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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: 1036937-CRF (Children’s Residential Facility/Department of Corrections) Investigator(s): Gessner Rivas gessner.rivas@state.mn.us Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was kept in an isolation cell for over five months with lights on and no exercise or sunlight, where the AV engaged in acts of self-harm with no meaningful medical treatment or mental health treatment. Date of Incident(s): January to July 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 June 27, 2024; from documentation at the facility; and through seven interviews conducted with the AV, two facility managers (P1-P2), the AV’s facility case manager (CM), the AV’s guardian (G), and two professionals who worked with the VA but were not employed by the facility; a legal professional (LP) and a mental health professional (M). Two staff persons (P4 and P5) did not respond to attempts to request interviews. The AV was diagnosed with attention deficit hyperactivity disorder (ADHD), fetal alcohol syndrome, schizophrenia, and intermittent explosive disorder. The AV was placed at the facility by the court pending judicial proceedings. The facility was a children’s residential facility that provided treatment, training, and detention for juveniles and was licensed by the Minnesota Department of Corrections (DOC). The secure areas of the facility in which the AV was placed consisted of two sections. The first section was the general population area with multiple individual cell units and a main common area in the center. All cells had windows looking out into the common area. The second section was known as the secure perimeter, an area where the facility had individual cells with no common area and no visibility outside of the cells. Within the secure perimeter, the AV was kept in cell 17, a locked cell located between the control room and a supervisor’s office; it had a window that the control room could look down into and a live camera feed into the control room. It was used for residents demonstrating violent behavior or those causing a disruption in the unit. The cell had overhead lights that remained on 24 hours a day. Per the DOC’s memo lnterim Guidance on the lmminent Approaching lsolation as Discipline Ban, issued on November 29, 2023; administrative separation was “staff-initiated separation used when a facility was looking into a resident’s serious behavioral offense, evaluating, or investigating criminal activity, or placing a resident in individualized modified environment, and determining next steps and requiring administrative approval.” The DOC’s ban on using isolation as discipline became effective on January 1, 2024. The guidance noted that administrative separation required administrative approval and daily documentation why it was necessary and why other alternatives were not available or unsuccessful. It required the creation of an Individual Modified Plan (IMP) to address daily programming. On January 3, 2024, the facility issued a document regarding Policy Approval for Safety-Based Separation to Replace Disciplinary Room Time, which required approval from the facility superintendent and daily documentation on the need for administrative separation and why other alternatives were not available or unsuccessful. At the facility, residents could be placed in administrative separation within their cells in the general population area or within the secure perimeter area. Residents placed in administrative separation were not allowed outside their cells unless it was for services required by law such as healthcare, education, recreational and leisure time. However, access to those services could be denied due to an active safety risk and staff persons had to document which services were denied and the safety risk that made the provision of that service unsafe. Residents not on administrative separation would program with the rest of the residents in the pod (unit). On the day this investigator visited the facility, cells in the general population area were open and residents moved freely about. The AV was admitted to the facility on January 10, 2024, and placed in cell 3 and then moved to cell 7 both which were in the general population area of the secure wing. Cells in the general population area had narrow vertical windows allowing residents to look out into the common area. The AV was first placed in administrative separation on January 16, 2024, within the general population area of the facility. Staff persons at the facility filled out daily logs which documented the times that the AV received meals and snacks, medications, schoolwork, showers, recreation, leisure time, phone calls, and visits. For each of these items, staff persons had to initial their recordings on the daily logs. The facility provided an undated document, Administrative Separation Approval and Review, regarding the required daily approval of the AV's placement on administrative separation. However, it only documented the daily administrative approval from January 17-26, 20242024; only 10 days out of the 182 days that the AV was placed on administrative separation. During that brief time period, the documented noted the reasons for the continued need for the AV to be on administrative separation included threats against staff persons and medication refusal. An undated note from P1 stated, "[AV] will continue on Administrative Separation and will have [her/his] IMP updated daily, or as appropriate." The document did not contain any information on why other alternatives were not available or unsuccessful or any