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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): Gessner Rivas Suspected Maltreatment Reported: It was reported that residents on a unit of the facility had a “sex party” and staff were unable to stop it. Two residents (AV1 and AV2) went into the courtyard and engaged in digital penetration of each other and bit each other’s necks. At the end of the party AV1 cut her/his wounds open and smeared blood on the walls and other residents drew on the walls in AV1’s blood. In addition, it was reported that an unknown resident tried to drink bleach from an unlocked laundry room and that residents have engaged in “cutting” parties with staff present. Date of Incident(s): September 8 to 9, 2024, and possible other unknown date(s). 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 site visits conducted on October 11 and 30, 2024, from documentation at the facility; and through seventeen interviews conducted with nine staff persons (P1 – P9), two facility administrators (P10 and P11), three residents (R1, R2, R3), AV1, AV1’s guardian (G1), and AV2’s guardian (G2). AV2 declined to be interviewed. A staff person (P12), who was working the overnight shift of September 8, 2024, did not respond to this investigator’s requests for an interview. The facility provided individualized, trauma informed psychiatric residential treatment (PRTF) services to youth 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 not in the bedrooms of residents; the video recordings did not have sound. AV1 was diagnosed with personality disorder. AV1 had a history of engaging in self-injurious behavior. Facility documentation showed that AV1 liked listening to music. AV2 was diagnosed with post-traumatic stress disorder (PTSD) and anxiety disorder. AV2 declined to be interviewed. Facility documentation showed that AV2 liked playing video games and sports. 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 residents to initiate a hold/intervention if needed, which meant that staff persons were to be in the same room with the resident, have eyes on the resident or have continued verbal contact with the resident when s/he was in the bathroom or shower. The shadowed resident 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 residents 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. The facility did not have a written policy or procedure regarding residents engaging in sexual behavior with one another. P10 stated that the facility sought guidance from DHS and law enforcement. Staff persons were to ascertain if the residents had consented to such behavior, if one resident had not consented then staff persons had to intervene, staff persons had to separate residents if they began to remove clothing. Regarding the “sex party” and AV1 and AV2 having sexual contact: The report did not detail which residents were involved in the alleged sex party, but that AV1 and AV2 engaged in digital penetration of each other and that some residents did not go to bed until 5 a.m. Video footage provided by the facility from the night of September 8, 2024, only showed AV1 and AV2, no other residents appeared to have been involved in any sexual activity. Video footage timestamped 9 p.m. on September 8, 2024, showed AV1 and AV2 going outside to the facility’s fenced in courtyard closely followed by P2 and P12. At times P1 could be seen on video footage assisting as well. Video footage showed no other residents engaged in any kind of sexual behavior. Video footage at one point showed that AV1 and AV2 went behind some bushes for approximately one minute while P2 and P12 stood a few feet away on the other side of the bushes. AV1 and AV2 remained outside for approximately 40 minutes before returning inside where they remained in a hallway where they engaged in hugging, kissing, and what appeared to be biting each other on the neck. In all videos provided by the facility, staff persons remained within close proximity of AV1 and AV2. There was no video provided showing that any residents remained awake until 5 a.m. AV1 stated that sometimes residents got together and stayed up late either in the hallway of a unit or in a resident’s room often when residents were struggling and need a distraction. AV1 recalled that s/he and AV2 went to the courtyard. Staff persons attempted to verbally redirect them. AV1 confirmed that there was digital penetration while they were behind some bushes in the courtyard. P10 and P11 each stated that the residents that were in the courtyard, AV1 and AV2, engaged in kissing and touching over clothing. P11 was contacted by staff persons on duty and provided tips on what to do about the situation. Staff persons were instructed to verbally redirect residents engaging in sexual behavior, make them “uncomfortable” with verbal redirection so they would stop, and try to position themselves between the residents, and separate the residents if the behavior was nonconsensual or if clothing was removed. AV1 and AV2 had been dating but had been separated to different units of the facility and would find ways to get together which involved stealing badges from staff persons and entering the other’s unit. Staff persons maintained supervision of AV1 and AV2 while in the courtyard and did not see digital penetration, the facility reviewed video footage which showed staff persons talking to AV1 and AV2. P1 stated that AV2 had taken a staff person’s badge and went to AV1’s unit. On September 8, 2024, when AV1 and AV2 went out into the courtyard, P1 instructed staff persons follow them. P1 stated that staff person were supposed to try to make the residents feel “uncomfortable” when they engaged in sexualized behavior with one another to attempt to stop the behavior. P2 stated that s/he was asked to monitor AV1 and AV2 when they went outside. Facility practice was that staff persons could not restrain residents for engaging in sexualized behavior, but