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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-PRTF (Psychiatric Residential Treatment Facility) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) shoved an alleged victim (AV) and they “locked arms.” The AV tried to break away/back away from the SP, but the SP grabbed the AV’s shirt and hair, then grabbed both the AVs’ arms and pulled the AV toward the SP. A staff person (P1) intervened, and after the incident, the AV had red marks on both arms, a scratch on the right forearm and on the lower back, and pain where his/her hair was pulled, but no injuries were observed to his/her scalp. Date of Incident(s): February 19, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); 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. 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. "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 19, 2026; from documentation at the facility; and through interviews conducted with P1, the SP, the AV’s guardian (G), and the AV. The facility provided individualized trauma informed psychiatric residential treatment services to youth from 10-19 years of age who had significant mental and behavioral health issues. The facility had a video recording system that recorded videos in the facility’s common areas, but the system did not record audio. Facility documentation showed that the AV had a history of engaging in self-harm and attempting to leave or leaving facilities without supervision. The AV’s diagnoses included disruptive mood dysregulation disorder and post-traumatic stress disorder. The AV might feel overstimulated when others raised their voices, and s/he might raise his/her voice in response or might become physically aggressive when others were aggressive or when there was physical conflict. The AV wanted to learn to manage his/her feelings and improve his/her communication skills. The AV liked spending time with friends. Interviews with this investigator, facility documentation, and the facility’s Internal Review, provided the following: · The AV said that on the date of the incident, s/he and another youth (Y) attempted to leave the facility without supervision from a staff person. The Y exited the facility, and staff persons followed him/her, but the AV did not leave the facility and sat on a bench in a facility common area. A health care professional (HCP) and the SP were near the AV but after a few minutes, the HCP left the area to prepare medications for the AV and other youth. The VA was upset, and the SP remained with him/her. · According to the AV, the SP told the AV that s/he did not know why the AV was upset because the AV had not been hit or kicked and told the AV that s/he was a “stupid little brat.” The SP continued, saying that s/he “could not take this fucking shit with [the AV] anymore.” The AV replied, “Then don’t,” and the SP approached the AV, said that the AV should not be crying, and told the AV that s/he was better than this, needed to do better, and that this was stupid. The SP kept moving toward the AV, so the AV extended his/her hand to create space between him/herself and the SP, but the SP did not stop, and the AV felt uncomfortable. The AV stood and backed away from the SP, but the SP “came after” the AV, grabbed his/her arms, and “whipped” the AV around, then grabbed the AV’s hair on the back of his/her head, and pulled it. The AV screamed at the SP to “get off” of him/her, but the SP did not let go of the AV until P1, who had been in the staff person office, approached them and instructed the SP to release the AV. The SP released the AV, and the AV ran down the hall to another part of the facility.
· The AV said that after the incident, s/he had red marks on his/her left side and back, bruises on his/her arms, and had a bump on his/her head for two weeks where the SP pulled his/her hair. On the date of the site visit, the AV showed this investigator a mark on his/her mid back that s/he said was from an injury s/he sustained during the incident. The mark appeared to be a recently healed scratch. · The video recording from the facility showed that at 7:24:53 p.m. on February 19, 2026, the AV was seated in a common area of the facility while the SP stood about eight feet from the AV. At 7:24:56 p.m., the AV stood and quickly moved toward the SP, then pushed the SP near his/her chest. The SP pushed the AV with his/her right hand, the AV moved backward, and the SP moved toward the AV, then grasped the AV’s arms near the outer/upper arms and the AV grabbed the SP’s arms. The SP and AV held onto each other’s arms/hands and moved in a circle, struggling with each other. At 7:25:06 p.m., the SP grabbed the hair at the back of the AV’s head with his/her left hand and pulled it. The AV bent forward at the waist, and the SP placed his/her right hand near the AV’s head, then released the AV’s hair and grabbed the AV’s arms again with both hands. The AV attempted to pull away or back away from the SP and P1 began walking toward the SP and AV. At 7:25:16 p.m., the SP released the AV, who held the back of his/her head with his/her hands and walked away from the common area. The SP and P1 walked toward the AV, but the SP stopped in the common area and P1 continued following the AV, who was still holding the back of his/her head with his/her left hand. At 7:25:31 p.m., the AV moved out of the camera’s view, followed by P1. The SP remained in the common area for a few additional seconds, then left the common area in a different direction. · The SP said on the date of the incident, his/her scheduled shift was in another unit at the facility, not in the unit in which the AV resided, and s/he had not met the AV prior to the incident. The SP was tired because tension was high at the facility all day and the SP wanted to take a break, but s/he was unable to because there were