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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: 831080-CRF (Children’s Residential Facility) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: Allegation One: It was reported that an alleged victim (AV) accessed a staff person’s (SP1’s) personal bag and “overdosed” on SP1’s prescription medication found in the bag. The AV was “mumbling, slurring [his/her] speech.” Staff brought the AV to an emergency room where s/he received intravenous fluids and was released back to the facility that same day, unharmed. Allegation Two: The AV “threatened to vomit” on a staff person (SP2) and in response, SP2 “swung” at the AV. Date of Incident(s): August 28, 2024 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 September 18, 2024; from documentation at the facility and medical records; and through interviews conducted with the AV, the AV’s family member (FM), facility staff persons (SP1, SP2, and P1), and supervisory staff persons (P2 and P3). According to the facility’s website, www.nexusfamilyhealing.org, the facility provided short- and long-term residential treatment programs for youth, ages 16-21, in need of intensive support and care. In January 2024, the AV, who was 17 years old, moved into the facility. The facility provided the AV with individual and family therapy, psychiatry, medication management, and education. The AV did not remember details of what happened during the incidents. [Note: This was believed due to the AV’s level of intoxication at the time.] The AV told this investigator that s/he liked some aspects of living at the facility and some of the staff, but not all. The AV did not believe s/he always received adequate services, including counseling sessions or skills specific to his/her needs. According to the AV, most of the programming was geared towards mental health and the AV believed s/he needed services geared towards behavioral needs. Facility documentation stated that SP1, SP2, P1, P2, and P3 received training on the facility’s policies and procedures and on the Reporting of Maltreatment of Minors Act.
Allegation One: It was reported that the AV accessed SP1’s personal bag and “overdosed” on SP1’s prescription medication found in the bag. The AV was “mumbling, slurring [his/her] speech.” Staff brought the AV to an emergency room where s/he received intravenous fluids and was released back to the facility that same day, unharmed. The AV’s support plans stated that s/he had a history of substance abuse, suicidal ideation with at least one attempt, and self-harm and physical aggression in response to high-stress situations. The facility had more than one dormitory (dorm) for the youth. The AV’s dorm had a dayroom and a long hallway off one side for the youths’ bedrooms, bathrooms, etc. The dayroom was divided into two sections by a shelving unit. One side was a lounge with various couches and chairs (herein referred to as the lounge) and the other side had round tables with chairs (the dorm dining room). There was also a larger dining room for all the dorms’ youths’ communal meals (the central dining room). The central dining room was in a different part of the building than the AV’s dorm.
P1-P3 and the AV’s medical records provided the following information: · On August 28, 2024, around noon, SP1 brought the youth to the central dining room for lunch. · P3 said that most youth ate meals in the central dining room; however, the AV struggled being around all of the youth at one time. The AV and staff agreed that it was best for the AV to eat his/her meals in the dorm dining room. · On August 28, 2024, after the youth left for lunch, P2 stayed in the dorm with the AV. The AV’s lunch was delivered, which the AV grabbed and moved into the lounge to eat. The AV sat on a couch facing away from P2. P2 could see the back of the AV’s head but could not see the AV’s body below his/her shoulder line. · When lunch was finished the AV went to school, which was in a separate area of the facility. · P1 worked in the school. When the AV arrived, P1 noticed the AV “seemed out of it. Not [his/her] normal self. Something was off.” The AV struggled to pronounce words and had a “glossy look” in his/her eyes. P1 contacted staff and escorted the AV back to his/her dorm. · Once back at the dorm, the AV told P2 that s/he was not feeling well and went to his/her bedroom. At one point, the AV went into the bathroom and took a shower before returning to his/her bedroom. P2 checked on the AV and observed the AV “slurring” his/her words and forgetting things. P2 then noticed the AV had vomited and defecated in the shower. P2 called staff and prepared to take the AV to an emergency room. During this time, or around 3 p.m., SP1 approached P2 and said that s/he had mistakenly left his/her bag unattended in the dorm dining room during lunch time. After lunch, SP1 found the bag and put it away in the staff locked closet. At that time, SP1 did not look inside the bag or check to ensure his/her belongings were still present. However, when SP1 was