staff persons responded. The CM noticed a shift in services that the facility provided around the time when the facility closed the previous CRS facility where the AV lived and began providing Crisis Respite Care to the AV in extended stay hotels. The AV’s behaviors began escalating. Toward the end of summer 2023, when the AV moved into the most recent hotel where the incident occurred, things had improved. On October 26, 2023, FM1 notified the CM that the AV stabbed a staff person. FM1 also said that the AV previously got a knife when a staff person left the AV alone at a park for “a few hours.” Prior to that, the CM was not aware of supervision concerns. According to the facility’s Emergency Use of Manual Restraints, Holds, Blocks and Positive Support Training, staff persons training included: · De-escalation techniques/methods and their “values.” · Alternatives to manual restraint procedures including techniques to identify “events and environmental factors that may escalate conduct that poses an imminent risk of physical harm” to him/herself or other persons. · “Simulated experiences of administering and receiving manual restraint procedures” allowed by the facility for emergency situations and according to Minnesota Statute. · What consisted of the use of a restraint, including chemical restraint, time out, and seclusion. · How staff persons properly identified thresholds for implementing and ceasing restrictive procedures. · How staff persons recognized, monitored, and responded to a client’s physical signs of distress, including positional asphyxia. · The physiological and psychological impact on a client and the staff person when restrictive procedures were used. · Relationship building and how to avoid power struggles. · Principles of person-centered service planning and delivery and how they apply to direct support provided by staff persons. · Staff persons responsibilities related to restricted and permitted actions and procedures according to Minnesota Statutes; why the procedures were not effective for reducing or eliminating “symptoms or interfering behavior;” and why the procedures were not safe. · Principles of positive support strategies and actual positive support strategies. · The relationship between staff persons interactions with the client and the client’s behavior and the relationship between the client’s environment and his/her behavior. · Situations where staff persons called 9-1-1 in response to “imminent risk of harm” to the client or other persons. · The procedures and forms staff persons used to monitor and report use of restrictive interventions that were part of the positive support transition plan. · The procedures and requirements for notifying the client’s team and the use of a restrictive intervention. · Understanding the client as a “unique individual” and how to implement treatment plans and responsibilities assigned to the facility, including cultural competency. · Personal staff persons accountability and self-care after emergencies. Facility documentation showed that SP2 received training on the facility’s Emergency Use of Manual Restraints, Holds, Blocks and Positive Support Training, the AV’s plans, and the Reporting of Maltreatment of Minor’s Act prior to the incident. Facility documentation showed that SP1 received training on the facility’s Emergency Use of Manual Restraints, Holds, Blocks and Positive Support Training and the Reporting of Maltreatment of Minor’s Act prior to the incident. However, the facility did not have documentation that SP1 and P2 were trained on the AV’s plans which was a violation of Minnesota Statute, section 245D.09, subdivision 4a, paragraph (a) which states in part that before having unsupervised direct contact with a person served by the program, or for whom the staff person has not previously provided direct support the staff person must review and receive instruction as they relate to the staff person’s job functions for that staff person. The facility also did not have documentation that P2 and P3 were trained annually on the Reporting of Maltreatment of Minor’s Act, which was a violation of Minnesota Statutes, section 245D.09, subdivision 5, which states in part that the license holder must provide annual training to direct support staff on topics including 260E governing maltreatment reporting. Relevant Rules and Statutes: Minnesota Statute, section 245D.07, subdivision 1a, states that the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum, and in compliance with the requirements of the chapter. Conclusion: A. Maltreatment: Regarding the AV unsupervised while in the community: The AV provided consistent information to this investigator, FM1, and the CP that on multiple occasions, including on or around October 12, 2023, SP1 brought the AV to a park. While the AV played basketball, SP1 left the basketball area and may have left the park, which was a violation of the AV’s plans and Minnesota Statute, section 245D.07, subdivision 1a. At some point, the AV was able to obtain a pocketknife which was possibly used later to cut his/her hands and stab SP2. SP1 stated on two occasions, while the AV played basketball with a friend, for approximately five minutes, SP1 sat inside his/her vehicle and SP1 was able to see the AV during that time. SP1 denied leaving the park. However, FM1 stated that s/he received a call from the AV requesting a ride home from the park because the staff person was not there. Consistent information was provided that on October 12, 2023, the CP called P2, a supervisory staff person, and said that the AV was alone at the park. On October 12, 2023, P2 called FM1 and told FM1 that the AV was unsupervised at a park and possibly had a knife. Although SP1 said s/he was inside