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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: 1036935-CRF (Children’s Residential Facility) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vaping device that contained tetrahydrocannabinol (THC) on a community outing and permitted an alleged victim (AV) to use the device. THC was the primary compound in marijuana that made users feel “high.” Date of Incident(s): December 27, 2024 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 January 15, 2025; from documentation at the facility; and through interviews conducted with facility staff persons (the P and the SP). The AV declined an interview with this investigator, but s/he provided information to the P, and in the Internal Review, and it was included below. The facility provided services to youths ages 10-18 that focused on treating the whole child, not a single issue. There was a school on the facility grounds to meet each student’s individual needs and vocational opportunities were available for youths to learn job skills while giving back to the community. Facility documentation including the AV’s Individualized Treatment Plan, showed that the AV was diagnosed with polysubstance dependence that was in remission, depression, and attention deficit hyperactivity disorder. The AV’s Admission Interview at the facility showed that s/he had a history of substance (including marijuana) use, and the Individual Guidance Plan showed that the AV wanted staff persons to help him/her stay positive and stay sober. The Intake Diagnostic Assessment Update documented that the AV was to refrain from using all mood-altering substances including alcohol, marijuana, and other “drugs” unless they were prescribed to him/her. The AV was loyal and had a great sense of humor. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · The VA declined an interview with this investigator, but in the facility’s Internal Review and/or in conversations with the P, the AV provided information that on a December 27, 2024, community outing, s/he took a hit from the SP’s vaping device and was aware that the device contained THC. The AV knew that s/he made a poor choice and thought that s/he would be given a “consequence” for not following his/her plans. According to the Internal Review, the facility observed and assessed the AV after the incident to determine any lasting effects of consuming THC, but there were no concerns, and the AV resumed his/her typical schedule. · The P said that on the date of the incident, s/he, the SP, additional unspecified staff persons, the AV, and several other youths went ice fishing on a community lake. Staff persons drove facility vans to the outing, and after the youths and staff persons returned from the outing, the P learned that some of the youths said that the SP permitted the AV to use his/her vaping device on the outing. Since the SP had previously been honest with the P, the P directly asked the SP whether s/he permitted the AV to use the device, and the SP told the P that s/he did. · It was foggy on the lake, and the P and the other youths did not see the AV or the SP using the vaping device, but they might have used the device while walking from one ice fishing hole to another. According to the P, the SP told him/her that the AV took one hit from the vaping device and then asked for a second hit, but the SP declined to let the AV use the vaping device again. Staff persons were not to use vaping devices in the facility, on facility grounds, in facility vehicles or drive facility vehicles after having vaped, or while on community outings. However, some staff persons likely brought their vaping devices to the facility and used them in their personal vehicles. Prior to this incident, the P had no concerns with the SP’s work. · The SP said that in the weeks prior to the incident, s/he frequently thought of personal matters which caused him/her to feel anxious and distracted. The SP had nicotine and THC vaping devices in his/her personal vehicle, and s/he used the vaping device that contained THC for anxiety. The devices were small and could be completely concealed in the palm of one’s hand, so it would be difficult to know whether someone was using the vaping devices due to their size, and difficult to see vapor/smoke from the devices if it was foggy, or cold since the vapor/smoke might look like someone’s warm breath on a cold day. · On the date of the incident, the SP took his/her personal coats and cold weather gear from his/her vehicle to the outing in case the youths on the outing forgot theirs or were cold. At the lake, the AV realized that s/he did not bring a coat, so the SP took off his/her personal coat that s/he was wearing and gave it to the AV to wear, because the SP wore multiple layers and was warm enough without the coat. The SP had used the THC vaping device earlier that day and both devices were in the SP’s coat pockets, but s/he did not think about that when s/he gave the coat to the AV to wear. The SP thought that the AV either saw him/her use the device or smelled the scent of the device on his/her coat and looked for it in the coat. When the AV found the device/s, s/he asked the SP to let him/her use the device/s and the SP agreed. The AV “hit” one of the devices, but the SP was unsure which device the AV used, and then gave the devices to the SP. The AV continued to ask the SP to let him/her use the devices again, but the SP realized his/her mistake, and declined to let the AV use them. · When the SP, the P, the AV, and the other youths returned to the facility, the SP talked with the P and told him/her that s/he let the AV use a vaping device and would accept any repercussions from his/her actions. In hindsight, the SP should not have let the AV use the coat with vaping devices in the pockets, but the AV was cold, did not have a coat with him/her, additional coats the AV might have used were with the P at another location on the lake, and the SP forgot that the vaping devices were in the coat. The SP said that s/he did not read the youths’ plans of care because s/he wanted to treat the youths equally and did not want to treat them differently based on what s/he read in the plans. The SP did not know that the AV had a history of substance use. The SP signed the facility’s Maintaining a Drug Free Workplace statement showing that s/he agreed to abide by the facility’s policies regarding substance use on August 26, 2024. In Minnesota, persons under the age of 21 were prohibited from using vaping devices. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Maltreatment of Minors Act and the facility’s policies and procedures prior to the incident. Conclusion: A. Maltreatment: The AV’s diagnoses included polysubstance dependence in remission, and s/he had a history of substance use, including marijuana. The AV wanted help from staff persons to stay sober and was to refrain from using mood altering substances. The AV declined an interview with this investigator, but s/he provided information to the P and/or in the Internal Review that on a community outing on December 27, 2024, the SP let the AV use a vaping device which contained THC. The SP said that s/he was anxious and distracted leading up to the incident and used the vaping device with THC for anxiety but did not think about the vaping devices being in his/her coat when s/he let the AV wear the coat. The AV found the vaping devices in the SP’s coat and asked the SP to let him/her use them. The SP agreed and the AV used one of the devices, but the SP was unsure which one, then asked to use the devices again, but the SP declined and obtained the devices from the AV. The SP realized his/her mistake and talked with the SP about it. In hindsight, the SP would have removed the vaping devices from the coat before letting the AV wear it. Although the AV did not appear to be harmed by using vaping device/s, given that the SP said s/he permitted the AV to use vaping devices/s, that the AV was under 21 years of age, and that the AV’s diagnoses included polysubstance dependence and s/he had a history of substance use, there was a preponderance of the evidence that there was a failure to protect the AV from conditions or actions that seriously endangered his/her physical or mental health when reasonably able to do so. It was determined that neglect did occur (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; or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP permitted the AV to use his/her personal vaping device/s, but s/he agreed to abide by the facility’s Maintaining a Drug Dree Workplace statement on August 26, 2024, and was trained on the Maltreatment of Minors Act prior to the incident. The SP 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 the SP was responsible did not meet statutory criteria to be determined as recurring or serious. The neglect was not recurring because it was a single incident, and was not serious because the AV did not sustain a known injury from the incident. 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 which determined that their policies and procedures were adequate but not followed. At the time this report was written, the SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment 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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