preparing to leave for the day at 3 p.m., s/he noticed that his/her prescription pill bottles were not in his/her bag as they had been earlier that day. · The AV’s medical records stated that at 4:48 p.m., the AV arrived at the emergency room with staff. Healthcare professionals (HCPs) were able to determine based on the AV’s statements and what was missing from SP1’s bag that the AV “overdosed” on 26 Ativan (anti-anxiety) 0.5 milligram (mg) pills and 30 buspirone (anti-anxiety) 10 mg pills. The AV told the HCPs that s/he took the pills to “get high.” The AV’s blood laboratories and vital signs were checked and within normal limits. The AV appeared oriented and without distress. The AV was given two liters of intravenous fluid and monitored in the emergency room. The AV did not develop worsening symptoms or signs of drug toxicity, and was released back to the facility at 7:53 p.m. · P3 said that some of the buspirone pills were later found in the AV’s bedroom. By the time the AV returned from the emergency room, all of the Ativan and buspirone pills were accounted for or found. · P2 did not have prior concerns with SP1’s conduct. “At all points in time” prior to August 28, 2024, SP1 kept his/her bag locked in the staff closet. · P3 said that some staff carried satchels with them to hold their radios and other work-related items. Personal items, including bags and medications, were supposed to be locked in the staff closet. SP1 did not have a history of leaving personal items unattended or any previous, related incidents. · P2 and P3 each said that there was not training specific for each youth. Staff attended weekly meetings, in which pertinent information about each youth was discussed, and when a youth moved into the facility, the counselors shared information about that youth’s history, including substance abuse or other concerns. SP1 attended these meetings, in which, at various points the AV would have been discussed. Although the AV had a history of substance abuse, the facility did not provide substance abuse treatment, and this was not something that would have been focused on with the AV’s care or services. The facility’s camera footage was provided for the investigation and showed the following for August 28, 2024: · Between 11:15:00 a.m. and 12:15:17 p.m., SP1 sat at a table in the dorm dining room across from another staff person with laptop computers and various paperwork. SP1 stood up at various points and completed unidentified tasks. SP1 was not carrying a bag during this time and there was not a bag obviously visible on the table or hung on the back of SP1’s chair at the table. [Note: The camera system was such that it recorded when there was movement. There were many cameras, which were individually activated as movement occurred through the space. When the movement stopped or moved out of the space, the camera deactivated.] · At 11:49:30 a.m., the AV entered the dorm. · At 12:08:08 p.m., the AV walked into the lounge, which activated the camera in the lounge to start recording. The AV sat down on a couch, which was facing away from the dorm dining room where the staff were situated. There was a brown item on the couch cushions. The AV grabbed the item and looked at it, while also glancing up over the back of the couch and shelving unit, talking to SP1. From where SP1 was standing, s/he could not see the AV’s body below his/her shoulder line. The lounge camera then shut off due to a lack of movement. · At 12:08:54 p.m., the lounge camera reactivated and showed the AV standing up from the couch and adjusting or touching his/her waistline or pockets. The AV walked out of the dayroom and down the hallway towards the youth bedrooms and bathrooms. The AV put his/her hand in his/her right pocket and walked into a bathroom. There was not a camera in the bathroom. At 12:10:50 p.m., the AV exited the bathroom and approached SP1 who was interacting with another youth (Y). The AV kept his/her hand in his/her right or left pocket during this time. · At 12:15:18 p.m., SP1 went to the main entrance of the dorm and left through the door. SP1 was not carrying a bag. The AV leaned against a wall watching SP1’s movements. The AV had his/her hand in his/her left pocket. The AV removed his/her hand and appeared to have something very small between his/her fingers. SP1 walked past and out of the dorm. The AV then brought his/her right hand up to his/her mouth. P2 was nearby sitting in a chair facing the bedroom hallway. · At 12:20:47 p.m., an unidentified staff person arrived carrying two lunch trays. The AV and the Y each took one. The Y sat at a dining table and the AV sat on the same lounge couch as earlier. · At 12:33:39 p.m., the AV walked down the bedroom hallway activating various cameras at s/he went. P2 was sitting in a chair facing the hallway; however, would have only been able to see the AV’s back during this time. At one point, the AV pulled an item out of his/her left pocket. At another point, a camera was activated that showed the AV from the front. The AV was holding and looking