his/her vehicle for approximately five minutes each of the times the AV was alone and that s/he could see the AV from his/her car, SP1 had reason to minimize his/her actions for fear of repercussions and at some point SP1 could not see the AV because the AV got into a fight and obtained a knife. Therefore, it was more likely that the incidents occurred as described by the AV. Given that the AV required 24-hour monitoring and supervision to ensure both his/her health and safety and the safety of other persons; required “extensive support and supervision” to monitor and address his/her mental health needs; and required 1:1 staffing to provide behavioral support and provide him/her with supervision at the facility and in the community, there was a preponderance of the evidence that leaving the AV at the park unsupervised on multiple occasions was a failure to supply the AV with necessary care and a failure to protect them from conditions or actions that seriously endangered their physical or mental health when reasonable 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). Regarding the AV having a knife: Consistent information was provided by the AV, FM1, P2, and SP2 that the AV had a history of getting knives while residing at the facility. According to the AV’s Support Plan Addendum – Basic Support Services, if the AV had an object used to hurt him/herself or other persons, staff persons removed the object and placed the item out of reach. GroupMe messages showed that on September 7, 2023, P2 notified staff persons that the AV threatened to stab staff persons. P2 “assured” staff persons that the AV threatened to harm him/herself and not a staff person; in the over three years that P2 knew the AV, the AV did not attack staff persons; and the AV was a “safe client to work with.” On October 12, 2023, at 3:30 p.m., the CP notified P2 that the AV got a pocketknife while at a park. P2 then sent out a GroupMe message to all staff persons that it was brought to P2’s attention that the AV bought a pocketknife from “someone” at a park recently, P2 asked if any staff persons had information on the situation, and no staff persons responded. P1 stated that P2 told P1 that on October 12, 2023, FM1 and FM2 told P2 that they were going to get the knife from the AV’s school. P2 did not tell P1 about any other follow up with FM1 or FM2 after the conversation. Information was provided by SP2 and P5 that P2 searched the AV’s room but did not find a knife but P2 did not provide information regarding searching the AV’s room for a knife. In addition, while at the facility the day the CP told P2 that the AV possibly had a knife, P2 talked to the AV about getting into a fight at the park but did not “press” the issue of staff persons supervision since the AV “shrugged off” the incident and P2 did not want to escalate the AV. P2 did not follow up after this because s/he no longer worked at the facility as of October 13, 2023. Although, P2 said s/he notified P1, P3, and P4 about the AV possibly having a knife prior to P2 ending his/her employment, P1 and P3 each stated that they were not aware of the knife until after October 26, 2023. Given that P2 was aware that the AV made threats to stab staff persons yet no additional action was taken; that multiple staff persons were aware that it was possible the AV had a knife on more than one occasion, yet little actions were taken to determine whether the AV had a knife and/or how the AV would have obtained a knife; that the AV did have a knife that s/he subsequently used to stab SP2, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure to protect them from conditions or actions that seriously endangered their physical or mental health when reasonable 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). Regarding the AV’s and SP2’s interaction on October 26, 2023: P4 said that on October 26, 2023, before leaving for school, the AV was “great” and “wonderful” and P4 did not have previous issues with the AV. However, at some point after school, the AV and SP2 got into an altercation that led to the AV stabbing SP2 with a knife. The AV did not remember what SP2 said during the incident, but recalled going over to SP2 who was in a chair, hitting him/her, and telling him/her not to be “rude” to FM1. According to the law enforcement report, while getting arrested, the AV told law enforcement that “someone inside” was “disrespecting” FM1. FM1 stated that while on speaker phone talking to the AV, FM1 heard SP2 yell in the background, “Of course I will not let you go to the park.” The AV asked SP2 about visiting another client at the hotel and SP2 responded, “Of course I will not let you go to someone else’s room.” SP2 did not provide reasons why the AV was not allowed to go to either place. The AV told SP2 s/he was “disrespectful” and SP2 said something along the lines of “You are just a [boy/girl].” FM1 responded that the AV was sixteen years old and a teenager. SP2 got “mad” and yelled, “You always let [the AV] disrespect you.” FM1 was “upset” by the comment so s/he told the AV s/he was hanging up and coming to the facility to get the AV. SP2 provided different information that after s/he told the AV s/he would not take him/her to a specific mall, s/he told the AV s/he would take him/her to any other mall. The AV also told FM1 that SP2 would not allow the AV to see C1 and SP2 responded that the AV had not asked that but that SP2 would contact C1’s staff person to see if they were at the hotel. SP2 said because s/he was in a different room than the AV it could have sounded like s/he yelled at the AV when s/he did not. The AV yelled and swore at FM1 so SP2 asked, “Why [FM1] was letting [the AV] talk to [FM1] like that?” SP2 said because of that, s/he