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AMENDED 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.” NOTICE: This Amended Maltreatment Investigation Memorandum supersedes a version dated September 23, 2026, which should be destroyed. The original version contained inaccurate/incomplete information, and the copy herein is the correct version.
License Number and Program Type: 831080-CRF (Children’s Residential Facility) Investigator(s): Samantha Wueste Samantha.wueste@state.mn.us Suspected Maltreatment Reported: Allegation One: It was reported that the AV sustained injuries after falling from a staircase but did not receive medical attention until six days later and was diagnosed with a mild concussion. Allegation Two: It was reported that a staff person (SP3) “slammed” the AV to the floor.
Date of Incident(s): Allegation One: May 9 to 15, 2026 Allegation Two: May 14, 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 visit conducted on June 2, 2026; from documentation at the facility and medical records; and through ten interviews conducted with the AV’s family members (FM1 and FM2), the AV’s social worker (SW), two facility staff persons (P2 and SP3), three supervisory staff persons (SP1, SP2, and P6), and two administrative staff persons (P8 and P9). Multiple attempts were made via phone to contact and interview four additional staff persons (P1 and P3-P5) and two facility nurses (P7 and P10), but the attempts were not successful. This investigator met and talked with the AV, but the AV declined to provide information for this report. The AV enjoyed cheerleading, helping/advocating for others, and spending time with his/her family members and friends. On January 29, 2026, the AV moved into the facility seeking services and support relating to his/her diagnoses which included major depressive disorder recurrent with psychotic features, social anxiety disorder, generalized anxiety disorder, disruptive mood dysregulation disorder, post-traumatic stress disorder, and substance use disorder. There was no information that the AV had a history of seizures. The AV was 15 years old at the time of the incident. On June 26, 2026, the AV was discharged from the facility. The facility provided residential treatment services for youth ages 6 to 18 who had mental health diagnoses. The facility was a campus style setting with multiple buildings and living units. The facility had cameras mounted in the common areas, which recorded video but not audio.
The unit where the AV lived had two levels and was able to house/support up to 15 youth. The main level of the unit contained a secured entrance, a large foyer, a living room, a dining area, five youth bedrooms, and two shared bathrooms. To the left of the foyer was access to a staircase that led to the upper level of the unit. The staircase consisted of 14 concrete steps that were covered with a thin layer of carpeting, with similar flooring at
both the top and bottom of the staircase. The staircase had walls on both sides. The upper level of the unit contained two youth bedrooms (including the AV’s bedroom) and a shared bathroom. The AV’s Referral Form dated September 2, 2025; the VA’s admission and ongoing care information including screenings, assessments, and treatment plans; and the AV’s Individual Support Plan/Crisis Plan and the Safety Plan updated May 7, 2026, provided the following information: · The AV had history of being a victim of abuse, domestic violence, and sexual exploitation. The AV also had a history of maladaptive and “high-risk” behaviors including impulsivity, “unsafe” decision-making, “dissociative tendencies,” truancy from school, emotional dysregulation, suicidal ideation, self-injurious behaviors, verbal/physical aggression towards others, “antisocial” behaviors, “defiant” behaviors towards “authority figures,” leaving his/her residency without the knowledge/supervision of caregivers, participation in illegal activities, and substance abuse. Additionally, the AV “struggled” in “controlling [his/her] anger” and utilizing his/her positive support and coping strategies to make healthy/safe decisions. · The AV’s health/behaviors were managed by prescribed medications, positive support strategies, and individual/group therapy which included weekly journaling. Direct support staff were to assist the AV in learning/developing coping strategies, independent living skills, stress management techniques, and the ability to make healthy/safe choices. · The AV had a history of providing inaccurate information and/or making false reports. FM1, FM2, and the SW each stated that s/he was aware of the incidents and did not have any additional information to provide regarding the allegations. The AV had a history of making false reports that included alleged physical assault from his/her caregivers. According to the SW, the AV “might” provide accurate information but also “might leave out important details or misinterpret events, especially if [the AV] felt that [s/he] was in trouble” for his/her behaviors and/or when “seeking attention.” The facility’s Employee Code of Conduct and Youth Rights policies stated the following: · The “principal role” of the facility’s staff was to keep youth emotionally and physically safe. Staff were responsible for “always upholding” a youth’s rights which included rights to positive and proactive adult guidance, support, and supervision; to courteous and respectful treatment; and to be free from abuse and harassment. · Staff were to encourage youth to follow the facility’s expectations by building positive relationships, role modeling, coaching, teaching, and using collaborative problem solving with youth. · Staff were responsible for their own behavior and choices.