rationale that taking medication was a prerequisite for the AV to have daily programming. The document noted that the AV spent 182 days on administrative separation. The following information was obtained from the facility’s documentation regarding administrative separation of the AV from January 16 through July 14, 2024: · January 2024: The AV was placed in administrative separation from January 16-31, 2024, within the general population area of the facility. The AV had numerous phone calls and visits, received recreational and leisure time, and was allotted time for showering. On a number of occasions, documentation showed that the AV refused recreation and leisure time. On January 19, 2024, the AV was denied recreation and leisure time, and showering time because the AV had made verbal threats toward staff persons. On January 22, 2024, the AV was denied recreation and leisure time because s/he was having behaviors at the time staff persons could offer recreation time. On January 23, 2024, a staff person wrote “unable to accommodate” for recreation time. On January 31, 2024, a staff person wrote "could not due to not having enough time," for recreation time. On four occasions throughout the month of January 2024, the AV refused his/her medications. Those dates were not the same dates on which the AV was denied programing such as recreation or leisure time by the facility. · February 2024: From February 1-10, 2024, the AV was on administrative separation within the general population area. On February 11, 2024, the AV assaulted a staff person and was moved to cell 17 in the secure perimeter of the facility where s/he remained on administrative separation in the secure perimeter for the rest of the month. The AV refused to take his/her medications on numerous occasions. On some of the same dates, the AV was denied recreation and leisure time and sometimes shower time. According to notes in the IMP forms written by staff persons, the reasons given were due to the AV’s behavior and not because the AV had refused to take some or all of his/her daily medications. On February 28, 2024, the IMP notes that the AV was placed in a physical hold after taking noon medications but a reason for the hold was not in the IMP. · March 2024: The AV spent the whole month of March in cell 17 in the secure perimeter. The AV refused various medications on March 4, 6, 9, 12, and 13, 2024. On March 4, 2024, the AV was denied recreation due to threatening staff persons. On March 6, 2024, the VA was denied a shower when threatening staff persons. On March 8, 2024, the AV was only given 20 minutes of recreation time with no reason given as to why. On various dates throughout March 2024, staff persons did not document whether the AV received recreation and leisure time or showers. On March 14, 2024, the IMP notes stated that the AV kicked the sink and repeatedly punched the wall until her/his hand was bloody, and which occurred again on March 31, 2024. On March 20, 2024, the IMP notes stated that the AV knocked on the control window, and punched the wall demanding free time, after the AV had received recreation and leisure time that day. · April 2024: Except for two days, the AV was in the secure perimeter area of the facility. On April 5, 2024, the AV was moved from cell 17 in the secure perimeter area back to cell 7 in the general population area but remained on administrative separation. On April 7, 2024, the AV was returned to cell 17 after assaulting a staff person. From April 7 to 9, 2024, the AV refused some or all of his/her medications. On April 8 and 9, 2024, the AV was denied all programming; the IMP forms noted “refusing [medications] is refusing to program.” For the following three days, the AV took his/her medications, but staff persons did not document any programming for the AV. With the exception of two days, from April 15 through 30, 2024, the AV refused some or all medications; on ten of those days, the AV was denied recreation and leisure time because s/he refused medications. On April 16, 2024, a staff person noted that the AV was awake at 5:55 a.m., biting and scratching her/his arms until they bled. On April 18, 2024, the AV attempted to assault a staff person and was placed in a WRAP (a restraint system, used to restrain a resident in an upright and seated position, designed to protect residents and staff persons by reducing risk of injury); the IMP did not provide a reason for the use of the physical hold, but notes that the AV stretched out the WRAP. The following day, the AV had her/his shoulder examined by a medical professional. (Note: The AV was diagnosed with a strained shoulder and prescribed over the counter medication to be taken as needed.) On April 20, 2024, it was noted that the AV reopened the wounds on her/his arm. As in previous months, on a number of days, staff persons did not document any programing for the AV. · May 2024: The AV spent the whole month of May 2024, in administrative separation in cell 17 in the secure perimeter area of the facility. From May 1-4, 2024, the AV refused some of her/his medications and was denied all programming except for showers on May 4 and 5, 2024. On May 6, 2024, the AV again refused some medication but was given recreation and leisure time. From May 5 to 12, 2024, and May 18 to 22, 2024, documentation on the IMP forms was scarce. On May 14, 2024, staff persons noted that the AV picked at scabs on her/his arm. On May 19, 24, and 27, 2024, the AV was observed punching the wall, door and/or control window, and “practicing eye gouging” on May 24, 2024. · June 2024: The AV remained in cell 17 from June 1 to 6, 2024, when the AV was then moved