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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: 1119782-CRF (Children’s Residential Facility) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) supervised an alleged victim (AV) who had one to one supervision because s/he threatened to harm him/herself. There was a miscommunication between the SPs, and the AV was unsupervised in his/her bedroom for a few minutes and tied a hoodie around his/her neck. When the SPs located the AV, s/he was “turning blue,” but recovered when the hoodie was removed. Date of Incident(s): August 17, 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 September 13, 2024; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P3, SP1, and SP2). The AV declined to complete an interview with this investigator, but s/he provided information to P1, who was an administrative staff person, which was included below. A staff person (P2) who was on shift when the incident occurred, initially agreed to complete an interview with this investigator, but did not respond to additional attempts to contact him/her. The facility provided individualized, trauma informed psychiatric residential treatment (PRTF) services to youths ages 10-19 who had significant mental and behavioral health concerns. The facility had a video recording system that recorded common areas of the facility, but there were no cameras in the youths’ bedrooms or in the offices/rooms used for therapy or counseling at the facility. However, cameras in the hallway outside the AV’s bedroom recorded the locations/actions of staff persons outside the bedroom. At the time/date of the incident, the doors to the bedrooms on the unit in which the AV resided were locked when youths were outside the bedrooms, and staff persons kept the keys to the doors with them. The facility’s Suicidal Ideation and Gesture Protocol showed that when youths were shadowed by staff persons, they were to be close enough to the youths to initiate a hold/intervention if needed, which meant that staff persons were to be in the same room with the youth, have eyes on the youth or have continued verbal contact with the youth when s/he was in the bathroom or shower. The shadowed youth was not to remain in his/her bedroom with the door closed unless s/he was changing clothes, and then staff persons were to keep verbal contact with him/her. When shadowed youths slept, staff persons were to remain awake in the hallway outside their bedrooms, and they were not allowed to use facility headphones when staff persons shadowed them for self-injurious behavior. Facility documentation showed that the AV was diagnosed with adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, anxiety, and attention deficit hyperactivity disorder. The AV had a history of engaging in self-injurious behaviors and was being shadowed by staff persons at the time of the incident, but s/he wanted to “be off” staff person shadow. The AV had frequently declined to take his/her prescribed medications since s/he began residing at the facility in late July of 2024, and the Columbia Suicide Severity Rating Scale forms completed for the AV showed that s/he had thoughts of harming him/herself but did not have a specific plan to do so. When the AV was upset, s/he might give one-word answers, say s/he did not know, or shake his/her leg. The AV was friendly but might have difficulty adjusting to new surroundings. Interviews with P1, P3, SP1, and SP2 with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · P1 said that on the date of the incident, the AV was to be shadowed by staff persons which meant that staff persons were to be close enough to him/her to intervene if the AV attempted to harm him/herself. The AV had an increased level of supervision because s/he recently made statements indicating that s/he intended to harm him/herself. Staff persons met at the beginning of each shift to discuss the needs of the youths, and on the date of the incident but prior to it, staff persons caring for the AV met to discuss the AV’s needs. SP2, who was a team lead, verbally instructed SP1 to shadow the AV during the shift. It was possible that instructions designating SP1 as the AV’s shadow were written on a white board in the unit office, but the white board was erased at the end of the shift or the next day. However, P1 had no firsthand information regarding staff shadow assignment, and thought that SP1 was shadowing the AV because SP2 said that s/he was. At about 4:40 p.m. on the date of the incident, the AV asked to go to his/her bedroom and SP2 opened the door which permitted the AV to enter his/her bedroom. · Video from the facility’s recording system showed that at 4:38 p.m., the AV went to his/her bedroom, and that SP2 opened the door for the AV to enter the bedroom. SP2 remained near the bedroom door and called SP1 to the bedroom to assist him/her. At 4:39 p.m., the SPs entered the bedroom with the AV and were either in the bedroom or in the hallway, until 4:42:43 p.m. when SP2 exited the bedroom and walked alone toward the common area, then walked through a door, and entered another part of the facility out of range of the camera that recorded the hall/AV’s bedroom. SP1 remained inside the bedroom. · At 4:44:15 p.m., SP2 re-entered the common area, and walked toward the AV’s