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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: 1103884-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon/Beth Virden Thomas.C.Nixon@state.mn.us Suspected Maltreatment Reported: It was reported that when an alleged victim (AV) tried to leave during an argument with a staff person (SP), the SP threw the AV into a window and attempted “wrestling moves” on the AV. The AV sustained a “swollen” hand. Date of Incident(s): July 10, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clause (1); 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. "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 July 25, 2025; from documentation at the facility and law enforcement records; and through five interviews conducted with the AV, the AV’s family member (FM), a hotel staff person (HS), a facility staff person (P1), and a supervisory staff person (P2). Attempts were made by telephone and mail to contact and interview a staff person (SP), but the SP did not respond by the completion of this investigation. The facility occupied more than one hotel room, in a hotel-complex, providing crisis respite (short-term) services to more than one client. Each client had their own hotel room and staff. The AV’s support plans, including Individual Abuse Prevention Plan and Positive Support Plan, provided the following information: · In January 2025, the AV moved into the facility seeking support and services relating to his/her diagnoses, which included reactive attachment disorder. The facility provided the AV with crisis respite (short-term) services and two staff persons for “24-hour supervision.” The AV was 17 years old. · The AV enjoyed being social and making people laugh. However, s/he was sometimes “triggered” when others made “aggressive/rude” comments towards him/her and might react by hitting, kicking, or slapping others. Should this occur, staff maintained a safe distance, removed furniture or objects out of the way, and used “blocking pads” to reduce the risk of injury. If the AV’s behavior posed an imminent threat of bodily harm, staff used the least restrictive measure to achieve safety, which might include an emergency use manual restraint (EUMR). · If the AV was yelling, swearing, or name-calling, and there was no risk of physical harm to anyone, staff were prohibited from using an EUMR. Staff watched for signs the AV was “upset” and encouraged the AV’s coping skills, which might include taking a break or a walk. “Reminders and verbal cues will be used to teach [the AV] to remember to use [his/her] coping skills independently.” · The AV had a history of “running (away) or sneaking off” unsupervised. Should this occur, staff closely monitored and followed the AV. · The AV was susceptible to abuse from others and might not understand potentially dangerous or harmful situations. Staff intervened when needed to ensure the AV’s safety and reported suspected or known abuse on the AV’s behalf. “Close monitoring and supervision will be used for [the AV] at all times.” The AV provided the following information: · On an unspecified date and time (July 10, 2025), the AV was in his/her hotel room bathroom. The bathroom door was closed, and the light inside was on. The SP was asleep on a couch in the hotel room and P1 was sitting in a chair outside the bathroom watching videos on his/her cellphone. The AV was in the bathroom for two to three minutes when s/he heard P1 “jump up” and state, “[The AV’s first name] ran away.” P1 and the SP then ran out of the hotel room. They never knocked on the bathroom door, opened the door, or asked if the AV was in the bathroom. The AV exited the bathroom and started watching something on TV. About two minutes later, the SP returned to the room without P1. · The AV called the SP, “[The R word]” because s/he thought the AV ran away. The SP responded, “Who thought you ran away?” and repeated this more than once, which “pissed off” the AV. The AV told the SP, “Shut the fuck up, bitch.” The SP appeared “annoyed” and told the AV, “Don’t talk to me like that. Who you talking to like that? … I’m not scared of you.” The AV stood and walked toward the door to leave the room. The AV said, “I was trying to get out of the situation, so I don’t get escalated.” · However, the SP “jumped up” and blocked the AV’s exit. The AV reacted by punching the SP “a couple of times.” “[The SP] grabbed me, threw me (across the room) into the mirror … [which] shattered.” The AV could not recall which part of his/her body struck the mirror. · Next, the AV and the SP fell to the floor. The AV landed facedown with the SP on top of his/her back. The SP wrapped his/her arms around the AV’s neck in “a chokehold;” however, the AV’s breathing was not impacted. The SP told the AV, “Calm down,” and the AV said, “Get the fuck off me,” like ten times, before the SP finally released the AV and stood up. The AV ran out of the room, to the hotel lobby, and told the HS to call 9-1-1. The HS called P2, who told the AV to stay with the HS until other facility staff arrived to replace the SP and P1. · The AV sustained a “wiggly tooth” from the incident, which, at the time of the DHS investigator’s site visit, s/he had an upcoming dental appointment to have it assessed. In addition, the AV’s right hand was “hurt” because s/he “punched [the SP].” Note: The conduct of leaving the AV unsupervised in his/her hotel room and in the hotel lobby with the HS was a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), which states, in part, the license holder must provide services in response to the person's identified needs as specified in the coordinated service and support plan and the coordinated service and support plan addendum. The HS provided the following information: · The HS routinely worked in the hotel lobby and was familiar with the AV and facility staff. · On an unspecified date (July 10, 2025), between 9:30 and 10:30 a.m., the AV ran down the stairs from the second floor, which was where the AV’s hotel room was, and told the HS, “Call the fucking police.” The HS guided the AV behind the hotel front desk to sit down and talk about what happened. The AV was alone and there were no staff with, or running after, the AV. · The AV told the HS that s/he and the SP got into an argument and the AV threw a glass of water at the SP’s face. They then started “fighting” and at one point, the SP was “choking” the AV from behind. · The HS told the DHS investigator, “You could visibly tell, by the way [the AV] was talking that [s/he] had got into an altercation with staff.” The AV was “shaking so bad.” · The HS did not see any marks on the AV’s neck but saw the AV’s right hand was “a little swollen.” The HS said, “[The AV] visibly looked like [s/he] hit something” but the HS did not ask what the AV might have hit. The HS gave the AV an ice pack and called P2.
