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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): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that during a hold, a staff person (SP) forced his/her arm into an alleged victims (AV’s) mouth, which caused bleeding and bruising on both the top and bottom of the AV’s lips and gums. Date of Incident(s): March 31, 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 April 22, 2026, from documentation at the facility and through eight interviews conducted with a facility supervisory staff person (P1), four facility staff persons (P2-P5), the AV, the AV’s guardian (G), who was also the AV’s case manager, and the SP. The AV was fifteen years old and was diagnosed with attention deficit hyperactivity disorder and oppositional defiant disorder. The AV enjoyed staying active, playing basketball, going for bike rides, playing video games and reading. The AV’s Diagnostic Assessment said that the AV had a history of physical aggression, struggled with emotional regulation, frequently lost his/her temper and acted out when s/he was upset. The AV actively declined to comply with rules and/or requests from authority figures and could be impulsive. The AV’s MHP Approval Use of Restrictive Pro[cedure] said that the AV could become physically and emotionally dysregulated and that the AV struggled with anger and impulsivity. The AV had a history of verbal and physical aggression towards others, as well as a history of running away from home and/or facilities. The facility’s Handle with Care Policy (HWC) said that staff persons were permitted to utilize physical holds with residents as a “last resort” to ensure the physical safety of residents and other individuals where imminent danger is present. Staff persons were required to use less restrictive interventions before engaging a physical hold with residents. At least two staff persons were involved in the hold process to provide a “check and balance” system to monitor the process for safety and well-being and the hold was terminated as soon as the threat to harm or self, subsided. If a resident bit or attempted to bite another individual, staff persons were trained to use their forearm to “drive into the mouth” and “apply slow steady pressure” to release the bite or use their forearm to “press and release” in short motions to release the bite. Staff persons could also hook both nostrils of the resident who was biting while applying pressure with their forearm. The facility provided video footage of the incident that was neither date nor time stamped, however, due to the distance of the camera and it being dark outside, the incident was unable to be clearly seen. The AV provided the following information: · On an unknown date, later to be determined March 31, 2026, the AV was upset and ran from the facility. Because the AV ran, P2, P3, and the SP placed the AV in a hold which eventually ended on the ground. While on the ground, the AV attempted to bite P3, and when the AV realized s/he was not going to bite through P3’s clothing, the AV “let go” and laid his/her head on the ground. · When the AV laid his/her head on the ground, the SP “pushed” the AV’s head down, put his/her forearm in the AV’s mouth and told the AV to “bite [the SP].” The SP “hit” the AV in the mouth with the SP’s forearm, and the AV’s mouth started to bleed. P2 told the SP to walk away, and the SP listened “for a second” and removed his/her arm from the AV’s mouth. The SP then pushed his/her arm into the AV’s closed mouth a second time before leaving the situation. · When the SP left, P2 and P3 looked at the AV’s lips because they were “all puffed up.” The AV had a “gash” in his/her top lip, and the bottom lip was bruised on the inside. The AV then asked to call P1, which s/he did, and explained what happened. · The next morning, the SP spoke with the AV at the facility and apologized, but the AV “blurred [the SP] out” and “refused” to talk to the SP. · The AV had been placed in a hold prior to this incident and said that when staff persons placed him/her in a hold, they went to the ground with the AV and held him/her “without force” to make sure the AV was safe. The AV denied anything similar happening, or any issue with the SP prior to this incident. P3 provided the following information · On March 31, 2026, around 9:50 p.m., the AV was placed in a HWC hold after s/he ran around the campus and used sticks as weapons while threatening staff persons. The SP initiated the hold on the AV by “bear hugging” the AV from behind, and P2, P3, and another staff person brought the AV to the ground. · During the hold, P3 lay on his/her left side with his/her back towards the AV and held the AV’s right arm. P3 felt the AV try to bite him/her near the back of P3’s left shoulder but said the AV bit P3’s shirt and did not bite through to P3’s skin. P3’s view was “obstructed” but s/he saw the SP use his/her palm to “shove” the AV’s head to the ground with “probably too much force.” The AV then lifted his/her head, and the SP reached over the top of P3 and “shoved” his/her forearm into the AV’s mouth and said, “if [you’re] going to bite someone, bite [me].” The SP then placed his/her forearm into the AV’s mouth a second time, “super-forcefully.” When the SP removed his/her arm, the AV was “sobbing” and had tears on his/her face and blood on his/her mouth. P2 then told the SP to leave, and the SP did so. · After the AV calmed, s/he talked with P1 on the telephone for approximately five to ten minutes. When the call was finished, P3 and P4 “took a good look” at the AV’s mouth, and offered to bring the AV to the hospital, but the AV refused medical treatment. The AV had a cut on his/her top lip where it appeared his/her canine tooth pushed into the lip, and the bottom lip was bleeding “all the way around.” There were no photographs taken of the injury and P3 then brought the AV to talk to P5. · If a resident attempted to bite a staff person, staff persons were trained to “feed the bite.” The purpose was to force the part of the body a resident bit further into their mouth, so it would naturally force the resident to let go. P3 did not believe there was a reason for the SP to feed the bite from the AV because the P3 did not see the AV attempt to bite the SP. · P3 did not have prior concern with the SP and found him/her to be “laid back” with a “positive attitude” and s/he did not present as “happy” to use physical hold with residents. P3 thought the SP’s emotions got “out of control” when the incident occurred. P2 provided the following information · On March 31, 2026, between 9-10 p.m., P2 responded to a call for assistance regarding a resident, later identified as the AV, that had run from the facility. P2 arrived approximately five minutes prior to the AV being placed in a hold, and learned the AV ran around the campus, threatening staff persons with sticks. · P2 did not know who initiated the hold on the AV, but P2, P3, the SP, and another staff person who P2 did not recall, utilized HWC and brought the AV to the ground in a supine hold. The AV started spitting at staff persons, so P2 put his/her hood over his/her head and turned away from the AV to avoid being spit on. The AV was verbally threatening the SP with “pretty vulgar” language and threats of physical harm. · Because P2 put his/her hood up, s/he did not see the AV attempt to bite anyone but witnessed the SP use “a bit of force” and put his/her forearm into the AV’s mouth twice and said, “bite [me], bite [me].” P2 told the SP to leave after witnessing this, and the SP did. P2 did not see any injuries on the AV because P2 did not return with the AV to the unit but saw the AV the next day and the AV had “a couple little cuts” in his/her mouth. · If a resident made contact with a staff persons skin, staff persons were trained to “feed” a bite by placing their forearm against a resident’s mouth. Staff persons were permitted to feed a bite for another staff person being bit, if that staff person was unable to do it themselves, and P2 thought it was “within training guidelines” for the SP to feed the bite for P3, however, P2 thought the SP’s actions were “hitting” rather than how they were trained. · P2 did not have prior concerns with the SP. P1 provided the following information: · On an unknown date, later to be determined March 31, 2026, P1 was not working but received phone calls from P3 and P4 with concerns regarding a hold completed on the AV, which resulted in an injury to the AV’s mouth. · P3 told P1 that after multiple hours of running from the facility and threatening physical aggression towards staff persons, the AV was placed in a HWC supine hold, during which, the SP used his/her elbow to push down on the AV’s mouth on two separate occasions. P4 was concerned that the SP was “aggressive” during the situation, and that the AV asked the SP to “go away” but the SP did not do so. · After speaking with P3 and P4, P1 spoke with the AV on the phone. P1 did not want to discuss the incident over the phone, but asked how the AV felt, and if s/he needed medical attention. The AV denied needing medical attention and told P1 s/he felt the SP was “too much” and that the AV wanted to “move forward.” P1 told P3 and P4 to monitor the AV’s injuries, and if they became worse or did not improve, to bring the AV for medical attention. · A supine hold was a HWC technique that consisted of the AV being “pinned” to the ground by a staff person on each arm and a staff person on his/her legs so s/he could not move his/her upper body or get into “biting” posture. This was utilized with the AV due to his/her history of aggression towards staff persons. Staff persons were trained to “feed” a bite from a resident by pressing down to open the jawline and releasing the body part that was being bit or rubbing the resident’s lower part of their chin. P1 did not believe the SP needed to feed the bite in this situation because if the hold was completed correctly, the AV was “pinned” and was unable to move his/her head to make contact. · Approximately two and a half weeks after the incident, P1 spoke with the SP who “took ownership” for what happened and said that s/he did not mean to injure the AV. P1 thought the SP sometimes carried his/her frustrations into his/her work and lacked some skills necessary to the