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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.” Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1028358-CRF (Children’s Residential Facility/Department of Corrections) Investigator(s): Scout Peterson Suspected Maltreatment Reported: It was reported that a staff person (SP) took five alleged victims (AV1-AV5) and one vulnerable adult (VA1) on a walk. After they returned from the walk, AV1-AV5 and VA1 appeared “high” and there was concern that the SP let AV1-AV5 and VA1 use a “vape” or “cart” containing tetrahydrocannabinol (THC) while on the walk. Date of Incident(s): March 22, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult’s physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during site visits conducted on March 31 and April 1, 2025; from documentation at the facility; and through 12 interviews conducted with two staff persons (SP and P1), a supervisory staff person (P2), AV1-AV6, and VA1-VA3. AV1’s-AV6’s guardians were contacted via phone and US mail and notified of this investigation, but none had additional information to provide. VA1-VA3 were not subject to guardianship. The facility provided services to youth aged 16 to 21. According to documentation from the facility, the SP began working at the facility on December 12, 2024, and on March 22, 2025, the SP worked from 8 a.m. to 8 p.m. According to the clients’ Group Residential Case Plans, AV1-AV3 were assessed as “low-risk” for substance use and abuse. VA3 was also assessed as “low risk,” however, his/her diagnoses at intake included cannabis dependence. AV4-AV6 and VA2 were assessed as “medium-risk” for substance use and abuse. VA1 was assessed as “high-risk” for substance use and abuse. AV1-AV6 and VA1-VA3 were each under 21 years old. P1 provided the following information in an interview and in the facility’s Internal Review: · On March 22, 2025, the SP took six youth, AV1-AV5 and VA1, on a walk which P1 thought was “odd” because the youth were doing chores, it was almost time for them to go to bed, and they did not like to do recreational activities. At the time, the SP “insisted” s/he take the youth on a walk, and P1 stated that “something felt weird” about it. · After the group left on the walk, AV6 approached P1 and told him/her that s/he “knew” why the youth wanted to go on a walk and that the youth used THC “carts” and nicotine “vapes” while on walks, but that the SP did not know about it. VA3 then told P1 that youth used “carts” and “vapes” on walks and that the SP did know about it. VA3 also told P1 that in the past s/he used the SP’s vapes but did not say anything because s/he wanted to continue to do so. · When the youth and the SP returned from the walk, they were all “visibly [high]” and were slurring their speech, apart from AV5, who did not seem under the influence. VA1 had “really red eyes” and AV3 could not keep his/her head up. P1 sent all the youth to their rooms and called P2 and a facility nurse. The nurse told P1 to monitored the youth. P1 did so and also did “extra checks” during the overnight. The next day, the youth talked to P2 and acknowledged using the SP’s vape and THC carts. P2 provided the following consistent information in an interview and in the facility’s Internal Review: · On March 22, 2025, P1 called P2 and said that six youth returned from a walk with the SP and seemed “high.” P2 told P1 to call nursing staff for instructions on what to do next. P2 also took the SP off the facility schedule and found another staff person to cover his/her shift scheduled for following day. · The next day, March 23, 2025, P2 spoke to AV1-AV5 and VA1 and also AV6, VA2, and VA3. AV1-AV4 and VA1 each stated that while on the walk with the SP, each used the SP’s “vape” with THC. AV5 stated that s/he did not use it but AV1-AV4 and VA1 stated that AV5 did so. When P2 spoke to AV6, VA2 and VA3, each stated that they used the SP’s “vape” in the past. · On March 24, 2025, P2 so to the SP about the incident, and the SP acknowledged that s/he allowed the youth to use his/her “vape,” but that it only contained nicotine and not THC. AV1-AV6 and VA1-VA3 each provided the following consistent information in their respective interviews and in the facility’s Incident Report: · AV1-AV4 and VA1 each stated that on March 22, 2025, they went on the walk with the SP and while on the walk, each used the SP’s “vape” and/or “cart” that contained THC. AV5 stated that s/he did not smoke while on the walk. AV1 stated that the SP let youth use the “vape” weekly; AV2 stated that the SP let youth use the nicotine vape whenever s/he worked at the facility; AV3 stated that the SP had let residents use the vape for “months;” AV4 stated that the SP did not let AV4 use his/her “vape;” AV5 stated that the SP let residents use his/he “vapes” and THC “carts;” and VA1 stated that the SP let him/her use his/her THC “pen” and “vape” “every time” the SP worked. · AV6, VA2, and VA3 each stated that they did not go on the walk on March 22, 2025. AV6, VA2, and VA3 each also stated that the SP gave nicotine “vapes” and THC “carts” to youth in the past. AV6 stated that it had been going on for “the last couple weeks;” VA2 stated that it had been going on for “about two months;” and VA3 stated that it had been going on since January 27, 2025. The youth stated that the SP allowed them to use the “vapes” and “carts” at the facility, outside, and in the van while the SP drove. The SP provided the following information during the interview and in the Internal Review: · The SP allowed the youth to use their personal THC and nicotine vapes on walks, during outings, and at the facility. The youth obtained the THC and nicotine vapes from school or work and brought them to the facility in their backpacks and kept them hidden in their rooms. At the beginning of his/her employment at the facility, the SP “shut it down” and did not allow the youth to use them, but eventually the SP “turned a blind eye” to the behavior because there was “nothing I could do about it to stop them.” The SP stated that it also “got to a point” where s/he stopped writing up the youth for having nicotine and THC vapes because s/he “did not know what to write anymore.” The SP stated that the