The facility’s Handle with Care policy stated the following: · The facility served high-risk and emotionally dysregulated youth, who might display physically aggressive and harmful behaviors toward themselves and others. The use of physical holds might be a necessary intervention to keep youth and staff safe from physical harm. · Physical hold techniques included a one-person escort, whereby the staff stood behind the youth with their chest close, elbows under elbows, fingertips and wrists pointed straight up, and then staff walked the youth forward or backward. · “Holding youth in uncomfortable or awkward positions as well as arm twisting, arms held high behind the back, hair pulling, or extensive squeezing of the youth is not acceptable or tolerated. The youth must always be treated respectfully throughout the physical hold procedure.” According to the facility’s policies on Youth Incidents and Emergency Protocols, during a time where a youth had a serious illness or life-threatening injury, staff persons were responsible for “immediately” providing first aid and calling 9-1-1, as needed. If staff persons had questions and/or concerns regarding a youth’s illness/injury, the facility’s nursing staff was to be contacted/consulted to review the youth’s symptoms/injuries for further direction on how staff were to respond to the situation. Supervisory staff persons and a youth’s guardian/family member were to each be contacted and notified of such situations as soon as staff persons were able to do so. Facility documentation showed that all staff who provided information for this investigation (including SP1-SP3) received training on the facility’s policies and procedures including the Employee Code of Conduct, Youth Rights, and responding to incidents involving injuries/illness or a youth’s behaviors; and the Reporting of Maltreatment of Minors Act prior to the incidents.
Allegation One: It was reported that the AV sustained injuries after falling from a staircase but did not receive medical attention until six days later and was diagnosed with a mild concussion. P2, P6, and P8; the AV’s daily Milieu Notes, weekly Treatment Notes, and Nursing Notes dated May 9 to 16, 2026; and the facility’s Employee Timecards, the General Incident Reporting (GER) form, Critical Incident Report, and the Internal Review provided the following information: · During the evening on May 9, 2026, P1 and P2 worked at the facility with the AV and eight additional youth who also resided in the AV’s unit at that time. There were also additional staff who worked in the other units within the campus that evening, including an on-site supervisory staff person (SP1). · On or around 8 p.m., the AV gathered his/her personal belongings from the main level of his/her unit and walked upstairs to go to his/her bedroom while P1 and P2 each remained on the main level assisting other youth. A “few” minutes later, P2 “heard [the AV] fall down the stairs” and “immediately” walked over to the staircase and saw the AV lying on the floor on his/her back. P2 also saw that the AV’s body was “shaking,” that the AV’s eyes were closed, and that the AV was not responding to P2’s verbal prompts. P2 stated that s/he was not aware if the AV had a history of seizures but “worried” that the AV was “possibly” having a seizure at that time and that the AV “might” hit his/her head against the doorframe near the staircase. P2 then rolled the AV to his/her side, “cradled” the AV’s head, and “called out” to P1 for assistance. P1 approached the situation and “took over” in caring for the AV while P2 assisted the other youth in getting ready for bed. During this time, P1 also contacted SP1 for assistance. · Shortly thereafter, SP1 arrived at the unit and observed the AV from the doorway while talking to P1 about the incident. According to P2, the AV “still appeared unresponsive” at that time. However, SP1 told P1/P2 that the AV did not need medical attention and to “keep an eye” on the AV. SP1 then left the unit. At some point later, the AV responded to P1 and “rested” on the floor near the staircase for about 30 minutes but “struggled” to stay awake. According to information that P1 provided in the facility’s Incident Report and Internal Review, SP1 called the unit during that time to check on the AV and talked to P1. P1 said that the AV was responding and updated SP1 on the situation which included: o The AV said that s/he reached the top of the staircase but fell backwards for an unknown reason, landing at the bottom of the stairs. During the fall, the AV hit his/her head on one of the steps near the bottom of the staircase. o P1 observed the AV’s injuries/symptoms at