· An unknown time later, the SP walked downstairs and sat on a lobby couch watching the AV. The SP did not say anything to them. At some point after, the HS and the AV walked outside. The SP did not follow them. About 30 minutes later, while still outside, P1 walked up to them from around the building and shortly thereafter, another staff person (P3) arrived in his/her car and drove away with the AV. P1 and P2 provided the following information: · P1 said that on July 10, 2025, the AV was in the bathroom for about 10-15 minutes and when P1 knocked on the bathroom door, the AV did not answer. P1 opened the door, and the AV was not inside. P1 alerted the SP that the AV was gone. P1 and the SP ran out of the room, splitting up and looking for the AV. P1 went to a nearby supermarket and then was headed back to the hotel when P2 called him/her to state the AV was with the HS. “A period of time” passed between when P1 left the hotel room and when s/he next saw the AV outside with the HS. There was a bandage on the AV’s hand but P1 did not see any injuries on the AV. The AV told P1 that the SP “beat [him/her] up” but did not provide additional details of what this entailed to P1. · P2 said that at an unspecified time, the HS called him/her stating the AV was at the front desk. The AV told P2 that s/he and the SP were arguing and when the AV tried to leave the room, the SP blocked him/her, grabbed and threw him/her into the mirror, and “attempted wrestling moves” on the AV. The HS texted a picture of the AV’s hand, which looked “swollen.” The AV declined medical attention. · P1 and P2 each separately asked the SP about the incident. The SP told P1 that the AV “jumped on” him/her, but did not provide additional details of what this entailed to P1. · P2 said that the SP stated the AV called staff “fucking idiots” for believing s/he ran away. The SP told the AV that his/her language was “not nice or appropriate” and the AV threw a water bottle at the SP and then stood to leave the room. The SP was standing by the door, and the AV pushed the SP against the door and then “swung on” the SP. The SP grabbed the AV’s arms “to get control of [him/her].” · P2 said, “I was confused about [the SP] trying to prevent [the AV] from leaving cause [SIC] that is [the AV’s] outlet and what [s/he] does, and staff follow from a distance.” P2 said that if the AV swung at a staff person, it was consistent with training to grab the AV’s arm but when the AV was initially trying to leave the room, the SP had no reason to stop him/her. “In my opinion, [the incident of the AV swinging on the SP] could have been prevented.” · P1 and P2 did not provide information whether the AV or the SP mentioned a “chokehold.” P2 said that the AV told him/her the SP “attempted (unspecified) wrestling moves.” P1 and P2 each saw the mirror in the AV’s hotel room was broken following the incident. · P2 said that staff were trained on EUMRs, but they should never do an EUMR with a minor, like the AV. P2 also said that in the event the AV left the room without supervision, one staff person should have stayed in the room while the other left to search for the AV. · P1 and P2 each said that the AV did not always provide accurate information and might “manipulate” or “lie … a little bit” about happenings. The facility’s daily summaries for July 10, 2025, stated the following: · The SP stated that at 11 a.m., the AV “snuck out” of the hotel room and the SP and P1 left the room looking for him/her. An unspecified time later, the SP returned to the room and discovered the AV watching TV. The SP asked the AV where s/he went and the AV responded, “Don’t fucking worry about it, you guys are [R word], really thought I ran away.” The SP told the AV that staff were out looking for him/her. The AV “got irritated” and told the SP, “Shut the fuck up.” The AV then threw water on the SP’s face and “hit” and “punched” the SP’s head and face. “[The SP] restrained [the AV] alone because [P1] was still looking for [the AV].” The SP released the restraint when (illegible). The AV then walked out of the room and the SP followed. At some point after, another staff person (P3) arrived, and the SP left. [Note: The SP’s daily summary did not state the technique used to restrain the AV or how long the restraint lasted.] · P1 stated that s/he did not witness the incident and P1’s daily summary did not provide additional information. · P3 stated that at noon, s/he arrived and found the AV “upset” and sitting outside with unidentified staff, who told P3 that the AV engaged in “physical aggression and property destruction.” P3 saw that the AV’s right hand was “swollen.” P3 offered to take the AV for a drive to give space and time to calm. The