P2 notified an unknown manager and P1. P2 attempted to verbally redirect AV1 and AV2 from their behavior. AV1 and AV2 said they were consenting to their behavior. P2 recalled that the incident continued for four to six hours. P2 stated that AV1 and AV2 may have engaged in digital penetration while they were behind the bushes but could not tell. P3-P9 each stated that they had no direct knowledge of the events from September 8-9, 2024. G1 and G2 were told that staff persons could not stop the residents from engaging in sexualized behavior. Regarding AV1’s self-harm, a resident accessing bleach, and residents engaging in “cutting parties” in the presence of staff: The report alleged that at the end of the sex party, AV1 cut his/her wounds open and smeared blood on the walls and other residents dew on the walls with the blood. Video footage provided by the facility showed no resident engaging in acts of self-harm or engaging in writing on the walls on the night of September 8 to 9, 2024, which was when the sex part was alleged to have occurred. AV1 stated that there had been many occasions in which s/he smeared her/his blood on the facility walls and most of the times s/he engaged in such acts of self-harm were in front of a staff person when AV1 found glass to use. P10 and P11 noted that staff persons were to try and redirect residents who were attempting self-harm and if the self-harm posed an imminent risk, they were to call 9-1-1 and implement a restraint. Other staff persons, P3-P9 provided consistent information regarding what staff persons were supposed to do. R1, R2, and R3 provided consistent information that staff persons would try to verbally redirect residents who engaged in self-harm that occurred in front of staff persons. Regarding a resident attempting to drink bleach or residents engaging in “cutting parties,” incident reports from September 2024 contained no such information regarding either of these occurring. P1-P11 did not have any knowledge of such incidents either. G1 and G2 shared concerns about the facility’s supervision of residents. Many residents had obtained glass shards from a bathroom wall at the facility which they used in self-harming which led to residents requiring medical attention numerous times due to acts of self-harm. (Note: This concern was investigated by DHS previously.) All staff persons interviewed were trained on the Maltreatment of Minors Act and the facility’s policies and procedures regarding restraints and supervision. Conclusion: It was reported that residents had a “sex party,” AV1 and AV2 had sexual contact, some residents stayed up until 5 a.m., and at some point AV1 cut him/herself, smeared the blood on the walls, and residents drew in it. The date of the alleged party was September 8 to 9, 2024. Video and information from interviews showed that AV1 and AV2 went to the courtyard and engaged in sexualized behavior but there were no other residents present, and staff persons were near AV1 and AV2 attempting to verbally redirect them for the duration of the incident. AV1 stated there was digital penetration between AV1 and AV2 but staff persons did not see it as it likely happened when AV1 and AV2 went behind some bushes. When AV1 and AV2 went back inside, they continued sexualized behavior and staff persons continued to be near and verbally redirect them. There was no information that AV1 cut him/herself that night and smeared it on the walls and other residents drew in it. AV1 stated that in the past s/he had cut him/herself and smeared it on the walls in front of staff persons. It was also reported that residents had cutting parties in front of staff persons. There was no additional information regarding which residents or dates this occurred. Information was consistent that residents at the facility engaged in acts of self-harm, often in the presence of staff persons. All staff persons and residents interviewed confirmed that when a resident engaged in self-harm, staff persons would attempt to verbally redirect residents. Staff persons were instructed to monitor such situations and intervene when a resident’s act of self-harm posed an imminent threat to the resident. With respect to residents engaging in sexual behavior, staff persons were instructed to try to verbally redirect residents, ascertain if there was consent from the residents to engage in such behavior and physical intervene if there was not or if residents began to remove the clothing. It was also reported that a resident accessed and drank bleach but there was no information regarding which resident or date of occurrence, and no one had information whether this occurred. Although AV1 and AV2 had sexual contact and AV1 stated that s/he had in the past cut him/herself in front of staff and smeared blood on walls, given that during the September 8 to 9, 2024, incident information was consistent that AV1 and AV2 were the only residents engaged in sexual activity and staff persons remained near them providing verbal redirection, that there was no information that that night AV1 smeared blood and others drew in it, and that there was no specific details or information whether any resident drank bleach or that there were cutting parties, there was not a preponderance of the evidence that there was a failure to supply children with necessary care or failure to protect children from serious danger to their physical or mental health. It was not 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). Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility conducted an Internal Review and determined that its policies and procedures were adequate, but staff persons would receive more training on how to deal with increased sexualized behavior. Action Taken by Department of Human Services, Office of Inspector General: No further action taken. 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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