that time which included a red mark towards the right side of the AV’s forehead and a bruise on the AV’s right thigh. The AV also “complained” of head pain and pain near his/her buttocks. · Consistent information was provided by facility documentation that at some point during 8:05 to 9:05 p.m., SP1 reviewed video footage of the incident and observed the AV’s injuries/behaviors. With this information, coupled with knowing the AV’s history, SP1 determined and informed P1 during the call that the AV did not need medical attention at that time and to continue monitoring the AV’s symptoms. Furthermore, SP1 “felt” that the AV “faked” falling down the stairs for “possible attention seeking motives.” After talking with SP1, P1 continued to monitor the AV as “instructed” by SP1 and administered the AV over the counter (OTC) pain medications and an ice pack. · Facility documentation provided consistent information that after the incident, the AV “initially seemed confused,” “tired,” and “disoriented.” Approximately one hour later, the AV was able to walk up the stairs to his/her bedroom with staff assistance but “stumbled a little.” At approximately 9:15 p.m., the AV told P1 that s/he was “fine” and went to sleep. P1 contacted/notified the AV’s care team about the incident, which included email notifications to FM1/FM2, the SW, and SP2. · The next morning (May 10, 2026), P2 worked at the facility in the AV’s unit. There were also additional staff who worked within the campus at that time, including SP1. At some point after 7 a.m., the AV woke and walked downstairs to the main level to eat breakfast. P2 stated that the AV “still seemed off and a bit shaky” but the AV started to return to his/her baseline after eating. Shortly thereafter, an additional staff person arrived at the unit and P2’s shift ended. P2 then left the facility. · On May 15, 2026, requested to meet with P8 to discuss “some concerns” that the AV had. At some point later, the AV and P8 talked in P8’s office and the AV told P8 about two incidents, including the AV’s “fall” earlier that week and the incident in Allegation Two. The AV also showed P8 his/her injuries that included “scratches” on the AV’s face and “minor bruising” on the left and right sides of the AV’s upper legs near his/her buttocks. The AV told P8 that s/he vomited two times after the incident and experienced headaches throughout the week, but the staff were not allowing the AV to be assessed by the facility’s nursing staff. · After speaking with the AV, P8 walked with the AV to the facility’s nursing department and informed a facility nurse (P10) of the incident. P10 talked with the AV, examined the AV’s visible injuries at that time, and recommended that the AV was evaluated at a hospital’s emergency department (ED). A staff person then transported the AV to the ED. At the ED, the AV was examined and diagnosed with a mild concussion. · According to P8 and facility documentation, P8 began an internal review of the incidents that the AV reported which included watching video footage and talking to facility direct support staff/nursing staff who worked with the AV that week. According to the facility’s internal review, SP2 was made aware of the incident and the AV’s injuries/symptoms at some point during May 11, 2026. Additionally, SP2 reviewed the video footage from the incident and “agreed” with SP1’s review which concluded that the AV “appeared” to have “staged the fall.” SP2 then asked P7 to review the video and assess if the AV needed medical attention resulting from the incident. SP2 also described the AV’s injuries and symptoms to P7 but did not have the AV examined by P7 at that time. After P7 reviewed the video, P7 told SP2 that the video was “not clear” in whether the fall was intentional and P7 could not determine the AV’s injuries without a physical examination of the AV. However, SP2 remained determined that the AV was “most likely” not providing accurate information to staff about the incident or his/her injuries, and so SP2 informed staff who worked with the AV at that time that the AV did not need medical attention. · P8 was not aware of any similar concerns involving SP1/SP2 prior to the incident. The facility’s video surveillance dated May 9, 2026, from 8:04 to 8:07 p.m. (three minutes) was reviewed by this investigator. The camera was positioned directly above a staircase and did not show any additional areas of the unit besides a small portion of the flooring at the top and bottom of the staircase. At the top of the staircase, there were various items belonging to the residents that were scattered around including a blanket, nail art supplies, a pair of shoes, a