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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 a staff person (SP) provided an alleged victim (AV) personal snacks and allowed the AV to watch television past the time allowed, provided the AV with a nicotine vape pen, had inappropriate conversations with the AV, and showed the AV sex videos of the SP. Date of Incident(s): December 11-12, 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 December 20, 2024; from documentation at the facility; and through three interviews conducted with two supervisory staff persons (P1 and P2), and the alleged victim (AV). Attempts to contact and interview the AV’s guardian were unsuccessful. The SP did not respond to this investigator’ attempts to request an interview with the SP. 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 AV was diagnosed with anxious personality disorder, borderline personality disorder, and ADHD. The AV’s Individualized Crisis Management Plan noted that the AV had a history of sexual abuse. The AV enjoyed visits with family, activities like bowling, swimming, and listening to music. The AV stated that the SP usually worked overnight and would let the AV watch a crime show on television and have personal snacks such as chips and candy bars. Such snacks were only allowed during a resident’s free time. The SP showed the AV two videos depicting the SP’s sexual encounters; in one video the SP was being tied up by her/his partner and the second video was of the SP having sex. The videos made the AV uncomfortable to watch and the AV wanted to sleep in more and had a loss of appetite. The AV stated that the SP told her/him, “I’m just showing you to get you to feel comfortable around me.” The SP talked to the AV about sexual “kinks” and asked the AV if s/he had any; the AV did not respond. The AV could not recall when the SP showed the AV the sex videos, but stated it was same week the AV talked to P1 and P2. The AV also stated that the SP provided her/him with a peach mango flavored nicotine vape pen that the AV used. The SP told the AV that if s/he did not come back for it, to “flush it down” the toilet. P1 and P2 provided the following information: · On December 13, 2024, P1 was notified that the AV told a staff person the SP had provided the AV with a nicotine vape pen, and that on the evening of December 12, 2024, the SP allowed the AV to watch a crime show on television while sharing a meat, cracker, and cheese tray with the AV. · P1 approached the AV and asked if s/he would be willing to talk to P1 and P2. During that meeting, the AV disclosed that the SP had provided her/him with a vape the night before, threatened the AV not to tell anyone, and told the AV to flush the vape when finished, which the AV did. The AV stated that the SP had planned to bring the AV and another resident a “vape” on December 13, 2024. The AV also disclosed that the SP had discussed sexual “kinks” with the AV and shared a sex video of the SP and her/his partner. P1 and P2 stated that sharing such videos with the AV, triggered the AV’s history with sexual abuse. P1 did not know if anyone witnessed the SP share the videos with the AV. According to P1, the AV stated that the SP showed the AV the videos around two weeks prior to December 13, 2024. · With respect to allowing the AV to watch a crime show, the SP was not following programing expectations, was not appropriate for the AV due to the violent content, and the AV should have been in bed. Likewise with snacks, residents were allowed to have personal snacks during their free time. If residents wanted snacks at any other time, residents were allowed to have snacks provided by the facility such as fruit but not personal snacks. · At the time of the alleged incidents, the AV was housed in one unit and the SP was assigned to work in a different unit at the facility. The facility spoke with the SP about the allegations regarding giving the AV a nicotine vape and talking about sex with the AV. The SP denied talking to any resident about vaping but mentioned that a different resident had asked the SP to bring her/him a vape which the SP declined. The SP denied having any conversation about sex with any resident but mentioned that a resident asked to see a picture of her/his partner but only showed the resident a headshot of the SP’s partner. The facility conducted an Internal Review which consisted of reviewing camera footage from the evening of December 11-12, 2024. Camera footage showed that the SP and the AV were watching tv around 11:20 p.m. and that the AV appeared to have fallen asleep on the floor. The review noted that there was no evidence of the SP passing a vape to the AV or allowing the AV to view the SP’s phone. The review went on to state that the SP did not follow protocol regarding watching television after “lights out” and that the SP would receive retraining related to bedtime expectations. The facility’s Alcohol and Drug Abuse/Testing policy prohibited staff persons from possessing controlled substances (defined as substances controlled by federal or state statutes) on the premises of the facility. The facility’s Employee Handbook also noted that the premises was a non-smoking (including e-cigarettes) and tobacco free work environment. Minnesota Statute, section 609.685, stated in part that persons under the age of 21 cannot be sold, given, or otherwise furnished tobacco, tobacco-related devices, or electronic delivery devices. Facility records showed that the SP was trained on the facility’s policies and on the Reporting of Maltreatment of Minors Act. Conclusion: A. Maltreatment: The AV provided consistent information that the SP provided the AV with a nicotine vape pen which the AV used and flushed down the toilet when s/he was done with it. In addition, the SP showed the AV personal videos of the SP engaged in sexual acts with a partner. The AV was interviewed by P1, P2, and this investigator about the allegations of the SP’s actions and provided consistent information. The SP denied the allegations to the facility and did not respond to requests for an interview with this investigator. The SP’s conduct of giving the AV a vape, having an inappropriate discussion with the AV, and showing the AV sex videos was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. Although the SP denied the allegations, given that the AV provided consistent information about the alleged maltreatment, and that SP had reason to minimize his/her actions for fear of repercussions, it was more likely that the incidents occurred as described by the AV. Therefore, there was a preponderance of the evidence that the SP provided the AV with a vape, allowed the AV to watch a crime show, had an inappropriate discussion with the AV, and showed the AV personal sexual videos which was a failure to supply the AV with necessary care and a failure to protect the AV. It was determined that neglect occurred (the 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 SP was trained on the facility’s relevant policies and the Reporting of Maltreatment of Minors Act prior to the incident. 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 because the SP’s actions were considered a single pattern of behavior or serious because it did not meet the statutory definition. 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 found that policies were adequate but not followed with respect to programming expectation and the SP would be retrained on bedtime expectations. 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. 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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