bedroom, then entered it. The AV’s bedroom door was open. At 4:44:44 p.m., the AV and SP2 talked at the AV’s bedroom doorway, and at 4:44:54 p.m., SP1 exited the AV’s bedroom, walked past SP2 who was still standing near the AV’s bedroom doorway, and walked away from the AV’s bedroom toward the common area. Then at 4:44:59 p.m., SP2 walked away from the AV’s bedroom while the AV was standing in the doorway. SP1 and SP2 were both in the hallway walking away from the AV’s bedroom at the same time, and SP2 was about 20 steps behind SP1. Both were walking toward the common area in the same direction and SP2 would have seen SP1’s back as they walked toward the common area. · At 4:45:02 p.m., while both SPs were walking away from the AV’s bedroom, the AV closed his/her bedroom door and was unsupervised inside his/her bedroom. SP1 stopped in the hallway and looked in a closet, and at 4:45:08 p.m., SP2 passed the closet and was about two to three feet behind SP1. The SPs continued walking into the common area, and at 4:45:11 p.m., SP1 turned to his/her left into another part of the facility and SP2 walked straight through the common area into a different part of the facility. The SPs were out of view of the camera until 4:46:25 p.m., when SP1 re-entered the common area and went into a door to his/her left, out of sight of the camera. At 4:47:02 p.m., SP2 re-entered the common area and walked toward the AV’s bedroom. · At 4:47:26 p.m., SP2 opened the AV’s bedroom door and observed the AV with the hoodie tied around his/her neck. SP2 entered the bedroom, and shortly after that, P2 walked toward the AV’s bedroom and entered it, followed by P3. At 4:50:30 p.m., SP2 and P2 exited the AV’s bedroom and stepped into the hall, then walked toward the common area. P2 was carrying a dark colored garment in his/her hands. P3 remained with the AV, and SP2 and P2 each entered other parts of the facility out of the camera’s view. · At 4:51:10 p.m., SP1 re-entered the common area with several youths, who walked toward the bedrooms, and SP1 opened the door that SP2 had just entered and appeared to speak with someone out of sight of the camera. SP1 then joined the youths in the hall near the bedrooms and entered the AV’s bedroom, while the youths remained in the hall. SP2 came into the camera’s view in the common area, and talked on a mobile phone, while P2 walked back and forth in the hall near the AV’s bedroom. · At 4:52:36 p.m., the SPs talked in the hall outside the AV’s open bedroom door. SP1 remained in the hall outside the AV’s bedroom door, and SP2 walked back and forth in the hall talking on the phone. The AV remained inside his/her bedroom and the video ended about two minutes later. No information showed that the AV required medical care after the incident or that first responders were called. · SP1 said that on the date of the incident, the AV was on staff shadow but there was a lot going on, and there were not enough staff persons to support the youths who needed assistance. SP1 was unsure who was assigned to shadow the VA but knew that it was not him/her and thought that SP2 was probably assigned to shadow the AV on the date of the incident. SP1 recalled that s/he and SP2 were talking with the AV in his/her bedroom, when SP2 exited the AV’s bedroom to help with other youths. The AV seemed to regulate him/herself but wanted SP2 to return to the AV’s bedroom so s/he could talk more with him/her. SP1 told the AV to “hang on” and said that s/he would get SP2 to return to the AV’s bedroom, but as soon as SP1 exited the AV’s bedroom and began walking away from it, the AV closed the bedroom door. SP1 stated that s/he thought that a couple of seconds later, s/he met SP2 walking toward him/her in the hall, and s/he remembered SP2 walking to the AV’s bedroom door and unlocking it. When SP2 opened the AV’s bedroom door, SP1 was in the hall with the other youths and did not see the AV but was later told that the AV put something around his/her neck. SP1 stated that s/he did not realize that the AV was unsupervised in his/her bedroom with the door closed. · SP1 thought that there was a miscommunication between him/herself and SP2 regarding the AV’s supervision and thought that s/he was being blamed for the incident when all staff persons were responsible for supervising the AV when the incident occurred. In addition, prior to the incident with the AV, P2 told SP1 that s/he needed SP1 to assist him/her outside with the other youths and said, “God damn it [SP1],” and “Jesus Christ [SP1].” SP1 told SP2 that P2 was not being supportive and SP1 felt that s/he was pulled in many directions. · SP2 stated that on the date of the incident, s/he instructed SP1 to shadow the AV during his/her shift. The AV asked to go into his/her bedroom, but SP2 knew that the AV seemed anxious and called SP1 to go into the AV’s room with the AV and SP2. The SPs talked with the AV, and s/he seemed to calm, so SP2 told SP1 that s/he would be right back and left the AV with SP1 while SP2 took a few outdoor recreation items and went into a courtyard at the facility with other youths. SP1 was out of SP2’s sight during this time, but when SP2 was with the youths, s/he counted them and realized that the AV was not in the group, then went to the AV’s bedroom, where s/he found the AV with a hoodie tied around