small microphone, and two bins of personal items. At approximately 8:04 p.m., the AV walked up the stairs and for unclear reasons appeared to lose his/her footing once s/he reached the top step. The AV then fell backwards down the steps while attempting to hold a handrail but the AV was unable to stop his/her fall and rolled over onto his/her neck/head, landing on the floor at the bottom of the staircase. Upon impact, the AV lay on his/her right side and began shaking in a manner that did not appear to be controlled. Immediately after this, two staff persons approached the AV and helped roll the AV to his/her side, but the AV appeared non-responsive. Due to the positioning of the camera, it was not clear what happened after this because the AV and the staff could not clearly be seen from that angle. SP1 provided the following information: · During the evening of May 9, 2026, SP1 worked at the facility as the on-site supervisory staff person responsible for overseeing the campus and all units, including the AV’s unit. Shortly after 8 p.m., P1 called and notified SP1 that the AV fell down the stairs and requested SP1’s assistance with the situation. Approximately five minutes later, SP1 went the AV’s unit and saw the AV was lying on his/her back at the bottom of the staircase with his/her eyes closed while making a “loud snoring sound.” P1 was next to the AV. The AV was unresponsive to staff’s verbal prompts at that time. Although SP1 was not aware of the AV being involved in similar prior incidents of “faking an injury for attention,” SP1 “knew” about recent incidents involving other youth who “pretended” to have injuries for various reasons. Therefore, SP1 advised P1 to “keep an eye” on the AV and to monitor the AV’s symptoms but did not determine that the AV needed medical attention at that time. SP1 then left the unit to respond to other incidents that also occurred at that time within the campus. · About ten minutes later, SP1 called the unit to check on the AV and spoke to P1. P1 told SP1 that the AV began to respond to staff but P1 “never” told SP1 that the AV had been “shaking” or that the AV reported head pain after the incident. SP1 did not watch video footage of the incident. · SP1 worked until about 11 p.m. and then returned the next day (May 10, 2026) to work a morning shift. After initially responding to the incident, SP1 did not physically assess the AV’s condition and was not aware of the AV sustaining any injuries. · SP1 was aware that the AV was unresponsive for approximately 10 to 15 minutes after falling down the staircase, but SP1 did not contact the on-call nurse or request that staff seek medical attention for the AV at that time. SP1 stated that the staff who were working in the AV’s unit at that time (including P1 and P2) “should have” elevated any ongoing concerns and/or contacted the facility’s nursing staff if the AV was displaying systems of a head injury that was not observed by SP1. SP2 provided the following information: · On May 11, 2026, SP2 worked at the facility and was “checking in” with each unit to ask about the weekend. At an unknown time, SP2 arrived at the AV’s unit. Shortly thereafter, the AV approached SP2 and said that during the weekend s/he fell down the stairs and had a seizure. Prior to this, SP2 was not aware of the incident. SP2 did not observe any injuries to the AV at that time, nor did the AV communicate any injuries at that time. SP2 was not aware that the AV had a history of seizures and told the AV that s/he would follow up on the incident to ensure that the AV did not need medical attention. · After talking with the AV, SP2 reviewed camera footage of the incident and stated that the AV appeared to “slide” down the staircase, with his/her legs “rolling over” the AV’s body but it was unclear whether the AV hit his/her head during the incident. SP2 then asked P7 to review the video footage to help determine if the AV needed medical attention at that time. P7 then watched the video but did not recommend that the AV be taken to a medical provider at that time. · SP2 was not aware of the AV sustaining any injuries from the incident and/or the AV communicating any symptoms of injury to staff persons during the days preceding the incident. On May 15, 2026, SP2 was informed by the facility’s administrative team that the AV complained of ongoing head pain that s/he sustained from the incident and was assessed by the ED, where the AV was diagnosed with a mild concussion. SP2 also stated that the AV was involved in a physical altercation (as detailed below in Allegation Two) two days prior that could have resulted in the injuries that were later noted by the ED.