AV asked to go to the grocery store and buy snacks. P3 and the AV “talked about what happened” (details not provided in P3’s daily summary) and the AV “calmed down.” They returned to the hotel and the remainder of day and night were uneventful. P3’s shift ended the next morning, July 11, 2025. · [Note: The SP’s use of a “restraint” was not reported as required and was a violation of Minnesota Statutes 245D.061, subdivision 8, which states, in part, the license holder must report within five working days the use of an emergency use of manual restraint to the Department of Human Services and the Office of the Ombudsman for Mental Health and Developmental Disabilities.] The facility completed an Internal Review, in which they interviewed the SP, P1, and the HS who provided the following information: · The SP stated that the AV swung at and pushed him/her, and that the SP wrapped his/her arms around the AV to place him/her in an unspecified restraint. About 15 seconds later, the AV seemed “less agitated,” and the SP released him/her. P1 then entered the room, and they all walked downstairs. · P1 stated that s/he returned to the hotel room and saw the SP and the AV against a wall with the AV “escalated” and “attempting to escape [the SP’s] grasp.” P1 redirected the AV and the three of them walked downstairs. · The HS stated that “when [the AV] and staff went downstairs,” the AV asked to speak privately with the HS and told the HS that his/her staff “attacked” him/her. The HS did not provide additional detail of what this entailed. · [Note: The SP’s and P1’s statements for the facility’s Internal Review were not consistent with their daily summaries.]
A police report stated that a law enforcement officer (LEO) followed up on the incident on July 17, 2025. The AV told the LEO that on July 10, 2025, the SP threw the AV into a mirror, which broke. The AV stated that s/he was not injured and did not want to pursue criminal charges against the SP. The law enforcement case was closed. [Note: The police report did not state anything about a “chokehold.”] The FM said that the AV was “complex” and might first appear “easy going, a people pleaser, wants to fit in.” However, when the AV was “uncomfortable or overwhelmed,” s/he became “angry” and yelled, punched walls and people, “very aggressive,” “very explosive.” The AV did not always provide accurate information and might “spin stories” or “manipulate.” Staff provided supervision and reminders to the AV. Regarding what happened on July 10, 2025, the AV told the FM that “there was yelling,” and staff thought the AV eloped, which “upset” the AV that staff thought this. The AV said that s/he punched and broke something with his/her fist. The facility’s Emergency Use of Manual Restraints (EUMR) policy stated: · Before a person’s behavior posed an imminent risk of physical harm, staff were supposed to attempt de-escalation techniques, like a “calm” discussion or alternate activity, or attempt the person’s individualized strategies that were written into the person’s Support Plan and/or Support Plan Addendum, or Positive Support Transition Plan. · If positive support strategies were ineffective at deescalating or eliminating a client’s behavior, an EUMR might be necessary and used only when the following conditions were met: a) Immediate intervention must be needed to protect the client or others from imminent risk of physical harm. b) The type of manual restraint used must be the least restrictive intervention to eliminate the immediate risk of harm and effectively achieve safety. c) The manual restraint must end when the threat of harm ends. · The facility allowed the following types of EUMRs:
a) Physical escort/walking: Stages 1 and 2: Staff walked beside and slightly behind the person with one hand on the person’s forearm, just below the elbow, applying firm, but gentle pressure. If this was ineffective, staff might use both hands with one on the small of the person’s back and the other on the person’s forearm applying firm, but gentle pressure. b) Arm restraint/one staff person standing: 1 arm and 2 arm: Staff held the person’s arm across the person’s body, above the wrist, while also securing the person’s other arm to their side. c) Arm restraint/one staff person sitting: 1 arm and 2 arm: Staff might need to transition from a standing to a sitting position. While restraining the person’s arm(s), staff verbally notified the person of what they were doing and slowly backed up and lowered the person to the floor. Staff then sat or knelt behind the person. In the event the person attempted to hit staff with their head or aggressively rock back and forth, staff pulled slightly back while maintaining their restraint.
