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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): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) pushed an alleged victim (AV) backwards into the AV’s bedroom and attempted to forcefully close the bedroom door, but the door bounced open. The SP then “slammed” the door a second time and it latched. The AV’s hand was caught between the door and its frame, and s/he sustained injuries to his/her hand. Date of Incident(s): February 17, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a), and subdivision 23, paragraph (a): "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 March 4, 2026; from documentation at the facility and the AV’s medical records; and through interviews conducted with facility staff persons (P1, P2, and P3), the AV, and the AV’s guardian (G). Two letters, one certified, were sent to the SP requesting an interview with this investigator, but the SP did not respond to the letters or attempts to contact him/her by phone or email. The facility was a juvenile detention facility that focused on providing individualized services to youth to meet their specific needs. At the time/date of the incident, the AV resided in the secure detention unit at the facility which was for youth 10 to 20 years of age. There was an educational program on site and youth who resided in the secure detention unit had individual cells/bedrooms with metal doors that latched into metal frames when the doors closed. The doors did not have doorknobs or handles on the inside of the bedroom but there were slots in the doors that youth inside the bedrooms could put their fingers in to push the door open. There were narrow windows with sliding covers set into the doors through which staff persons could see the youth inside the bedrooms. The facility had a video recording system that recorded common areas of the facility, but the system did not record sound. Facility documentation showed that the AV was diagnosed with asthma and sometimes had behaviors that caused other youth in the unit to become upset. Staff persons documented that the AV treated them with disrespect and provided inaccurate information to them. However, the AV was outgoing and liked listening to music. Interviews with this investigator, the AV’s medical records, facility documentation, video recordings from the facility, and the facility’s Internal Review, provided the following: · Information was consistent that on February 17, 2026, the AV’s hand was injured at the facility, and the AV was evaluated at the emergency department of a hospital. An x-ray taken at the hospital showed that the AV had an open displaced fracture of his/her right index finger, a laceration of the right index finger without foreign body or damage to the nail, and a laceration of the right little finger without foreign body or damage to the nail. The AV was prescribed an antibiotic, the lacerations were closed with stitches, and the AV was referred to an orthopedic/sports medicine center for additional care. · The AV said that on the date of the incident, s/he was upset because s/he had to reside at the facility. The AV stood in his/her bedroom doorway talking with an unspecified staff person when s/he felt that the SP interrupted his/her conversation. The AV told the SP that s/he was not talking to him/her. The SP walked quickly toward the AV, who continued to stand in the doorway of his/her bedroom, then grabbed the door and slammed it. The AV’s hand was between the door and the door frame and was caught between them which prevented the door from latching. The AV removed his/her hand from the doorway, and the SP slammed the door again. The AV stated that his/her hand was “busted open” and s/he thought s/he might faint. There was blood dripping from the AV’s hand and s/he saw some of the bones in his/her hand. Two or three minutes later, P1 checked on the AV in his/her bedroom, realized that the AV was injured, and called other staff persons for assistance. P1 gave the AV paper towels to hold against his/her hand, and a staff person who was not involved in the incident drove the AV to the emergency department of the hospital. · The video recording from the facility showed that at 9:36:07 a.m., on the date of the incident, the AV opened the door to his/her bedroom, stood in the doorway, and spoke to the SP and P1, who were seated at a desk in the common area of the unit, with their backs toward the AV. The SP turned toward the AV with the SP’s back to the camera, shrugged, appeared to talk with the AV, shrugged his/her shoulders, and then stood and walked toward the AV at 9:36:40 a.m., who continued to stand in his/her bedroom doorway. P1 stood and took a couple of steps toward the AV’s bedroom but could not see into the bedroom from where s/he stood. At 9:36:47 a.m., the SP pushed the AV near the AV’s chest with his/her right hand while using his/her left to simultaneously close the AV’s bedroom door. The door did not close and latch, and the SP closed the door again with both hands at 9:36:50 a.m., then returned to the desk in the common room. · The SP and P1 talked and worked on their laptops, then at 9:38:51 a.m., P1 stood, walked to the AV’s bedroom, opened the sliding window cover which was closed, then looked through the window and took the walkie talkie from his/her waist at 9:38:56 a.m. to call for assistance. P1 then closed the sliding window cover and walked away from the AV’s bedroom toward the desk where the SP sat. P1 and the SP talked and went to a cabinet in the common area where they put on blue nitrile/latex gloves. Several other staff persons, including P2 who was a supervisory staff person, entered the common area, put on gloves, and entered the AV’s bedroom at 9:39:51 a.m. The video recording system did not show the interior of the AV’s bedroom. The SP did not enter the bedroom and stood near the desk in the common area, then at 9:42:16 a.m. the SP moved to the left of the view shown by the camera and stood behind the desk. At 9:45:18 a.m., staff persons assisted the AV to put on his/her shoes, and at 9:46:28 a.m., the AV and a staff person left the common area of the unit in which at AV resided to go to the hospital. · P1 said that s/he witnessed the incident and assisted the AV after s/he discovered