According to the AV’s medical records, on May 15, 2026, the AV was examined at the ED and diagnosed with a “concussion- loss of consciousness less than 30 minutes, initial” that was sustained on May 9, 2026, when the AV fell down the staircase and hit his/her head. The ED provided after-visit care instructions for the AV that included rest, OTC pain medications, and limited physical activities until “cleared” to resume such activities by the AV’s primary doctor. [Note: There was no information provided that the AV followed up with his/her primary doctor regarding the incident.] Conclusion for Allegation One: A. Maltreatment: The AV’s plans showed that the AV had a history of reporting inaccurate information and engaging in maladaptive behaviors that included self-injurious and attention-seeking behaviors. Consistent information was provided from all sources, which included video, that on May 9, 2026, the AV fell backwards down 14 steps. Immediately after the AV’s fall, staff persons (P1, P2, and SP1) observed that the AV was unresponsive for approximately 15 to 20 minutes but the staff did not attempt to contact the on-call nurse, nor did any staff seek medical attention for the AV at that time. Additionally, facility documentation showed that the AV sustained injuries from this incident that included a mark(s) on the AV’s face, bruising on the AV’s upper leg(s), and head pain. The AV also had symptoms of “shaking,” being “confused/disoriented,” and not being able to stay awake after the incident. However, SP1 denied being aware that the AV sustained such injuries or displayed such symptoms. Although the AV declined to be interviewed for this investigation, the AV provided information to P1 that s/he hit his/her head on one of the steps during the fall and had head pain. Two days later, the AV told SP2 about the incident and six days after the incident, the AV told P8 and P10 about the incident, that the AV vomited two times the next morning, and that s/he continued to have headaches throughout the week. However, staff did not seek medical attention for the AV until May 15, 2026 (six days later), where at the ED the AV was diagnosed with a mild concussion. Although, P8 observed the AV’s visible injuries and noted that the AV had scratches on his/her face and bruising on each side of the AV’s upper legs near his/her buttocks, consistent information also showed that the AV was involved in a separate incident including a physical altercation with another youth on May 14, 2025, prior to speaking with P8/P10 or being examined by the ED. SP2 stated that s/he became aware of the incident two days after it occurred and reviewed video footage of the incident at that time. SP2 then requested that P7 review the video footage to determine if the AV required medical attention. However, there was conflicting information on P7’s response. In addition, SP2 denied being aware that the AV had any visible injuries or symptoms of a head injury at that time. There was also conflicting information about whether SP1 and/or SP2 determined that the AV “appeared” to “stage” his/her fall and therefore, did not require medical attention. However, whether the AV intentionally fell down the stairs was irrelevant. Regardless of the AV’s history and/or how/why the AV fell, the video showed that the AV fell backwards down 14 steps, rolled onto his/her neck/head, and landed on cement flooring that was covered by a thin layer of carpet. In addition, although SP1 denied being aware of the AV displaying seizure-like activity after the incident, the video showed the AV shaking in a manner that did not appear to be controlled and
that the AV appeared to be unresponsive. After the incident, the AV also displayed symptoms consistent with a head injury. Given that the AV fell backwards down a flight of stairs, was unresponsive for approximately 15-20 minutes, had symptoms for the next six days including vomiting and head pain, and that the AV was not taken to be evaluated at the ED for six days, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and/or a failure to protect the AV from actions that seriously endangered his/her 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 and/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). 