facility felt “inescapable” and that it was “impossible” to enforce the rules because the youth “did not care about the consequences.” · The SP denied providing THC vapes or cartridges to any youth. but stated that on one occasion s/he gave VA3 a “hit” off his/her personal nicotine vape while at the facility. The SP stated that it was a “mistake” and that s/he was “entirely remorseful.” However, the SP provided conflicting information during the facility’s Internal Review. On March 24, 2025, the SP stated that s/he allowed the youth to use his/her “vape” but stated that it contained nicotine and not THC. · The SP thought that the youth might say that the SP gave them the THC and/or nicotine vapes/carts because the youth did not want to get in trouble and/or “rat out” the other youth for bringing the items into the facility. · The SP stated that s/he was trained on the facility’s policies regarding drugs and nicotine at the facility. The SP added that when s/he used his/her personal nicotine vape while working, s/he did so in his/her car. According to the facility’s Drug-Free Workplace policy, [The facility] prohibited the unlawful manufacturing, distribution, sale, dispensing, possession, transfer or use of alcoholic beverages, intoxicants and narcotics, illegal or unauthorized drugs (including marijuana), ‘look-alike’ (simulated) drugs, and/or any related drugs paraphernalia on its premises, facilities, or workplaces. The SP, P1 and P2 were each trained on the facility’s Drug-Free Workplace policy, the Reporting of Maltreatment of Vulnerable Adults Act, and the Reporting of Maltreatment of Minors Act, and the youths’ plans. Relevant Rule and Statute: Minnesota Statute, section 209.6855, subdivision 1, paragraph (a) states in part that an individual may not give any product containing or delivering nicotine to an individual under 21 years of age. Minnesota Statute, section 342.09, subdivision 1, paragraph (b), clause (7) states in part that an individual may not give cannabis to an individual under 21 years of age. Conclusion: Information from AV1-AV6, VA1, P1, and P2, was consistent that on March 22, 2025, the SP took AV1-AV5, and VA1 on a walk and when they returned each appeared to be under the influence of a substance with the exception of AV5. AV1-AV5, and VA1 each stated that when they were on the walk the SP allowed them to use the SP’s vape/carts that contained THC and/or nicotine. In addition, information from AV1-AV6, VA1, and VA2 was consistent that there were multiple other times at the facility and in the van when the SP allowed the youth to use the SP’s vape/cart that contained nicotine/THC.
The SP denied allowing the youth to use his/her vapes/carts with marijuana. Although during the interview the SP denied giving the youth his/her vape/cart with nicotine, with the exception of one occasion when s/he allowed VA3 to use his/her personal nicotine vape, during the Internal Review, the SP stated that s/he allowed the youth to use his/her vape with nicotine. The SP stated that the youth obtained the vapes/carts with nicotine and/or marijuana from school or work. The SP stated that initially s/he did not allow the youth to use their own vapes/carts but eventually allowed them to do so while on walks, during outings, and while at the facility, and did not do anything to stop the youth from doing so. In addition, the SP stated that it “got to a point” where s/he stopped writing up the youth for having nicotine and THC vapes because s/he “did not know what to write anymore.” Although the SP denied allowing AV1-AV6, and VA1-VA3 to use his/her vape/cart that contained marijuana and/or nicotine, given that AV1-AV6, and VA1-VA3 provided consistent information that the SP did so; that their own admissions to using marijuana/nicotine exposed each to possible ramifications; and that P1 observed intoxicated behaviors in AV1-AV4, and VA1 when they returned from their walk, there was a preponderance of the evidence that the SP gave and allowed AV1-AV6, and VA1-VA3 to use his/her and/or their own vape/carts that contained marijuana and/or nicotine which was not accidental or therapeutic conduct. There was no information provided that AV1-AV6, and VA1-VA3 were harmed. However, each was under 21 years old and therefore, it was illegal for a person to give marijuana and/or nicotine to each and encouraged each to participate in actions that were illegal. In addition, AV4’s-AV6’s, VA2’s, and VA3’s plans each stated that they were at either a medium or high risk for substance use/abuse and VA3 had a history of substance use. Therefore, there was a preponderance of the evidence that the SP allowing the youth to access and consume marijuana and/or nicotine was a failure to supply AV1-AV6 with necessary care; a failure protect AV1-AV6 from conditions or actions that seriously endangered his/her physical or mental health when reasonably able to do so; and a failure to supply VA1-VA3 with care that was reasonable and necessary to their physical and mental health and safety. 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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult’s physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was responsible for the care and supervision of AV1-AV6 and VA1-VA3 and was trained on the facility’s Drug Free Workplace policy, the Reporting of Maltreatment of Minors Act, and the Report of Maltreatment of Vulnerable Adult Act prior to the incident. The SP was responsible for maltreatment of AV1-AV6 and VA1-VA3. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible was recurring maltreatment because the SP provided THC and/or nicotine to nine youth (AV1-AV6 and VA1-VA3) on more than one occasion. 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 policies and procedures were adequate but not followed. The SP no longer worked at the facility, therefore, there was no need for additional staff training or corrective action. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. The facility is licensed by the Minnesota Department of Corrections. A copy of this report was forwarded to them for their review of possible licensing violations. 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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