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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: 831080-CRF (Children’s Residential Facility) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not intervene in a manner necessary to prevent youth from continuously “bullying” an alleged victim (AV) for around two hours. Date of Incident(s): May 18, 2026 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 3, 2026; from documentation and camera footage at the facility; and through six interviews conducted with the AV, a facility youth (Y1), the AV’s guardian (G), facility staff persons (the SP and P1), and a supervisory staff person (P2). The facility was a campus with multiple buildings that provided residential treatment services to youth, ages 9 to 18, who needed emotional, behavioral, and mental health support. The facility provided supervision, education, recreation, and therapy, and had more than one dormitory (dorm) for the youth. The AV’s support plans stated that on May 1, 2026, the AV moved into the facility seeking help to regulate his/her emotions and minimize unsafe- and disruptive-behaviors. At the time of the incident, the AV was 14 years old. Y1 said that on May 18, 2026, s/he and some other youth “had enough” of the AV’s behaviors, which included “lying” and “bothering” others. Y1 and the other youth chased the AV around the dorm and sprayed water on him/her. Y1 said that the SP was present but did not do anything to stop them and instead, the SP told them, “Just don’t get me wet.” The AV said that the SP was “just standing there,” and told the youth, “I bet you can’t catch [the AV],” which prompted them to chase him/her. At least once, the AV told the SP, “Tell them to stop … Get them to stop,” but the SP did not do so and instead told the youth, “Just don’t get me involved.” “A couple of times,” a youth punched the AV and one time, a youth struck the AV with a skateboard, but the SP did not do anything to stop them. Eventually, the youth just stopped and went to their respective bedrooms for the night. There was another staff person (P3) present, but s/he was “somewhere else” in the dorm. The AV did not sustain injuries. The facility’s camera footage from inside the dorm provided the following information: · [Note: The camera footage did not have audio, or a clock. The times listed below were provided by the facility’s Internal Review and Incident Report and/or estimated times.] · On May 18, 2026, the SP and P3 worked in the dorm with 16 youth, including the AV and Y1. P3 was initially present on the camera footage but was not seen again until the end of the footage and incident. The SP was the sole staff person present for the duration. Throughout the footage, there was a lot of activity with youth running around and/or pretending to punch or kick each other. One youth carried a skateboard and pretended to swing the skateboard at others. There was no physical contact during these incidents. · However, there was physical contact when it came to the youths’ interactions with the AV. At the start, or around 6:30 p.m., the AV was going in and out of his/her bedroom or bathroom and there were youth in the hallway. [Note: P2 said that the youth were kicking the bathroom door with the AV inside and going in and out of the AV’s bedroom. The conduct was not clear on the footage to this investigator.] · Around 7:30 p.m., the AV ran to the dorm exit door followed by four youth, including Y1. One youth held the AV’s arms behind his/her back while the others gathered around in a circle. The SP was standing nearby and appeared to say something to the youth but did not approach them. The youth let go of the AV and the AV ran down the hallway followed by four or five youth, including Y1. The SP did not follow but sat in a chair facing the hallway. · At one point, the AV ran past the SP, who was still sitting down, and stopped within five to ten feet of the SP. Y1 and four or five youth surrounded the AV, and Y1 swung his/her fist downward striking the top of the AV’s head. The AV put his/her hands on top of his/her head, pointed at the SP, and appeared to say something. The SP looked at them but did not stand up or appear to say anything. · Around 8 p.m., four or five youth cornered the AV by the dorm exit door and two youth made humping motions in front of the AV, and another swung a skateboard at the AV but did not appear to make physical contact. At this point, the SP stood up and walked towards them and the youth walked away. The AV opened the exit door and the SP quickly stepped in front of him/her and pushed the AV backwards away from the door. The SP was holding his/her two-way portable radio (walkie-talkie) during this time. Four or five youth, including Y1, ran up quickly and surrounded the AV and the SP, who stood next to each other in the corner. The SP held out his/her arm and appeared to tell the youth to back away. A youth approached with a water pitcher and the SP grabbed the