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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: 1056498-CRF (Children’s Residential Facility) Investigator(s): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) did not check on an alleged victim (AV) in his/her bedroom for about seven hours. During the time the AV was not supervised, the AV left the facility and was located three days later in the community. Date of Incident(s): June 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 27, 2025; from documentation at the facility and law enforcement records; and through interviews conducted with facility staff persons (P1, P2, and the SP), the AV, and the AV’s guardian (G). DHS received the concerns investigated in this report on July 31, 2025. The facility provided services to youths 14-19 years of age and offered 24 hour a day supervision with individualized coaching and mentoring. The facility’s programs were designed to keep families engaged throughout the treatment process and ensure that those served by the program were wrapped with necessary supports. The facility had a video recording system which recorded interior common areas of the facility, but the system did not have sound or record the facility's exteriors. Facility documentation showed that the AV was diagnosed with anxiety and was vulnerable to maltreatment. When the AV was stressed, s/he might have difficulty making well thought out decisions and might seek concerning methods to calm him/herself. The AV had a history of leaving facilities without the knowledge or supervision of staff persons and might use substances when s/he was unsupervised in the community. The AV was intelligent and resourceful. Interviews with this investigator, facility documentation, records from a law enforcement agency, and the facility’s Internal Review, provided the following: · The AV said that on the date of the incident, s/he felt fine and told the SP that s/he was going to his/her bedroom to relax. The SP “never” checked on the AV that day, and s/he left the facility at about 11 a.m. by climbing out of his/her bedroom window (which had no alarm), then jumping to the ground. The AV was not injured and was surprised that staff persons did not see him/her when s/he crossed the facility grounds while leaving. It was common that staff persons did not check on youths in their bedrooms or other parts of the facility and did not search the youths or their belongings when the youths returned to the facility after time in the community. Staff persons at the facility were not engaged with the youths and were inconsistent when they enforced the facility’s policies and procedures, according to the AV. · The SP said that on the date of the incident, P1 worked with him/her and took several youths on outings, which meant that the SP remained at the facility to supervise the youths there. Staff persons rotated taking youths on outings so that they were not continuously the staff person who went on outings or the staff person who remained at the facility to supervise the youths. The AV told the SP that s/he did not feel well several times, took a shower at about 1 p.m., and then went to lie down in his/her bedroom. The SP had a good relationship with the AV and did not think that the AV would leave the facility, so s/he did not check on the AV in his/her bedroom until about 7 p.m., to give the AV time to rest and sleep. When the SP opened the door to the AV’s bedroom, s/he discovered that the AV was not there. The bedroom window was open, so the SP thought that the AV left through the window. The SP immediately notified supervisory staff persons and called 9-1-1 to notify the law enforcement agency that the AV left the facility without supervision. The SP felt sick to his/her stomach and was very worried about the AV. No information showed that the SP evaluated the AV for signs/symptoms of illness prior to the AV entering his/her bedroom. · The Resident Count sheet for June 22, 2025, showed that the SP documented checks on the youths at the facility that day. The SP marked that s/he checked on the AV regularly as required from 6:30 a.m. to 2:30 p.m., but did not check on the AV between 3 p.m. to 7 p.m. · P1 worked the shift with the SP on the date of the incident and took youths on outings that day, while the SP stayed at the facility to supervise the youths who did not go on outings. After P1 returned to the facility at a time s/he did not recall, but between 7 and 9 p.m., s/he realized that s/he had not seen the AV since returning, and s/he and the SP checked on the AV, then realized the AV was not in his/her bedroom. P1 and the SP searched the facility and its grounds, but the AV was not there. P1 called 9-1-1 and a supervisory staff person to let them know the AV left the facility without supervision. · Records from the law enforcement agency showed that the agency responded to the call from the facility, and on June 25, 2025, the AV was found in the community, then taken to a secure facility. The AV did not return to the facility and later began residing in a different facility that provided similar services. No information showed that the AV sustained an injury or whether s/he used substances when s/he exited the facility or while s/he was unsupervised in the community. · P1, P2 (who was a supervisory staff person), and the SP, provided consistent information that staff persons were to check on the youths every 15-30 minutes depending on the youths’ individual needs and when they were not within the immediate sight of staff persons. According to P2, when the youths were in their bedrooms or lying in their beds, staff persons were to check on the youths every 15-30 minutes to ensure that the youths were present and look for chest rise/fall or other signs to confirm the youth was breathing and not in distress. On the date of the incident, staff persons were in ratio and supervising an appropriate number of youths. P2 added that if a youth might be ill, staff persons should check on them frequently to determine if the youth required additional care. · After the June 22, 2025, incident, P2 reviewed video recordings of the SP’s shift and observed that the AV entered his/her bedroom just before 1 p.m. and was last seen on the recording at about 1:30 p.m., when s/he opened the bedroom door and looked up and down the hall. P2 thought that the AV was possibly looking for the SP in the hall and probably left the facility through his/her bedroom window shortly after checking the hall. The recordings showed that the SP intermittently sat at a desk in the hall periodically and sometimes used his/her cell phone during the shift. The SP checked on some of the youths during the shift, but staff persons did not check on the AV until 7:33 p.m., which meant that staff persons did not check on the AV for about seven hours. · P2 said that the facility did not report the incident to DHS in a timely manner and thought that the lapse occurred because the incident occurred at a time when there was turnover among administrative staff persons. Prior to the incident, there were previous concerns regarding the SP’s use of his/her cell phone on the floor and P2 had previously discussed cell phone use on shift with the SP. 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: Information was consistent from the AV, P1, P2, and the SP, that on June 22, 2025, the AV left the facility without the knowledge or supervision of a staff person. The AV said s/he exited the facility through his/her bedroom window. According to P1, P2, and the SP, staff persons were to check on youths who resided at the facility every 15-30 minutes, depending on the supervision needs of the youths. The SP said that s/he did not check on the AV in his/her bedroom because the AV told the SP that s/he did not feel well, and video recordings from the facility confirmed that the AV entered his/her bedroom and closed the door at about 1:30 p.m. on the date of the incident. There were no further recordings of the AV, but recordings showed the SP intermittently sitting at a desk, using his/her cell phone, and checking on other youths periodically during the shift. When the SP and P1 checked on the AV at 7:33 p.m., they observed the AV was gone, and P1 called 9-1-1. Records from the law enforcement agency showed that the AV was found on in the community on June 25, 2025. Although no information showed that the AV was injured or used substances when s/he left the facility or was unsupervised in the community, given that the SP said that the AV told him/her that s/he did not feel well and entered his/her bedroom at about 1:30 p.m., but the SP did not check on the AV for an extended time, which was not consistent with facility policies and procedures and inconsistent with the actions of a professional caregiver in a DHS licensed facility, there was a preponderance of the evidence that there was a failure to supply the AV with health or other care required for 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). 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 AV’s supervision when the incident occurred and a video recording from the facility’s video recording system showed that the SP did not check on the AV for about seven hours. 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 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 because it was a single incident, and no information showed that the AV was injured when s/he left the facility without supervision. 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 were not followed. The facility revised its Reporting of Maltreatment Policy to more clearly show what steps should be taken within specified time frames to ensure that reports of possible maltreatment were made quickly and retrained staff persons on completing proper well-being checks. In addition, P2 (or a designated supervisory staff person) was instructed to randomly review portions of video recordings for each shift to ensure that staff persons properly completed checks on the youths. The SP and P1 each received written corrective actions. 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. Because 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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