that the AV’s hand was injured. The incident started when the AV stood in the doorway of his/her bedroom and “yelled” at the SP and P1 about the educational program at the facility. P1 and the SP redirected the AV to remain in his/her bedroom and the AV replied to the SP, “I’m not talking to you, bitch.” The SP then went to the AV’s bedroom, pushed the AV into the bedroom, and closed the door. The door did not close, and the SP closed it again, then returned to sit at the desk. P1 did not think that the SP was upset or angry when the incident occurred. · After a minute or two, P1 heard the AV hitting the bedroom door, yelling, and “swearing” so s/he checked on the AV and discovered that the AV’s hand was injured. P1 immediately called for help and multiple staff persons quickly came to the unit. The account of the remainder of the incident provided by P1 was largely consistent with the recording from the video recording system. P1 said that s/he did not follow the facility’s policies and procedures and that s/he should have asked the SP to leave the unit when s/he pushed the AV and forcefully closed the AV’s bedroom door. P1 said that s/he should have checked on the AV quicker and s/he would have checked on the AV sooner if s/he had realized that the AV was injured. · P2 did not have firsthand knowledge of the actions that led to the incident, but s/he reviewed the video recording of it and talked with P1 and the SP regarding their actions during the incident. The SP’s actions were inconsistent with the facility’s policies and procedures, and staff persons were not permitted to push/shove youth. The SP should not have closed the bedroom door without making sure that the doorway was clear. After the incident occurred, staff persons and P2 focused on getting the AV to the hospital as soon as possible. · The AV’s medical records showed that the AV’s injuries were initially treated on February 17, 2026, at the emergency department of the hospital. The lacerations were stitched closed and the AV was prescribed an antibiotic. The next day, the AV had an appointment with an orthopedic physician who determined that the AV required surgery to repair the injuries to his/her right hand. The physician documented that s/he felt the AV would benefit from reduction of an articular condyle fragment of the middle phalanx at the distal interphalangeal joint with pinning and explained that the AV would experience stiffness in that joint, with possible further deterioration of the joint, making future surgeries necessary. On February 19, 2026, the AV had surgery to repair the injuries to his/her hand and then was discharged back to the facility with instructions to attend follow up appointments and seek additional medical care if needed. · The SP did not respond to this investigator’s attempts to contact him/her and no information from the SP was included in the facility’s Internal Review. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Minors Act and the facility’s policies and procedures prior to the incident. Conclusion: A. Maltreatment: Information was consistent that on February 17, 2026, the AV’s hand was injured at the facility when the SP closed the door to the AV’s bedroom and caught the AV’s hand between the door and the door frame. A video recording of the incident from the facility and an account of the incident from P1 who witnessed the incident showed that the AV stood in his/her bedroom doorway and spoke with the SP and P1 who were sitting at a desk in the unit common area. The SP went to the AV’s bedroom, pushed the AV’s chest causing the AV to step backward into his/her bedroom, and the SP forcefully closed the door onto the AV’s hand. The SP returned to the desk, and after a couple of minutes, P1 checked on the AV and observed that the AV’s hand was injured. P1 called for assistance and multiple staff persons came to the unit. The AV was taken to the emergency department of the hospital where s/he was evaluated and diagnosed with an open displaced fracture and laceration of his/her right index finger and a laceration of the right little finger. The AV was prescribed an antibiotic, the lacerations were stitched closed, and on February 19, 2026, s/he had surgery on his/her hand to repair the injuries sustained when the door was closed on his/her hand. After surgery, the AV was discharged back to the facility with follow up appointments scheduled. P2 reviewed the video recording of the incident and said that the SP’s actions were inconsistent with the facility’s policies and procedures. Staff persons were not permitted to push or shove youth and the SP should not have closed the bedroom door without ensuring that the doorway was clear. Given that the video recording showed the SP push the AV into his/her bedroom and close the door on the AV’s hand, that the AV required the care of a physician and surgery to repair the injuries to his/her hand, and that P2 said that SP’s actions were inconsistent with the facility’s policies and procedures, there was a preponderance of the evidence that the AV sustained physical injuries by means other than accidental. 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 video recording showed the SP push the AV into his/her bedroom and close the door on his/her hand. 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 abuse for which the SP was responsible was serious because the AV sustained injuries including skin lacerations, tissue damage, and fractures as a result of the incident. The abuse for which the SP was responsible was not recurring since it was a single incident. The SP was disqualified from providing direct contact services. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate but were not followed. The SP was immediately placed on leave after the incident and at the time this report was written, the SP was no longer employed at the facility. P1 was initially placed on leave after the incident then suspended for three days for failure to follow the facility’s Emergency Plan and Procedures Policy. P1 was retrained and returned to work at the facility. The incident was not similar to past incidents. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each 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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