job, but that s/he could be taught those things. P5 provided the following information: · On an unknown date, later to be determined March 31, 2026, around 10:30 p.m., P3 asked P5 to speak with the AV because there had been a “pretty significant” hold that happened. P5 met with the AV for approximately one hour to “process” what occurred. · The AV told P5 that s/he ran from the facility, and after telling the SP to “get away” from the AV, the SP continued to follow the AV. The AV threatened to hit the SP with a stick, so the SP put the AV in a standing hold, and P2 and P3 took over the hold to place the AV on the ground. The AV attempted to bite P3, so the SP kept “jamming” his/her arm into the AV’s mouth until P2 told the SP to stop. The AV did not know how many times the SP pushed his/her arm into the AV’s mouth but thought the SP was “pretty rough.” The AV did not provide additional detail regarding the incident. · The AV was “emotional,” and his/her lips were “visibly swollen” so P5 got the AV ice. The AV showed P5 cuts on the inside of his/her lips that were bleeding and told P5 it was “pretty sore.” P5 did not take photographs of the AV’s injuries. · P5 did not have prior concern with the SP and his/her interactions with residents at the facility. P4 provided the following information · On an unknown date, later to be determined March 31, 2026, the AV was “dysregulated” and left his/her dorm without permission so P4 and P3 spoke with the AV outside and let the AV “run out [his/her] energy.” At an unknown time, the SP and P2 came outside and the AV “took off.” · The AV eventually came back towards his/her dorm, at which time P4 saw the SP, P2, and P3 ahead of P4. When P4 reached them, the AV was placed in a hold on the ground. P4 did not see the SP at first but saw P3 holding the AV’s left arm and P2 holding the AV’s right arm, and another staff person lay on the AV’s legs. P4 saw the SP “pull” him/herself out of the hold and was on his/her knees near P3’s and P4’s head. · The AV was “yelling and swearing,” threatened to kill the SP, spit on staff persons, and tried to bite P3. P4 heard the SP say something about “feeding the bite” but did not see the AV try to bite the SP. The AV continued to yell, threatened to kill the SP, and spit on the staff persons doing the hold. P4 then saw the SP move P3’s body away from the AV, and the SP reached over P3 and put “the meaty part” of his/her right forearm over the AV’s mouth two times. · When the SP put his/her arm into the AV’s mouth, P4 saw the SP move his/her arm “slowly back and forth like a sawing motion” and said that was how staff persons fed a bite. P4 did not believe it looked “super aggressive” and said the SP did not hit the AV, but the AV’s mouth was bleeding. The AV told the SP, “You can’t do this,” and the SP told the AV, “Yes, I can, I’m just feeding the bite.” · Staff persons were trained to feed a bite if a resident attempted to bite them, however, P4 did not believe staff persons were trained to defend others. P4 did not have previous concern with the SP, and thought this incident was “completely out of character” for him/her. The SP provided the following information: · On an unknown date, later to be determined March 31, 2026, the SP worked at the facility at 3 p.m. At 8:45 p.m., the SP was outside when the AV and another resident set off an alarm on a company vehicle. The SP approached to ensure there was no damage to the vehicle. When the SP did so, the AV “took off running” and the SP followed. When the SP found the AV, the AV had two sticks and told the SP to “back the fuck up” and to “leave [the AV] the fuck alone.” The SP told the AV to head back to his/her unit, and the AV said s/he was going to “start beating” staff persons with sticks, and then ran from the SP. At this point, the AV had been outside for almost two hours, and the SP felt s/he was the only staff person attempting to get the AV to a safe environment, which was “irritating.” · The SP caught up to the AV and at this point, the SP, P3, P4, and two other staff persons were near the AV. The AV was “fixated” on the SP, so the SP stayed further back than P3 and P4 and asked the AV what the issue was, and the AV said, “I already know your fuck ass is going to try to get me back on my unit.” The SP said s/he tried to “reason” with the AV and told the AV s/he was not creating a safe environment, but the AV was not “receptive.” The AV still had sticks at this point and used them to “distance” him/herself from staff persons, which was when P2 arrived. · P2 asked the SP what s/he needed help with, and the SP told P2 that s/he thought staff persons needed to escort or hold the AV because s/he was creating an unsafe environment. The AV then advanced towards the SP, so the SP completed the “initial hook” on the AV, by grabbing the AV from behind and “hooking” his/her arms over the top of the AV’s shoulders and holding the AV’s back to the SP’s chest. P2 and P3 removed the sticks from the AV and then P2 took the AV’s right arm and P3 took the AV’s left arm. The SP, P2, and P3 lowered the AV to a seated position and then to a supine hold on the ground. At that point the SP let