not enough staff persons to supervise the youth at the facility. Youth were kicking facility doors and planning to leave the facility without supervision to meet in a wooded area near the facility. In addition, a youth who resided in another unit hit the SP in the face prior to the incident with the AV. Multiple youth were in crisis at the facility, and the SP and several staff persons were assisting with the situation. The SP was with the AV while other staff persons were outside attempting to redirect the Y back into the facility. · When the SP supervised the AV, the AV was upset and told the SP that the common area was too loud. The SP wanted to redirect the AV back to his/her unit, so s/he attempted to dysregulate the AV as s/he had been trained to do by talking loudly to the AV to make the common area an unpleasant environment for the AV to encourage the AV to return to the unit in which s/he resided. The AV then lunged at the SP, who went into “self-defense” mode and attempted to bear hug the AV to hold his/her arms to his/her side. The SP was unable to hold the AV and there was no one the SP could call for support or back up. The SP continued to try to hold the AV’s arms to his/her side but could not grasp the AV and one of the SP’s rings became tangled in the AV’s hair. The SP was initially unable to untangle the ring from the AV’s hair, and s/he was afraid that the AV would pin him/her against a wall or get him/her to the ground and hurt him/her. The SP’s ring loosened from the AV’s hair, and the SP separated from the AV, then P1 approached the AV and SP after exiting his/her office. The SP removed him/herself from the area and had no additional contact with the youths at the facility. · The SP felt that s/he should not have been asked to supervise youth in another unit, and that s/he received conflicting training and feedback. A staff person whose identity the SP could not recall told him/her that the SP “froze” during crises and the SP did not want to freeze with the AV. In hindsight, the SP thought s/he should have listened to the AV’s concerns, and stepped back then blocked the AV’s aggressive actions, but the incident happened so fast that the SP was unsure whether s/he had time to deflect the AV. When staff persons used radios to communicate with each other or wore earpieces, the youth at the facility actively attempted to take the radios from staff persons and “rip” the earpieces from their ears. The SP felt that staff persons had no authority at the facility. · P1, a supervisory staff person, said that s/he did not witness the entire incident but was in an office in a virtual meeting when it began and heard raised voices coming from the hall. P1 exited the office and walked toward the common area where s/he saw the SP holding the AV by his/her forearms which did not look consistent with restraints or procedures that staff persons were trained to use at the facility. P1 instructed the SP to release the AV, and s/he did. The AV cried and backed away from the SP, then ran down a hall away from the common area. P1 followed the AV and asked him/her what was wrong, and the AV replied that the SP pulled his/her hair, yelled at him/her, and grabbed at him/her. · P1 asked the HCP to assess the AV, viewed the video recording of the incident, and then asked the SP what happened. The SP told him/her that s/he had to “get big” and put the AV in his/her “place.” P1 discussed the incident with a supervisory/administrative staff person, and it was decided that the SP should leave the facility immediately and the rest of the shift was uneventful. P1 said that staff persons were instructed that their responses to the youths’ requests might dysregulate the youths, but staff persons were not trained to intentionally dysregulate the youths. Staff persons should not be afraid to tell youths no if youths asked to participate in an activity that was not in the youths’ best interest or if the activity was not consistent with the facility’s policies and procedures. If the SP had called for assistance using a radio, P1 would not have heard the call, because his/her radio was turned down while s/he was in the meeting, but s/he heard yelling/raised voices and left the office immediately to intervene. · This investigator attempted to contact the SP again to ask whether the SP called the AV a little brat, said that s/he could not “take this fucking shit anymore,” or told the AV that s/he was better than this, needed to do better, that this was stupid, or said that s/he had to “get big” to put the AV in his/her place. However, the SP did not respond to additional attempts to contact him/her. · A Progress Note written by the HCP at 8:20 p.m., on February 19, 2026, showed that the HCP observed that there was redness on both of the AV’s biceps, a red scratch on the top of the AV’s right forearm, and some redness on his/her left forearm. There were no visible injuries to the AV’s scalp, the scalp was not red, and there was no missing hair. The AV was given a cold pack to apply to painful areas according to the Internal Review. · Photos of the AV’s injuries provided by the facility showed that the AV had a scratch approximately .25 inch long on his/her upper left back with broken skin that was healing over with redness around the scab, faint redness on the AV’s right forearm, and on his/her right and left biceps. · The facility’s staffing schedule for the date of the incident showed that eight staff persons and the HCP were at the facility and there were twenty-two youths who resided at the facility. The staffing ratio at the facility was one staff person for three youths. The facility was within staffing ratio when the incident occurred. · The G was aware of the concerns investigated in this report and was concerned that the AV was able to leave the facility without staff person supervision on several occasions. The AV had a history of providing inaccurate information. The facility’s Restraint Procedures Policy showed that staff persons were permitted to use physical restraints to protect a youth or others from imminent risk of harm. The SP’s actions in the incident did not fit the description of restraints that the facility utilized. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Maltreatment of Minors Act and the facility’s policies and procedures prior to the incident. The SP was trained on the facility’s policies and procedures between January 5 and January 26, 2026, and refresher courses on February 16, 2026. Conclusion: A. Maltreatment: Information was consistent that on February 19, 2026, there was a physical interaction between the AV and the SP. The AV said that the SP called him/her a stupid little brat, said that s/he could not take “fucking shit” with the AV anymore, grabbed the AV’s arms, whipped the AV around, and pulled the AV’s hair. After the incident, the AV had red marks on his/her side and back, bruises on his/her arms, a bump on his/her head, and a mark on his/her back that might have been from a recently healed scratch. The SP said that many youth at the facility were in crisis on February 19, 2026, s/he had not met the AV prior to the incident, and the SP had been hit by another youth earlier that day. While supervising the AV in the common area, the SP attempted to redirect the AV to the unit in which s/he resided by talking loudly to create an unpleasant environment for the AV. The AV lunged toward the SP and the SP attempted to hold the AV’s arms to his/her side, but a struggle followed, the SP’s ring became tangled in the AV’s hair, and the SP was afraid that the AV would pin him/her against a wall or get him/her to the ground and hurt him/her. The SP untangled the ring from the AV’s hair and released it but continued to hold the AV’s arms. P1 then approached the SP and AV. P1 said that s/he became aware of the incident when s/he was attending a virtual meeting in the office but heard raised voices in the common area. P1 exited the office and observed the SP holding the AV’s forearms in a way that was inconsistent with facility policies and procedures, so s/he instructed the SP to release the AV, and s/he did. According to P1, the AV told him/her that the SP pulled the AV’s hair, and yelled and grabbed at the AV. The SP told P1 that s/he had to “get big” to put the AV in his/her “place.” The video recording showed that the AV moved toward the SP and pushed him/her. The SP pushed at the AV, the AV moved backward, and the SP moved toward him/her then the AV and the SP grabbed each other’s arms, moved in a circle, and struggled with each other. The SP grabbed the AV’s hair and the AV bent forward at the waist, and the SP placed his/her right hand near the AV’s head then released the AV’s hair and grabbed the AV’s arms again with both hands. The struggle continued, but when P1 exited the office and walked toward the SP and AV, the SP released the AV, and the AV walked away from the common area followed by P1. The SP then left the common area in a different direction. The incident lasted about less than one minute. After the incident, an HCP assessed the AV and documented that there was redness on both of the AV’s biceps, a red scratch on the top of the AV’s right forearm, and some redness on his/her left forearm. There were no visible injuries to the AV’s scalp, the scalp was not red, and no missing hair was noted. P1 and the facility’s Restraint Procedures and Policy showed that the SP’s actions were not consistent with permitted restraints at the facility. This investigator attempted to contact the SP again to ask whether the SP called the AV a brat, said that s/he could not “take this fucking shit anymore,” or said that s/he had to “get big” to put the AV in his/her place, but the SP did not respond. Regarding neglect: Although it was unknown whether the SP called the AV a brat or used profanity with the AV, given that P1 said that the SP told him/her that s/he had to “get big” to put the AV in his/her place, that the video showed the SP push the AV and hold his/her arms, that the SP did not physically disengage with the AV and walk away, and that the SP’s actions during the incident were non-therapeutic and not consistent with facility policies and procedures, there was a preponderance of the evidence that there was a failure to supply the AV with care required for his/her physical or mental health when reasonably able to do so. 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; or 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). Regarding abuse: Although the AV had redness on his/her arms and a scratch on his/her back after the incident, given that the AV had aggressive behavior during the incident, that no information showed that the AV sustained the redness and scratch by any means other than accidental, and that the SP said that s/he was trying to hold the AV’s arms to his/her side, it was determined that the SP’s actions, while nontherapeutic, did not meet the definition of physical abuse. It was determined that abuse did not occur ("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 supervising the AV at the time of the incident and was trained on the facility’s policies and procedures 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 or serious because it was a single incident and the AV did not sustain injuries during the incident that reasonably required 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 completed an Internal Review which determined that their policies and procedures were adequate but not followed. The SP was not injured during the incident and was no longer employed at the facility when this report was written. 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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