at a pill bottle in his/her hands. The AV entered his/her bedroom at 12:34:47 p.m. · At 12:37:24 p.m., the AV exited his/her bedroom and walked back to the dining room and stood in front of a Dutch door at the far end of the room. The AV appeared to be walking normally during this time. · At 12:42:00 p.m., the AV was squatting in front of the Dutch door and fell over but corrected him/her and continued squatting with his/her hands to his/her face. The AV then stood and walked back down the hallway, past P2, and appeared to be walking without issue. The AV entered his/her bedroom. · At 12:55:54 p.m., the AV walked back towards P2 and the dorm dining room. The AV appeared to be walking normally during this time. The AV walked into the dining room, sat down, and put his/her head down on the table. SP1 had returned to the dorm at this point. · At 1:02:15 p.m., SP1 opened the main entrance and appeared to prompt the AV to go to school. The AV stood and walked to the door without apparent issue. However, SP1 stepped away making the AV wait. The AV walked away from the door and back into the bathroom from 1:03:25 p.m. The camera footage, which was provided for this investigation, ended at 1:15:12 p.m. with the AV remaining in the bathroom. The FM said that the prescription bottles should not have been left out for the AV to access. However, it was ultimately the AV’s choice to ingest the pills. The FM did not blame SP1 but was disappointed that the incident occurred at all and with the facility’s communication (e.g. the AV’s medical treatment and follow-up). In addition, although the facility had already been considering referring the AV to a different facility at the time, this incident did not help things and had a potential to prevent other facilities from accepting the AV in the future. SP1 provided the following information: · On August 27, 2024, SP1 picked up two of his/her own prescriptions from a pharmacy, Ativan and buspirone. SP1 typically stored his/her medications at his/her home; however, on this day, SP1 mistakenly left them in his/her car. · On August 28, 2024, SP1 was scheduled to start work at 7 a.m. When s/he arrived, the prescriptions were still sitting on his/her front passenger seat. SP1 did not want to leave them in the car due to the projected hot weather that day so s/he put both prescription bottles in his/her bag. SP1 then went into work and locked his/her bag in the staff closet which s/he “always” did. · At some point prior to noon, SP1 took his/her bag out of the closet for his/her breaktime. When s/he returned from break, s/he began doing routine paperwork at a dining table and hung his/her bag on the back of his/her chair. · Around 12:10 p.m., SP1 brought the youth to the central dining room for lunch forgetting that his/her bag was in the dorm on the back of the chair. After lunch, the youth were escorted to school. When SP1 returned to the dorm, s/he discovered his/her bag had been left out and unattended. SP1 immediately locked the bag back in the staff closet. SP1 did not check the contents of his/her bag at that time. · At some point later, the AV returned to the dorm from school and was acting “loopy and tired.” SP1 did not consider this might be related to the medications in his/her bag. · At 3 p.m., SP1 prepared to leave for the day and got his/her bag out of the closet at that time. SP1 then noticed both prescription bottles were missing and told P2 “right away.” · SP1 did not intend to leave his/her bag out and had never done anything similar previously. Conclusion for Allegation One: A. Maltreatment: On August 28, 2024, SP1 left his/her bag unattended in the dorm, which allowed unsupervised and unrestricted access to the AV. SP1’s medications were in the bag, which were then also accessible to the AV. The AV ingested SP1’s medications and experienced symptoms including slurred speech, which prompted staff to take the AV to the emergency room. SP1 did not immediately notice his/her medications were missing or that the AV might have had access until s/he went to leave for the day. Although the AV was ultimately unharmed, the AV had a history of substance abuse and suicidal ideation with at least one attempt. Therefore, there was a preponderance of the evidence that leaving harmful items, including medications accessible to youth and the AV, was a failure to supply the AV with necessary care and a failure to protect the AV from conditions that seriously endangered the AVs physical health when reasonably able to do so. It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). 