to cell 5, in the general population area still in administrative separation, after a court appearance. Throughout the month of June 2024, documentation on medication administration was scarce. On numerous days the IMP form did not contain a spot for recording what medications were taken or refused and staff persons did not document whether the AV had recreation or leisure. On June 4, 2024, the AV was denied recreation and leisure time and denied shower time due to behavior issues. On June 12, 2024, the AV did not finish recreation time, shower time, and a phone call due to “unpredictable behavior.” On June 16, 2024, the IMP notes stated that the AV did not get recreation or leisure time due to “aggressive behavior,” the following day the AV received solo programming due to behaviors the prior day. On June 24, 2024, the AV was denied leisure and afternoon recreation due to behaviors. · July 2024: From July 1 to 14, 2024, the AV remained in the general population cell and on administrative separation. Staff persons did not document any medication administration on the IMP forms. The facility did not provide an IMP form for July 2, 2024. On numerous days, staff persons did not document recreation, leisure, and/or shower time. Note: When the AV engaged in acts of self-harm, the AV was provided with basic medical care. The AV provided the following information: · The AV stated that while s/he was in cell 17 in the secure perimeter, the AV felt like s/he was “dying” in large part because the lights were on constantly, it messed with her/his mind, and s/he went “crazy” because there was a lack of human interaction. The AV stated that being in cell 17 messed with her/his mind to the point that the AV believed that staff persons were “tripping” her/his medications so many times the AV would refuse medications. The AV also believed that s/he heard voices of other residents wanting to hurt him/her. The AV told a judge at a court hearing that s/he did not want to go the general population area. · The AV recalled being in cell 17 and having to move the mattress to the floor because the lights were “so bright.” That same day staff persons came in and placed the AV in a WRAP. The AV stated that staff persons used excessive force when applying restraints and believed that staff persons injured her/his shoulder in the process of restraining her/him prior to being placed in the WRAP. · The AV pointed out that s/he had been in a number of other juvenile centers and none of them had cells like cell 17. The AV further stated that no kid should have to be placed in a cell like cell 17. The M provided the following information: · The M began working with the AV in February of 2024 due to aggressive/assaultive behavior and acts of self-harm such as biting her/his forearm. The AV had reported having delusions and paranoia that people were out to get her/him but then would say, “I don’t really think that is happening.” · At first the AV was easily agitated, paranoid, and his/her stream of thoughts went from topic to topic. The M was aware that the AV was kept in cell 17 and the room was very well lit. The AV told the M that s/he had a hard time sleeping at night and would sleep during the day. · The M noted that being in a small area with lights constantly on, and “being by yourself more hours of the day than not,” could exacerbate the AV’s irritability, agitation, and aggressive behavior. · The M stated that s/he talked to facility management, on an unspecified date, about the effects of being in cell 17 had on the AV. Their goal was to move the AV to the main area once the AV’s behavior was less dangerous. The M spoke to management about alternatives to cell 17 but was told there was no other option. · The M estimated that the AV spent about three and a half to four months in cell 17 but would be let out of the cell 4-5 times a day for various reasons. · The M was aware that the AV would engage in acts of self-harm; biting her/himself, removing areas of skin on both arms, and picking at scabs which staff persons would clean and bandage. The M also noted that it was reported that the AV would bang her/his head on the wall. The following information was obtained from the AV’s mental health records regarding visits with the M: · On February 9, 2024, the M wrote up a temporary prescription, at the request of P2, for four medications that the AV was about to run out of or had run out. · On February 20, 2024, the G consented to having the M work with the AV. After every visit with the AV, the M would discuss the administrative separation with P1, P2, and the CM. The M discussed with P1, P2, and the CM using a long-acting injectable to help the with AV’s aggressive behavior. The G agreed to proceed, and the new medication was prescribed and ordered and while waiting for approval from the AV’s insurance; an appeal was filed. Other medications changes were made. · March 22, 2024, the M conducted an initial evaluation with the AV. The AV reported having anger issues and needing help, having difficulty sleeping at night, often sleeping during the day, and feeling tired. The AV also reported having a poor appetite, feeling nervous almost daily, feeling restless, easily becoming annoyed and irritable, but that her/his mood could change quickly and s/he struggled with paying attention, heard voices, and engaged in self-harm. · On April 5, 2024, the AV reported being placed in more than one physical hold by staff persons due to her/his behavior. The AV stated, "I do not want to hurt anyone. I'm not that kind of person." The M discussed with the G and agreed to starting a new medication, lithium carbonate. The AV