pitcher and waved his/her hand back and forth in a gesture commonly known to mean, “No.” · The AV appeared to be repeatedly trying to step behind the SP, but the SP kept his/her hand on the wall, which prevented the AV from going behind him/her, and the SP was leaning against the exit door. · Around 8:09 p.m., the SP’s head was turned focusing on a youth off to the side when another youth approached and quickly punched the AV’s stomach and then walked away. The AV bent over and grabbed his/her stomach. The SP did not react or appear to see what happened. The SP then looked down at his/her watch and Y1 sprayed water from a water bottle into the AV’s face. The SP did not move or appear to say anything to Y1. Y1 then repeatedly sprayed water at the AV and the SP appeared to step out of the way from getting wet. The AV’s shirt was visibly wet. The SP used his/her own shirt to wipe the SP’s face at various points as though it too was wet. · At various points, the SP appeared to shake his/her head “no,” at the youth and more than once, waved his/her hand back and forth at the youth indicating “no.” · Around 8:13 p.m., P1 arrived and walked into the dorm and at that point, everyone stopped what they were doing but continued standing in a circle by the door. P1 walked around and interacted with some of the youth. Y1 sprayed water at the AV, and the SP looked at Y1 and then pointed at him/herself (the SP) as though indicating that Y1’s water spray hit the SP. · Around 8:15 p.m., a youth walked up to the AV and held a skateboard sideways in front of the AV’s groin. The youth’s actions were not fully visible on the camera footage. The SP looked down at the skateboard and then the AV appeared to scream and cover his/her groin with his/her hands. The SP put a hand on the youth with the skateboard and the youth stepped away. The SP did not move or appear to say anything. P1 had his/her back turned at that point and did not appear to see what happened. · A youth then approached and kicked the AV in his/her groin, and the AV bent over and grabbed his/her groin. The SP appeared to be watching this happen but did not move or say anything. P1 was talking and pointing in another direction when this occurred but looked when the AV bent over. P1 watched the youth walk away and then Y1 sprayed water at the AV and P1 said something to the youth. The SP put a hand on the AV and directed him/her to walk and Y1 followed while repeatedly jumping up and down next to the AV and spraying him/her with water. The AV removed his/her shirt which appeared soaking wet, and the SP and the AV walked off camera view. Other youth gathered around P1 to talk and then s/he left, and the camera footage ended. P1 was in the dorm for about four minutes. P2 provided the following information: · The AV was younger than the other youth and had “a lot of energy” and lacked impulse control. The older youth and the AV bantered back and forth, and staff had been intervening and managing the interactions without incident. · P2 watched the camera footage and saw that the SP did not make attempts to step between the youth or redirect them away from the AV. When the AV tried to leave the dorm, the SP stopped him/her from leaving. At times, the AV was laughing and appeared to be trying to keep things “lighthearted,” but the AV also looked “distressed” and was repeatedly trying to get away. · P2 said that the SP should have done more to stop the youths’ “bullying” of the AV. The SP could have radioed to another dorm to ask for additional staff or ask that the AV go to another dorm until bedtime. The SP could have let the AV leave the dorm and sit on the couch directly outside the door. The SP could have stepped between the youth and told them to leave or go to bed. P2 said, “I could go on with options for a while” on what the SP could have done but did not. · On May 19, 2026, P2 gathered the youth for a group meeting to talk about bullying and what happened the night before. Y1 was not present for the meeting. During the meeting, more than one youth said that the SP did not do anything to stop them and instead told them, “Just don’t get me wet.” Later, P2 met individually with Y1, who said that the SP told them, “I bet you can’t catch [the AV],” which was what prompted them to chase the AV. · P3, who was also working in the dorm, told P2 that s/he was on the other end of the hallway watching the youth in his/her vicinity, and although P3 saw youth running around by the SP, the youth were laughing and so P3 did not believe s/he needed to intervene. P2 said that the camera footage showed P3 walking in the hallway up to the bathroom area but not past the bathrooms. [Note: It was not possible to see the dorm exit door from the hallway bathroom area and there was no information that any physical contact occurred in any other locations, but the dorm exit area.] P1 said that on May 18, 2026, at an unknown time, s/he walked into the dorm to deliver an item to a youth. P1 