would not take the AV out in public with the way that the AV swore. SP2 also said to FM1, “it [was] crazy how [FM1] was sitting on the phone letting [the AV] disrespect [FM1].” Given that SP2 had reason to minimize his/her actions for fear of repercussions, it was more likely that the incidents occurred as described by FM1. SP2’s interactions with the AV were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the AV’s plans and Minnesota Statute, section 245D.07, subdivision 1a. The AV’s Support Plan Addendum – Basic Support Services stated that when the AV was upset, s/he preferred that staff persons intervened with verbal prompts that assisted the AV with coping skills along with helping the AV “walk away” from a situation. It was important to the AV that staff persons allowed him/her to “vent” his/her frustrations and feelings and that staff persons validated the AV’s feelings and let the AV know s/he was heard. At the time of the incident, the AV was on the phone with FM1 and did not require intervention by SP2. When SP2 yelled at the AV and FM1 regarding the AV’s verbal interaction with FM1, SP2 failed to follow the AV’s plans, and likely escalated the situation and increased the AV’s verbal and physical aggression. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care. 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). 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. Regarding the AV unsupervised while in the community: SP1 was working with the AV at the time of the incidents and responsible for the care and supervision of the AV. Facility documentation showed that SP1 received on the Reporting of Maltreatment of Minor’s Act prior to the incident. However, SP1 stated that s/he was not trained on the AV’s plans which included the AV’s supervision requirements, and the facility was not able to provide documentation that SP1 was trained as such. Therefore, SP1’s responsibility was mitigated and the facility was responsible for the maltreatment of the AV. Regarding the AV having a knife: Multiple staff persons were aware that the AV might have a knife and may have threatened to stab staff persons. However, P2 was hired by the facility as an independent contractor who oversaw compliance and who also provided oversight to the AV and problem solved ways to deescalate the AV. Although the facility did not have documentation that P2 was trained annually on the Reporting of Maltreatment of Minor’s Act or the AV’s annual plans, information showed that P2 had worked with the AV for three years and was the sole person who made the decision that the AV possibly threatened in a “moment of anger” regarding stabbing staff persons but “never followed through EVER,” and apart from damage to property, the AV was a “safe client to work with.” FM1 and FM2 were informed about the knife and were possibly going to get it from the AV, but there was no follow up from P2. P2 failed to notify other supervisory staff persons or provide documentation that the AV possibly had a knife prior to P2’s employment ending. Therefore, P2 was responsible for the maltreatment of the AV. Regarding the AV and SP2’s interaction on October 26, 2023: SP2 was trained on the facility’s Emergency Use of Manual Restraints, Holds, Blocks and Positive Support Training, the AV’s plans, and the Reporting of Maltreatment of Minor’s Act prior to the incident. SP2 was responsible for the care of the AV at the time of the incident. SP2 was responsible for the maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” The Office of Inspector General is also 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. Regarding the AV unsupervised while in the community: It was determined that the substantiated neglect for which the facility was responsible did not meet statutory criteria to be determined as serious because the AV did not require the care from a physician as a result of being unsupervised at the park. Regarding the AV having a knife: It was determined that the substantiated neglect for which P2 was responsible did not meet statutory criteria to be determined as recurring or serious because P2’s actions represented a pattern of behavior and therefore a single incident for which the AV did not require the care from a physician as a result of having the knife. Regarding the AV and SP2’s interactions on October 26, 2023: It was determined that the substantiated neglect for which SP2 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the AV did not sustain a serious injury that reasonably required the care of a physician. 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 and followed. SP2 and P4 received additional training on how to implement positive supports and how to conduct themselves professionally when interacting with clients or their teams. SP2 and P4 received additional training on emergency use of manual restraints on how to implement holds “correctly” to assist them with “feeling more confident and to ensure they are implementing them safety.” SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP2 and P2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 and P2 were each 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 SP2 or P2. The determination that SP2 and P2 were each responsible for maltreatment is subject to appeal. On March 29, 2024, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. In addition, it was determined that facility mandated reporters had knowledge of two alleged incidents and did not report the incidents as required. The license holder was ordered to forfeit a fine of $400 for failures to report maltreatment. The Order to Forfeit a Fine is 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.
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