his/her neck. · SP2 immediately began untying the hoodie, but the AV held the hoodie with his/her hands to prevent SP2 from removing it, and SP2 called P3 for assistance. P3 entered the bedroom and held the AV’s hands, which permitted SP2 to untie the hoodie and remove it from the AV’s neck. The AV’s face was turning blue, but his/her normal color returned, and s/he breathed normally when the hoodie was removed. The AV was assessed by a facility health care professional (HCP) and a mental health care professional (MHCP), and s/he was moved to a bedroom that was closer to the common area of the facility to ensure that staff persons could supervise him/her more closely. There were no marks or injuries to the AV’s neck. · P2 did not complete an interview with this investigator, and P3 said that s/he was unsure how the AV came to be unsupervised in his/her bedroom, but s/he responded to SP2’s call for assistance when the AV was found with clothing tied around his/her neck. P3 entered the AV’s bedroom and assisted SP2 to remove the hoodie from the AV’s neck then remained with the AV while SP2 made calls to supervisory/administrative staff persons regarding the incident. The facility’s Staff Management Policy showed that the facility was to provide enough adequately trained staff persons to ensure that youth treatment needs were met. Nursing staff persons were to be available at all times, and during awake hours, there was to be at least one staff person to three youths within the living unit. During sleeping hours, there was to at least one staff person for every four youths within the living unit with the ability to access other staff persons within the facility as needed. Staff persons must remain awake overnight. The facility’s employee scheduling software showed that SP1, SP2, P2, and P3 were working in the unit in which the AV resided at the time of the incident. SP1, P2, and P3 worked from 2 p.m. to 10 p.m., and SP2 worked from 3:30 p.m. to 10 p.m. Information from the facility showed that there were eight additional youths who resided in the same unit with the AV on the date/time of the incident. Excluding the AV and SP1 from the number of staff persons/youths present when the incident occurred, the staffing ratio was one staff person for each 2.67 youths. The facility’s Suicidal Ideation and Gesture Protocol showed that if a youth expressed suicidal ideation or engaged in a suicidal gesture, staff persons were to ask the youth whether s/he had a plan, or had thought about how s/he might harm him/herself, and how likely s/he was to implement his/her plan to harm him/herself, then consider whether the youth had the means to carry out his/her plan/whether the facility could restrict the youth’s access to the means to carry out his/her plans. Staff persons were to support youths according to their plans, offer distress tolerance skills to the youths, complete an assessment of the youth using a Columbia Screen, and contact a mental health care professional (MHCP) or therapist for more guidance/support. If the MHCP/therapist determined that staff persons should “shadow” a youth, staff persons were to be close enough to the youth to initiate a hold/intervention if needed, which meant that they should be in the same room or have eyes on the youths. Youths were not permitted to close their bedroom doors unless they were changing clothes. When shadowed youths slept, a staff person was to be in the hallway at all times. The need for staff shadow was reassessed every 24 hours, and youths were not removed from staff shadow unless it was approved by a MHCP. 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. Relevant Statutes: Minnesota Statutes, section 245A.04, subdivision 14, (b), (1-3), states that license holders shall provide training to program staff related to their duties in implementing the program's policies and procedures developed under paragraph (a); document the provision of this training; and monitor implementation of policies and procedures by program staff. Conclusion: A. Maltreatment: On August 17, 2024, the AV was on staff shadow at the facility because s/he recently made statements that s/he intended to harm him/herself. Staff shadow meant that staff persons were to be close enough to the AV that they could intervene if the AV attempted to harm him/herself. P1 and SP2 each stated that SP2 assigned SP1 to shadow the AV on the date of the incident when staff persons met prior to the shift, but SP1 said s/he was not assigned to shadow the AV on the date of the incident and thought that SP2 was shadowing the AV. Video from the facility’s recording system showed that at about 4:38 p.m., the AV went to his/her bedroom, and that SP2 opened the door for the AV. At 4:39 p.m., SP2 called SP1 for assistance and the SPs were in the bedroom or in the hallway, until 4:42:43 p.m. when SP2 exited the bedroom and walked alone out of camera range. SP1 remained with the AV. At 4:44 p.m., SP2 walked toward the AV’s bedroom and entered it. At 4:44 p.m., the AV and SP2 talked at the bedroom doorway, and at 4:44:54 p.m., SP1 exited the bedroom, walked past SP2 (who was standing in the AV’s bedroom doorway), and walked toward the common area. Five seconds later, SP2 walked away from the AV’s bedroom and the SPs were both in the hallway at the same time