immediately sensed that “something was off,” but no one seemed angry, and no one said anything or showed “signs.” The SP was standing by the dorm exit door and did not say anything to P1. P1 saw Y1 spray water from a water bottle at the AV. The SP did not say anything to Y1 about this, and the AV did not say anything in response. P1 did not work in the AV’s dorm or with the age group or gender in the dorm and so did not know what the culture was like or if s/he should intervene given that the SP was standing right there among the youth. P1 was in the dorm for about five minutes, and when s/he left, s/he emailed a supervisor with his/her observations. The SP provided the following information: · On May 18, 2026, the AV was acting “squirrely,” which was “normal” for him/her. The AV was younger than the other youth and had a history of being “extremely antagonistic” and liking to “stir the pot.” · The AV “antagonized” Y1 and the “older youth” and then ran away from them. The SP told the AV that s/he was a fast runner and that the AV should join a track and field team. The SP did not say anything to the other youth about the AV’s speed and did not “challenge” them to catch the AV. · Y1 and other youth filled their water bottles and sprayed water at the AV as the AV ran away. The SP told them, “Stop this,” and “I’d really rather not get wet,” but they did not stop. · The AV ran toward the dorm exit door and made comments about running away and jumping from a nearby bridge to die by suicide. The SP moved to block the AV from leaving the dorm. The SP said that there was a youth from a different dorm, at that same time, who was actively running away and so a lot of staff were preoccupied following that other youth. There was a limited number of available staff who would be able to respond if the AV ran. · While standing by the door, the older youth gathered around the SP and the AV, and the AV hid behind the SP. More than once, the SP told the AV, “Stay behind me.” More than once, the SP told the older youth, “Leave [the AV] alone … Back up … Stop spraying water,” but the older youth “refused to listen.” The SP told the AV to go to his/her bedroom, but the AV said that s/he was not going if the older youth were not going to their respective bedrooms too. At one point, when the SP was focused on someone else, a youth “jabbed” their skateboard towards the AV. The SP asked the AV if s/he was okay and the AV said that the skateboard did not hit him/her. · The SP said that they were in a “standoff,” and the SP was focused on keeping the AV safe. The SP was unable to call for additional staff help because when s/he moved quickly to block the exit door, s/he forgot to grab his/her “walkie” (two-way portable radio) from the desk. The SP said that s/he was supposed to keep his/her walkie close by but had removed it from his/her pocket to sit comfortably at the desk. The SP said that at this time of day, the dorm was typically “mild” as the youth were getting ready for bed. · Twice, the SP yelled for P3 who was on the other side of the dorm, but P3 did not appear to hear the SP. The SP said that staff typically “split the dorm in half” with a staff staying on either side; the youth could go between the sides and staff were supposed to pay attention and help on either side as needed. The SP believed that P3 was most likely distracted by his/her cellphone and not paying attention to what was happening. [Note: P3 later told the SP that s/he did not hear the SP’s call for help. P3 told the SP that s/he saw youth running around and when they were within range of P3, s/he told them to stop running.] · At one point, P1 walked past the dorm and waved at the SP and the youth, but s/he did not enter the dorm. P1 appeared to be doing something or talking to someone and so the SP could not signal him/her to help. Eventually, the older youth backed off and later apologized to the SP and the AV. · The SP said that the facility never provided any training about what to do in a bullying situation. · The SP believed the allegations were made against him/her (e.g., challenging the youth to catch the AV and not intervening) because P2 and other administrators told the youth that due to the incident, they would have their privileges “paused,” which prompted the youth “to point their fingers at” the SP. The G said that s/he did not have concerns with the facility’s overall care and supervision but that the AV had a history of struggling to acclimate to new settings. The facility’s Handle with Care policies and procedures stated that all staff were trained to intervene in a manner necessary to disrupt escalating tension. Staff were to respond in a calm and unafraid manner and to be firm, fair, and consistent without being intimidating. Staff were to listen to the youth, encourage assertiveness but not aggression, and offer alternative choices. Staff might need to physically intervene to protect a youth from youth-on-youth aggression. The SP’s job description stated that the SP’s responsibilities included: · Serving as a role model to youth by communicating and interacting in a manner that was professional. · Ensuring compliance with all safety policies and procedures. · Remaining cognizant of each youth’s trauma triggers and adapting interactions accordingly. · Engaging in trauma-informed, strength-based therapeutic interventions with youth while maintaining appropriate boundaries. Facility documentation stated that the SP, P1, and P2 received training on the facility’s Handle with Care policies and procedures and on the Reporting of Maltreatment of Minors Act.