continued to report having a poor appetite. · On April 24, 2024, the AV reported experiencing increased paranoia, hearing voices, and believing others were plotting against the AV. Schizophrenia was added as a diagnosis for the AV. It was noted that the AV’s insurance declined coverage of the long-action injectable. The AV continued reporting having a poor appetite. · On May 2, 2024, the AV reported continued auditory and visual hallucinations. The AV could not recall being in a catatonic state, standing in one spot for over two hours in her/his cell. The AV reported having a poor appetite. The AV’s long-action injectable Aristada Initio (an antipsychotic used to treat schizophrenia) was started on May 3, 2024, and other medications were discontinued. · May 8, 2024, after the first dose of Aristada, the AV reported doing better and was reading and eating. At times the AV would get irritable and upset but calmed down with non-physical interventions by staff persons. The AV was reminded that s/he could take lorazepam for anxiety or other strong emotions as needed. Staff persons at the facility reported that the AV had not shown any aggressive behavior after taking the injection. · May 16, 2024, the AV reported to still having auditory hallucinations, but feeling calmer and less stressed, and having an improved appetite. The AV had become more engaged, read books, and played basketball with staff persons and a social worker. · May 22, 2024, the AV reported feeling calmer and less stressed since receiving the long-acting injectable and had an improved appetite but still had some auditory hallucinations. The AV reported doing better, had been playing basketball with staff persons and the social worker. Due to insurance coverage, the long-acting injectable was changed from Aristada to Abilify Asimtufii, also a long-acting injectable antipsychotic medication used to treat schizophrenia. · May 30, 2024, the AV received a shot of Abilify Asimtufii, which was to be administered every two months or sooner if symptoms of agitation, irritability/anger, hallucinations, or other negative symptoms were observed. · June 6, 2024, the AV reported “doing better,” and was able to stop and think about her/his next actions or words leading to fewer outbursts and less physical aggression. June 13, 2024, the AV reported feeling more in control, becoming less irritated and upset. The AV requested to have melatonin started again due to trouble falling asleep at night. June 20, 2024, the AV reported s/he got upset, threw a tray, and put her/himself in “lockdown.” The AV requested to have melatonin to aid her/him sleep at night. June 26, 2024, the AV reported being called a racial slur by another resident which made the AV mad but the AV reported being able keep her/himself from becoming aggressive and physically acting out. · July 5, 2024, the AV noted getting more irritated and wanted another shot of the long-acting injectable. The AV discussed an upcoming request for a furlough on July 29, 2024, to see her/his family on her/his birthday. Since receiving the first long-acting injectable, the AV had few instances of demonstrating physical aggression, the AV reported sometimes arguing with staff persons but then listening to them. July 10, 2024, the AV again noted that s/he had been getting more irritated and wanted another shot of the long-acting injectable. The AV was told s/he would have to wait until it was due again, the following week. July 18, 2024, the AV was given another dose of the long-acting injectable. July 24, 2024, the AV reported doing well; managing behavior and was looking forward to a home visit on July 29, 2024. · August 1, 2024, the AV noted that s/he had four weeks of positive behavior management. The AV remained in the secure unit of the facility but would be programming with youth in the non-secure unit. P1 provided the following information: · The AV had previously been housed at the facility numerous times and had a history of aggressive behavior toward staff persons and peers. On January 10, 2024, the facility was informed that the AV would be placed at the facility that same day while awaiting judicial proceedings. P1 was concerned about the AV’s placement at the facility due to the AV’s history at the facility and their available resources but noted that for some youth, the facility was the only option for the courts to place them. · P1 stated that when a resident was placed on any kind of separation P1 must provide approval. P1 stated that the AV had been in administrative separation on and off since February 2024. The AV did not spend 24 hours a day in separation but was allowed out for hygiene, phone calls/visits, recreation, leisure time, and appointments. If the AV’s behavior did not allow for her/him to be in the common areas, the AV would be served meals in the cell. While in separation, staff persons were required to check in on the AV every 30 minutes. · On April 18, 2024, the AV was placed in a WRAP because s/he was hiding under a blanket during a check and refused to remove the blanket. When staff persons went in, the AV jumped up and attempted to bite staff. The AV was secured and placed in a WRAP. While in the WRAP, the AV attempted to stretch out the WRAP. The following day the AV was evaluated by a facility nurse and later taken to a medical facility to have her/his shoulder examined; the AV was diagnosed with a muscle strain and was prescribed 400mg of ibuprofen every six to eight hours as needed. · P1 was not aware of the AV engaging in acts of self-harm while in administrative separation but did note that the AV would pick at a scab on her/his arm. P1 was aware of