go because, due to an injury, the SP was not supposed to do holds. · P2, P3, and P4 then got the AV into a supine hold on the ground, and the AV began spitting in the SP’s face. The AV then attempted to bite P3, so the SP put his/her hand on the AV’s forehead briefly but then removed it because it was not an approved technique. The SP then put the back part of his/her forearm on the AV’s mouth and pushed down towards the AV’s chin to “feed the bite.” The SP “knew” s/he fed the bite wrong because s/he accidentally pushed up rather than down, which caused the AV’s teeth to press into his/her lips. The SP thought s/he fed the bit for “no more than five seconds.” · The SP did not see the AV crying or upset, and when s/he left, the AV was still being held by P2, P3, and P4. The G was aware of the incident and saw the AV two days after it occurred. The AV showed the G his/her mouth, but there were no visible marks on the outside, but when the AV pulled down his/her bottom lip there was a “bump or scratch” on the inside of his/her lip that looked like a canker sore. The G did not have prior concerns with the facility. Personnel files showed that P1-P5 and the SP were all trained on the AV’s plans, facility policies and procedures, and the reporting of Maltreatment of Minors Act. Conclusion: A. Maltreatment: Consistent information was provided that on March 31, 2026, the AV verbally and physically threatened staff persons with sticks, which resulted in the AV being placed in a physical hold by P2-P4 and the SP. During the hold, the AV bit P3, but did not bite P3’s skin. After the AV released the bite, the SP responded by putting his/her forearm into the AV’s mouth. Staff persons involved all stated they were trained how to “feed a bite,” in order to get the AV to release the bite, however, at the time the SP put his/her arm in the AV’s mouth, the AV had released his/her bite on P3 and was not biting any staff person including the SP. Therefore, there was no need for the SP to put his/her arm in/on the AV’s mouth. The AV told P5 that the SP kept “jamming” his/her arm into the AV’s mouth until P2 told the SP to stop. The AV did not know how many times the SP pushed his/her arm into the AV’s mouth but thought the SP was “pretty rough.” P4 said s/he saw the SP move P3’s body away from the AV and reach over P3 putting “the meaty part” of the SP’s right forearm over the AV’s mouth two times and move his/her arm” slowly back and forth like a sawing motion.” P4 did not believe it looked “super aggressive” and said the SP did not hit the AV, but the AV’s mouth was bleeding. P3 said his/her view was “obstructed” but s/he saw the SP use his/her palm to “shove” the AV’s head to the ground with “probably too much force.” The AV then lifted his/her head, and the SP reached over the top of P3 and “shoved” his/her forearm into the AV’s mouth and said, “If you’re going to bite someone, bite me.” The SP then placed his/her forearm into the AV’s mouth a second time, “super-forcefully.” When the SP removed his/her arm, the AV was “sobbing” and had tears on his/her face and blood on his/her mouth. P2 did not see the AV attempt to bite anyone but saw the SP use “a bit of force” and put his/her forearm into the AV’s mouth twice and said, “Bite [me], bite [me].” P2 saw the AV the next day and the AV had “a couple little cuts” in his/her mouth. The SP said s/he placed his/her forearm in the AV’s mouth when s/he saw the AV bite P3 to “feed the bite,” and that s/he completed the maneuver incorrectly and pushed up rather than down which caused the AV’s teeth to press into his/her lips. The SP thought s/he fed the bite for no more than five seconds and denied seeing the AV crying or upset when s/he left. Given that at the time of the incident, there was no need for the SP to put his/her arm in/on the AV’s mouth; that when the SP did so, it was described as “pretty rough,” “super aggressive,” using “probably too much force” and “a bit of force;” and that as a result of the SP’s actions, the AV sustained bleeding/bruising on his/her mouth/lips, there was a preponderance of the evidence that the SP’s actions were not accidental and caused injury to the AV. 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.)
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. 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 facility policies and procedures, the AV’s plans and the Reporting Maltreatment of Minors Act. At the time of the incident, the SP was responsible for providing necessary cares to the AV to ensure the AV’s health, safety and wellbeing. 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 physical abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring because it was a single incident. However, it was serious because the AV sustained tissue damage to his/her mouth including bleeding and an injury that was present days later. 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 and followed. The SP was retrained on how to respond to crisis situations and received additional supervision and support when s/he worked. 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
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