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 responsible for the AV’s care and supervision. SP1 received training on the facility’s policies and procedures and on the Reporting of Maltreatment of Minors Act. SP1 was responsible for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which SP1 was responsible was “serious” maltreatment. SP1 was responsible for a single incident of maltreatment, which resulted in the AV requiring the care of a physician, including two liters of intravenous fluid. SP1 was disqualified from providing direct contact services. Allegation Two: The AV “threatened to vomit” on SP2 and in response, SP2 “swung” at the AV. The facility’s policies and procedures stated, “The interaction between staff and the youth are the cornerstone to developing a physically and emotionally safe environment … Regardless of the time of day, [the staff person] is an adult model from whom the youth can learn and grow.” At the outset of the investigation, information was provided that it appeared SP2 swung his/her fist at the AV on August 28, 2024. SP2 provided the following information: · At the time of the incident, August 28, 2024, around 9 p.m., SP2 was in the dorm helping youth with snacks and medications. · The AV had just returned from the emergency room. “[The AV] wasn’t feeling well … [S/he] seemed still under the influence and very aggressive.” The AV followed various staff around and made “sexual” and “threatening comments” towards them. “I was one of [the AV’s] main targets.” SP2 repeatedly moved away from the AV but the AV kept returning or following him/her. · At one point, SP2 was sitting in a chair in an open area of the dorm bedroom hallway. The AV was in a bean bag chair next to SP2’s chair. The AV abruptly stood and told SP2 that s/he was going to punch and vomit on him/her. SP2 immediately stood up in response. SP2 did not swing at the AV but “moved away … trying to create space as I didn’t know if [s/he] was going to punch me. That was a body reflex to protect myself. A natural reflex. I made no attempt at swinging. There was no swinging. I made no contact.” “I have a lot of experience in responding to incidents, but I can’t control my body reflex to protect myself.” The faciilty’s camera footage was provided for the investigation and showed the following for August 28, 2024: · At 9:02:05 p.m., SP2 sat on a wooden chair facing the bedroom hallway. The AV walked around SP2 into an alcove and sat in a bean bag chair facing SP2. SP2 remained looking down the hallway and appeared to be periodically engaging verbally with the AV. · Between 9:06:05 and 9:06:55 a.m., the AV shook his/her upper body back and forth rapidly while curled up on the bean bag chair. SP2 remained sitting in the chair and occasionally glanced at the AV. At least once, the AV looked at SP2 and at one point, the AV repositioned his/her leg to not fall off the bean bag chair. At 9:06:56 a.m., the AV abruptly stopped shaking and immediately stood up walking towards SP2. [Note: Information was provided that the AV did not have a history of seizures. At the time of this incident and following, staff believed and determined the AV was “faking” a seizure. There was no information or signs or symptoms the AV experienced a seizure on August 28, 2024.] · The AV took a few steps towards SP2. SP2 moved to stand with the AV standing over him/her. The AV lunged towards the back of SP2’s head. SP2 stood up fully and raised both of his/her arms while facing the AV. The AV stepped away and SP2 lowered his/her arms at 9:07:00 a.m. SP2 stood in place with his/her arms at his/her sides, no longer raised. The AV left the area. SP2 did not make any physical contact with the AV. P2 and P3 each reviewed the camera footage. P2 said that SP2 was one of the “top de-escalation people” at the facility. P2 and P3 each had no concerns with SP2’s reaction to the AV and did not see SP2 swing at the AV. P3 said SP2 “flinched.” “[SP2] pulls [his/her] arm back and makes a fist and then stops … [SP2] didn’t swing or intend to swing … [S/he] didn’t even swing across [his/her] body at all.” SP2 did not make any contact with the AV. Conclusion for Allegation Two: Information was provided that on August 28, 2024, SP2 swung his/her fist at the AV. The AV did not remember the incident. SP2 said that the AV had threatened to punch and vomit on him/her, which caused SP2 to stand up and have a body reflex. SP2 denied swinging at the AV, and camera footage did not show SP2 swinging at the AV. P2 and P3 reviewed the camera footage and had no concerns with SP2’s conduct. SP2 did not make any physical contact with the AV. Given that there was no information to support that SP2 tried or intended to swing or hit the AV, there was not a preponderance of the evidence that SP2 swung at or hit the AV. It was not 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). 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: Allegation One: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The incident was not similar to past events with SP1 or the AV. “At this time, it appears the [bag] was left out by accident.” Allegation Two: The facility completed an internal review and determined that policies and procedures were adequate and followed. The incident was not similar to past events with SP2 or the AV. “Based on camera footage, it did not reveal that [SP2] swung at [the AV].” 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. 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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