the AV having auditory hallucinations. The AV had reported hearing others talking and not knowing if it was real or imagined. · P1 stated, “We are doing everything we can to get [the AV] everything [s/he] needs,” but noted that when the AV first arrived at the facility, they “could not do much with [the AV].” The AV received educational services on a 1:1 basis with the CM because it was too dangerous to have the AV in the classroom. Sometimes P2 would do schoolwork with the AV. P1 stated that the AV was 1:1 throughout February and March 2024, and they tried to get the AV back in the classroom in April 2024, but because the AV was still displaying some aggression, a staff person would sit with the AV in the day room near the entryway of the classroom during some lectures. · In March of 2024, the AV began to see a mental health provider and received educational services at the facility. In April 2024, the AV started an injectable medication that was changed in May 2024. · The facility tried multiple times to place the AV back in the general population, the AV had made significant progress but was still a “very dangerous adolescent when not on injectable medications.” · P1 stated that while in cell 17, the AV would pound on the walls for hours at night, make barking noises for hours, and when staff persons would open the door to provide service, the AV would hide around the corner. On July 11, 2024, P1 wrote a letter to the DOC Commissioner responding to the maltreatment report. The letter made no mention of the AV being denied programming due to refusing her/his medications. P2 provided the following information: · P2 stated that residents at the facility could be denied programming such as recreation and leisure time if the resident was a safety threat to other residents or staff; such behavior would get documented in Chronos (the facility’s documentation system). For residents that were placed in administrative separation, staff persons had to document the residents’ activities on the IMP form which noted the time that a resident was given programming activities along with the staff persons initials. If that was not documented on the form, staff persons would go back and document on the IMP or document in Chronos that it was not documented in the IMP form. · Residents were required to be given two hours of recreation time per licensing rules. Residents also got recreation time while in school, but that time was not counted as part of the facility’s requirement. When residents were not given the required time, it was to be documented. A resident may be denied programing or have their programming cut short if they were a safety threat to other residents or staff persons, or resources were needed elsewhere in the facility and such behavior was to be documented. When it was not documented, staff persons could retroactively document why in Chronos. A resident may also not get their required recreation time if they had visits or other appointments. · Regarding a note written on IMPs about the AV not getting recreation time, P2 stated that if a staff person wrote down on the form something like “not enough time,” or “unable to accommodate,” that it probably meant staff persons had other things going on or they did not have the ability to do so, such reasons should be documented in Chronos and may not be on the form because of HIPPA rules. A resident’s programming may be cut short if they become verbally or physically aggressive. · With respect to the AV being denied programming because s/he had refused to take medications, P2 stated that the AV was court ordered to take that medication and when the AV refused it caused a “huge safety concern.” P2 also stated that it was highly suggested that the AV take her/his medication for the safety of the AV and others. P2 referenced a court date on January 26, 2024, where this was mentioned but that the actual court order from that day did not specifically say anything about the AV taking her/his medications. P2 stated that the facility viewed the AV’s refusal to take medications as not following expectations that the court and the facility expected of the AV. P2 mentioned that there were meetings in which it was discussed denying the AV programming for refusing medications; P2 specifically mentioned a notebook with notes about the AV from meetings, but noted it might have been “shredded.” · P2 noted that the AV sometimes would have more issues in the evening, past 4:30 p.m., but the AV would do individual recreation and leisure time. P2 went on to note that administrative separation was new at the time and it kept changing. · Regarding cell 17, P2 stated a resident could be placed there because s/he was a threat to themselves or because they were a disruption to the rest of the unit; such as, constantly screaming in the middle of the night keeping the rest of the residents from getting a good night’s rest. P2 stated that s/he and the M raised concerns sometime after January 25, 2024, about the lights in cell 17 being on 24/7. The lighting was changed to just having a small pilot light so the resident could be seen instead of a “full blast of light in your face.” P2 could not recall when that change was made. · When residents like the AV engage in acts of self-harm, such as scratching themselves, it would not be considered life threatening and staff persons would not “go hands on.” · The AV was discharged from the facility on October 18, 2024, and a couple of months prior to that, on an unspecified date after July 14, 2024, the AV was moved to the non-secure unit of the facility. Note: The facility did not provide any documentation regarding a court