· Staff were prohibited using an action or procedure that might restrict or obstruct a person’s airway or impair breathing, including techniques whereby individuals use their hands or body to place pressure on a person’s neck. Facility documentation stated that the SP, P1, and P2 received training on the Reporting of Maltreatment of Minors Act. The SP and P1 also received training on an unnamed course, which covered manual restraint techniques, including escorts and one- and two-arm holds; de-escalation skills; and avoidance and redirection. The SP and P1 also received training on the AV’s support plans, including Individual Abuse Prevention Plan and Positive Support Plan; P2 wrote or contributed to the AV’s support plans. Relevant Minnesota Statutes and Rules: Minnesota Statutes, section 245D.06, subdivision 5, which states the license holder is prohibited from using chemical restraints, mechanical restraints, manual restraints, time out, seclusion, or any other aversive or deprivation procedure, as a substitute for adequate staffing, for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience. Conclusion: A. Maltreatment: The AV, the SP, and P1 provided consistent information that on July 10, 2025, the SP and P1 worked with the AV in the AV’s hotel room. At some point, the AV went into the attached bathroom, and the SP and/or P1 mistakenly believed the AV left the hotel room without supervision. The SP and P1 both left the room searching for the AV. The AV then exited the bathroom and remained in the room until the SP returned. The AV provided information to the HS, P1, P2, the LEO, and the DHS investigator, which included that when the SP returned to the hotel room, the AV and the SP argued and when the AV tried to leave the room “to get out of the situation,” the SP blocked the AV’s access to the door. The SP grabbed and threw the AV into a mirror, which broke, and the AV punched and pushed the SP. They fell to the floor with the SP was on top of the AV’s back with his/her arms wrapped around the AV’s neck. The AV repeatedly told the SP to get off him/her before the SP finally released the AV and the AV ran out of the room and told the HS what happened. The HS’s observations immediately following the incident, included, “You could visibly tell, by the way [the AV] was talking that [s/he] had got into an altercation with staff.” The AV was “shaking so bad.” The SP provided information to P1 and P2 that there was a physical altercation and that s/he grabbed the AV’s arms to “get control,” but s/he did not provide additional detail about what occurred. The SP’s daily summary stated that s/he “restrained” the AV but also did not provide additional detail about what occurred. The SP did not provide information to the DHS investigator and the SP’s “restraint” was not reported as required to Department of Human Services and the Office of the Ombudsman for Mental Health and Developmental Disabilities as noted above. Given the aforementioned and that the AV’s account included an explanation for the broken mirror and did not diminish the AV’s own actions, including that s/he punched the SP, and with incomplete information from the SP, it was determined the AV’s account was more credible than the SP’s account. Regarding neglect: The AV said that the SP appeared “annoyed” and made statements, like, “Don’t talk to me like that. Who you talking to like that? … I’m not scared of you.” The AV’s support plans stated that s/he might be triggered by “aggressive/rude” comments and that the AV’s coping skills included taking a break or a walk and that staff were supposed to provide “reminders and verbal cues … to teach [the AV] to remember to use [his/her] coping skills independently.” However, when the AV tried to leave the room, the SP blocked him/her from leaving. There was no information the SP made any attempt to get out of the AV’s way or allow the AV to leave the room. The AV’s conduct was consistent with what s/he was supposed to do when “upset”; however, the SP’s conduct was not and was a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a). Given that the SP conduct likely escalated the situation and/or caused the physical altercation, and that P2 also believed the physical altercation “could have been prevented” if the AV had been allowed to leave the room, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and services required for the AV's physical or mental health. 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). Regarding physical abuse: The SP’s conduct of restraining the AV on his/her stomach on the floor and using a “chokehold” or wrapping arms around the AV’s neck was a violation of Minnesota Statutes, section 245D.06, subdivision 5. The SP’s conduct also included throwing the AV into a mirror and breaking the mirror which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. Therefore, there was a preponderance of the evidence that the SP’s conduct included an overt act that was not accidental and represented a substantial risk of injury to the AV. It was 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). 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 care and supervision. The SP received training on the AV’s support plans; manual restraint techniques, including escorts and one- and two-arm holds; de-escalation skills; and avoidance and redirection; and the Reporting of Maltreatment of Minors Act. 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 SP was responsible for a single incident of maltreatment, which met two definitions of maltreatment, and although the AV sustained a “wiggly tooth” and “swollen” hand, it was not determined if this occurred as a result of the SP’s actions or by other means (e.g., the AV said that s/he hurt his/her hand when s/he punched the SP). 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 that policies and procedures were adequate and followed. “[The SP’s] statements were as a whole the most inline [SIC] with what we have seen in comparison to previous incidents of behavior, the appearance of escalation cycles, and has found to have good rapport with many of the individuals served, including [the AV]. [The SP] was pulled from working with [the AV] due to the rapport lost and [the AV’s] hesitance to continue working with them.” The facility provided additional training to staff on supervision and communication. 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. On November 3, 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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