Conclusion: A. Maltreatment: On May 18, 2026, for around two hours, more than one youth chased the AV around the dorm, sprayed the AV with water, and punched and kicked the AV. The SP was present throughout the incident and although the SP appeared to say things to the youth or hold up his/her arm to block the youth, the SP’s attempts to intervene were not adequate and ineffective at stopping the conduct. Camera footage showed the SP looking on as a youth physically aggressed towards the AV, but the SP did not move between the youth or make any obvious or meaningful attempts to redirect the youth or protect the AV. Given that the SP did not intervene to protect the AV as multiple youth chased him/her, sprayed him/her with water, and physically assaulted the AV including punching the AV in the stomach causing the AV to bend over and grab his/her stomach and another occasion when the AV was hit with a skateboard in the groin appearing to make the AV scream and cover his/her groin with his/her hands, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care required for the AV’s physical or mental health and a failure to protect the AV from conditions or actions that seriously endangered the AV's 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. 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. Regarding P1: P1 arrived in the dorm at a point when the incident had been ongoing for over an hour. P1 was in the dorm for about four minutes and was not familiar with the youth and did not see or hear anyone asking for help. P1 felt there was “something off” but said that the SP was standing right there among the youth and had been prior to P1’s arrival. After P1 left, s/he emailed a supervisor about his/her observations. Given the situation and limited time for P1 to fully observe what was transpiring, P1’s responsibility was mitigated. Regarding P3: There was no information P3 was present for or witnessed any physical aggression towards the AV. P3 told P2 and the SP that s/he saw the youth running around but did not believe there was a need for him/her to intervene given that the SP was present. It was typical for the dorm to be split in half and for there to be a staff on either side. P3 said that s/he did not hear the SP call for help, and the camera footage did not show the SP yelling out at any points. Therefore, P3’s responsibility was mitigated. Regarding the SP: On May 18, 2026, the SP was responsible for the AV’s care and supervision. The SP was working on the side of the dorm where the AV was located and the incidents occurred. The SP received training on the facility’s Handle with Care policies and procedures and on the Reporting of Maltreatment of Minors Act. Although the SP said that the facility did not provide training about what to do in a bullying situation, the Handle with Care policies and procedures provided information about disrupting escalating tension and intervening to prevent client-on-client aggression. Although the SP said that s/he was in a “standoff” and did not have his/her walkie to call for help, the camera footage showed the SP holding his/her walkie. The SP also said that P1 never entered the dorm and so the SP could not ask P1 for help, but P1 and the camera footage showed P1 entering the dorm and staying for about four minutes. P1 and the camera footage provided consistent information that the SP did not say anything to P1 or indicate that s/he needed help. In addition, the AV and Y1 each said, and other youth told P2, that the SP did not make any attempt to stop the youth and instead made comments that prompted the youth to chase the AV. Therefore, 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. It was a single incident of maltreatment failing to intervene over the single period of time, for which the AV did not sustain a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought. 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 determined that policies and procedures were adequate but not followed by the SP. The facility provided additional training to all staff to ensure that youth-on-youth bullying did not occur and that staff were prohibited from encouraging, facilitating, or participating in any action that involved youth-on-youth aggression. 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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