order or documentation of group discussions regarding withholding programming from the AV for refusing to take medications. At the time this investigator visited the facility, the lights in cell 17 were still two large panel lights. P3 and P4 also entered comments into the AV’s IMP forms regarding the AV being denied programming because the AV refused to take her/his medications. P3 and P4 each did not respond to requests for an interview with this investigator. The CM provided the following information: · The CM stated that at first the AV’s behavior was fine for the most part but the assaultive behavior began with another resident and then progressed toward staff persons. After the first assault, the AV was continually on administrative separation. Attempts were made to remove the AV from administrative separation but each time the AV’s “explosive behavior,” came out. The CM stated that administrative separation could be implemented in any cell. · A resident on administrative separation was separated from the rest of the pod in terms of programming which would depend on that resident’s IMP. Programming while on administrative separation would depend on the resident’s behavior. If the AV was doing well, s/he could program outside of the cell, such as being in the classroom as opposed to being in the day room with a staff person; eating meals with other residents as opposed to eating in the cell. · A resident’s placement in cell 17 had to be approved by P1. Cell 17 was the only cell with cameras in it and with lights that remain on constantly, all other cells had nightlights. · The AV engaged in acts of self-harm, picking at scabs, biting her/his arm, punching her/himself repeatedly in the face; the AV stated it was because her/his nose did not look right and s/he was trying to fix it. · The CM stated that after the AV began receiving an injectable medication, the AV’s behavior before and after was like “night and day.” Although the AV still had moments of explosive behavior, the AV was able to calm down faster and seemed to be in control unlike before. The CM stated that “without this med, I don’t think [the AV] would have been able to program as much as [s/he] had.” · The CM recalled an incident in cell 17 when the AV was covering her/his head and was told numerous times that staff persons needed to see that s/he was breathing and conscious. Mid to late evening, the AV was still not cooperating, and staff persons went in to remove the blanket, the AV jumped up and tried to punch a staff person. The AV had to be restrained by multiple staff persons and was placed in a WRAP. · The CM stated that the AV was court ordered to take her/his medications and that refusing medications was also refusing court orders. The LP provided the following information: The LP noted that while the AV was in cell 17, s/he was allowed out of the cell to shower and to call the G. While in cell 17, the AV engaged in numerous acts of self-harm such as banging her/his head against the cell walls, biting off scabs on her/his arm, and punching her/himself in the face. The AV was not allowed to leave the cell if s/he refused medication and phone calls with the G were also denied. The LP stated that as a result of the AV’s placement in cell 17, the AV was a “shell of [her/his] former self, had no light in [her/his] eyes.” The G stated that s/he was aware of the AV’s placement in administrative separation but believed that the facility was placed in a difficult situation when the AV was placed there by the court. A document placed on the AV doorway to cell 5 regarding programming read as follows: “If [the AV] argues with staff, makes false allegations, threatens staff, repeatedly demands things, or harms [her/himself] or others in any way, [s/he] will not program for the rest of the day. [S/he] will remain locked down until [s/he] can be evaluated by an Administrative Staff the next business day.” Conclusion: A. Maltreatment: Information showed that the VA was admitted to the facility on January 10, 2024. On January 16, 2024, the AV was placed in administrative separation after the AV had assaultive behaviors; the AV remained on administrative separation through July 15, 2024. The facility was required to document daily the need for the AV’s placement in administrative separation including why other alternatives were not available or successful and receive approval. The facility only documented the daily review of the AV’s placement on administrative separation for 10 days out of 182 days. The cells in the general population area had windows looking out into the common area. Cell 17 in the secure perimeter area had no window or visibility outside of the cell, was away from the other resident’s area and cells, and full lights were kept on all day and night. On January 16, 2024, when the AV was first place on administrative separation, the AV remained in the cells in the general population area. On February 11, 2024, the AV was placed in cell 17 where the AV remained until April 5, 2024, which was a total of 54 days. The AV was then placed back in a cell in the general population area but remained on administrative separation status. On April 7, 2024, the AV was placed back in cell 17 and remained there until June 6, 2024, which was a total of 60 days. From June 6 to July 14, 2024, the AV was placed in cell 5 in the general population area but remained on administrative separation status. The AV spent a total of 114 days in cell 17. Many times, the AV was denied programming, sometimes because the AV exhibited aggressive behavior or made threats toward staff persons. Many times, throughout the AV’s placement on