walking away from the AV’s bedroom. SP1 left first and SP2 was about 20 steps behind him/her. The SPs were walking in the same direction and SP2 was behind SP1. At 4:45:02 p.m., the AV closed his/her bedroom door. SP1 stopped at a closet and almost immediately, SP2 passed the closet and was about three feet behind SP1. The SPs continued into the common area, and each went into a different part of the facility out of camera range. About two minutes later, SP2 walked toward the AV’s bedroom, opened the closed bedroom door, and entered. SP2 found the AV with a hoodie tied around his/her neck, which s/he quickly removed. The AV’s face was blue, but s/he recovered and the HCP who assessed him/her determined that the AV did not require additional care. SP1 said there was a miscommunication, thought that SP2 was the AV’s shadow, did not think that s/he was the AV’s staff shadow, and thought that all staff persons were responsible for supervising the AV when the incident occurred. SP2 might have verbally instructed SP1 to shadow the AV during the shift, but the video recording showed that the SPs were both with the AV in his/her bedroom, then SP1 walked past SP2 away from the AV’s bedroom while the AV remained in the bedroom without supervision from a staff person. The SPs exited the AV’s bedroom within seconds of each other, and there were no staff persons supervising the AV. The AV then tied a hoodie around his/her neck and his/her face was blue when SP2 located him/her. After the AV and SP1 were excluded from the ratio counts, there was one staff person for each 2.67 youths when the incident occurred. The facility was in ratio. However, SP1 felt pulled in several directions and thought there were not enough staff persons to meet the needs of the youths. Given that the AV was not supervised according to the facility’s Suicidal Ideation and Gesture Protocol which was a violation of Minnesota Statutes, section 245A.04, subdivision 14, (b), (1-3), and tied a hoodie around his/her neck causing his/her face to turn blue, there was a preponderance of the evidence that there was a failure to protect the AV from conditions or actions that seriously endanger the AV’s physical or mental 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; 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). 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. 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 Staff Management Policy showed that the facility was to provide at least one staff person to three youths within the living unit during awake hours. On August 17, 2024, P2, P3, SP1, and SP2 were responsible for supervising nine youths in the unit of the facility in which the incident occurred. The facility’s Suicidal Ideation and Gesture Protocol showed that when staff persons shadowed youths, they were to be in the same room with the youth or have eyes on the youth. Youths were not permitted to close their bedroom doors unless they were changing clothes. SP2 said that s/he assigned SP1 to shadow the AV and the facility’s policies showed that staff persons were to supervise youths by keeping eyes on them or being close enough to youths to physically intervene. SP1 thought that SP2 was shadowing the AV on the date of the incident. Video from the facility showed that SP1 and SP2 were both in the hall outside the AV’s bedroom when the AV closed the bedroom door and that SP2 walked past SP1 in the hall, moving away from the AV’s bedroom to a facility common area after the AV closed the bedroom door. Given that the facility’s Suicidal Ideation and Gesture Protocol instructed staff persons how to supervise youths when they were shadowed, and that the facility was in staffing ratio when the incident occurred, the facility’s responsibility was mitigated. According to staff ratios, there were enough staff persons to supervise the youths when the incident occurred, but SP1 thought that SP2 was shadowing the AV, and SP2 said that SP1 was assigned to shadow the AV. SP1 felt that his/her attention was being pulled in multiple directions, leaving him/her unable to supervise the AV. Information was consistent that the responsibility for staff shadow was written on a white board in the facility office that was erased at the end of the shift. Given the aforementioned, that it was unknown whether adequate instructions were given to SP1 to ensure that s/he knew that s/he was shadowing the AV, that the SPs were each in the hall near the AV’s bedroom when the AV closed the bedroom door, and that there was conflicting information regarding who was responsible for shadowing the AV on the date of the incident, the responsibility for the maltreatment was inconclusive. Action Taken by Facility: The facility completed an Internal Review which determined that their policies and procedures were adequate but were not followed. The facility retrained its staff persons on staff shadow protocol, and staff persons who were responsible for completing safety checks/staff shadow for the AV were given “corrective action.” Action Taken by Department of Human Services, Office of Inspector General: On April 23, 2025, the facility was issued a Correction Order for the violations outlined in this report. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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