administrative separation, s/he refused medications, sometimes the AV still received programming such as recreation and leisure time; however, on April 8, 2024, the facility began to deny the AV programing for refusing medication and documented that on the AV’s IMP forms. Prior to April 2024, IMP records did not indicate that the AV was denied programming for refusing to take medications, although on many such occasions the AV refused to participate in programming. P2 stated that the AV was court ordered to take medications but later noted that there was no court order specifically referencing the AV taking medications. IMP records indicated that the AV was denied programming for refusing medications twelve times in the month of April 2024, and four times in May 2024. From April through July 2024, the facility did not document recreation and/or leisure time for the AV on 25 separate days. There was a note on the door of the AV’s cell in the general population area that stated, “If [the AV] argues with staff, makes false allegations, threatens staff, repeatedly demands things, or harms [her/himself] or others in any way, [s/he] will not program for the rest of the day. [S/he] will remain locked down until [s/he] can be evaluated by an Administrative Staff the next business day.” The AV stated that while s/he was in cell 17 in the secure perimeter, the AV felt like s/he was “dying” in large part because the lights were on constantly, it messed with her/his mind and s/he went crazy because there was a lack of human interaction. The AV believed that staff persons were “tripping” her/his medications so many times the AV would refuse medications. The AV also believed that s/he heard voices of other residents wanting to hurt him/her. The AV stated that s/he had to move the mattress to the floor in cell 17 because the lights were “so bright.” The AV further stated that no kid should have to be placed in a cell like cell 17. The M stated that being in a small area with lights constantly on, and “being by yourself more hours of the day than not,” could exacerbate the AV’s irritability, agitation, and aggressive behavior. The M stated that s/he talked to facility management about the effects of being in cell 17 had on the AV and about alternatives to cell 17 but was told that their goal was to move the AV out of cell 17 but there was no other option. IMP records showed that the AV first engaged in acts of self-harm while on administrative separation on March 14, 2024, and numerous other acts afterwards, such as: punching walls until the AV bled, biting and scratching her/his arm until they bled, and reopening existing wounds. All but one of these acts occurred while the AV was in cell 17. P1 noted that somedays the AV would have a bandage on her/his arm. One occasion the AV was placed in the WRAP and tried to remove it. The AV was then seen by a medical professional and diagnosed with a strained shoulder. The AV was prescribed over the counter pain medication to be taken as needed. Treatment notes provided by the M showed that the M began working with the AV on February 9, 2024, when the M provided a prescription refill for several medications. The M performed an initial evaluation of the AV on March 22, 2024, to establish care for psychotropic medication management services. Periodic changes to the AV’s medications were made by the M. On May 3, 2024, the AV received a long-acting injectable antipsychotic medication and again on May 30, 2024, which improved the AV’s mental health symptoms. Although the AV had aggressive behaviors and the facility stated there were attempts to move the AV out of cell 17 and from administrative separation, given that the AV was in cell 17 with no windows and full lights on 24 hours a day which the AV stated increased his/her mental health symptoms for 54 consecutive days and then 60 consecutive days, that there were only 10 days that documented the review of the AV’s administrative separation out of 182 days total, that on some occasions when the AV refused mediations, s/he was refused programming, and that there was minimal documentation to show what programming the AV did receive, there was a preponderance of the evidence that the AV being in this environment for this length of time was a failure to provide care or services which were reasonable and necessary to maintain the AV’s mental health and safety and a failure to protect the AV form conditions that seriously endanger the AV’s physical and 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. 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 AV was placed on administrative separation for 182 days and was placed in cell 17 for 114 of those days. Multiple staff persons worked with the AV during this time, multiple staff persons documented refusing the AV’s programing for refusing medication, and multiple staff persons did not adequately document the AV’s programing. In addition, there were staff persons in multiple levels of authority who were aware of the AV’s administrative separation and time spent in cell 17. Therefore, the facility was responsible for maltreatment of the AV. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious because the AV did not require the care of a physician. 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 was licensed by DOC and was not required to conduct an internal review. Action Taken by Department of Human Services, Office of Inspector General: 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. The maltreatment determination is subject to appeal. 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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