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. Facility documentation showed that SP1, SP2, P1, and P2 each received training on the facility’s policies and on the Reporting of Maltreatment of Minors Act prior to the incident. Consistent information showed that SP1, P1, and P2 each observed that the AV was unresponsive for approximately 15 to 20 minutes after falling down a staircase, that was followed by seizure-like activity and symptoms consistent with a head injury, but staff did not seek medical attention for the AV at that time. Then two days after the incident, the AV told SP2 that s/he fell down the stairs and had a seizure, which was not consistent with the AV’s history. After SP2 reviewed the video footage, s/he consulted with a facility nurse but SP2 did not have the nurse physically examine the AV for any injuries and did not seek other medical attention for the AV at that time. The AV was not taken to the doctor until six days after the incident. Saff persons at multiple levels of authority were aware of the incident and the AV’s condition after falling, had watched the video, and were aware of the AV’s continued symptoms, yet no medical care was sought for the AV. This represented a systemic failure. Therefore, individual staff persons responsibility was mitigated and the facility was for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by the facility meets the statutory criteria to be determined as “serious.”
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 facility was responsible was not “serious” maltreatment because although the AV was taken to the doctor and diagnosed with a concussion, the AV was not provided treatment by the doctor. Allegation Two: It was reported that SP3 “slammed” the AV to the floor. Consistent information was provided by P6 and P8; the AV’s daily Milieu Notes, weekly Treatment Notes, and Nursing Notes dated May 14 and 15, 2026; and the facility’s Employee Timecards, the General Incident Reporting (GER) Form, and the Internal Review, which included the following information: · During the evening on May 14, 2026, P3, P6, and SP3 worked at the facility in the AV’s unit with the AV and eight additional youth. Around 7:25 p.m., the AV was involved in a verbal “altercation” with another youth (Y) which “escalated” into a physical altercation and led to the AV being placed within a hold that was completed by P3 and P6. · After the AV was released from the hold, the AV “struggled” with remaining “calm” and began to engage in verbally aggressive behaviors towards other youth. At approximately 7:37 p.m., the AV ran towards the Y in an aggressive manner so SP3 stepped in front of the Y to prevent the AV from getting at the Y trying to avoid another physical altercation between the two. However, the AV ran into the side of SP3’s body which caused the AV to fall to the floor. The AV then stood without staff assistance and “briefly” continued to make verbally aggressive comments towards the Y and staff. The AV then walked away from the situation to talk with P6. · On May 15, 2026, the AV met with P8 to talk about concerns regarding his/her previous fall down the stairs. During the conversation with P8, the AV said that SP3 “body slammed” the AV to the floor during an incident the previous evening. After talking with the AV, P8 reviewed video footage of the incident and did not see any time when SP3 body slammed the AV. P8 stated that there were no prior concerns with SP3’s conduct or interactions with other youth. · P6 and P8 each stated that s/he was not aware of any injuries that the AV sustained as a result of the incident and/or SP3’s actions. However, P8 provided information for Allegation One that s/he observed visible injuries to the VA on May 15, 2026, that included scratches on the AV’s face and bruising on each side of the AV’s upper legs near his/her buttocks. P3, SP2, and SP3 each provided information that was consistent with the information provided by P6, P8, and facility documentation. However, P3, SP2, and SP3 each stated that SP3 was facing to the side when the AV “ran into” and “bounced off” SP3 body, with the AV falling to the floor. SP3 denied “slamming” the AV to the floor during this incident or during any previous incidents when interacting with other youth. Additionally, P3, SP2, and SP3 each stated that SP3 did not move towards the AV, “block” the AV, and/or attempt to make “any intentional physical contact” with the AV at any point during this incident. According to SP2, s/he reviewed the video footage of the incident and stated that the AV “might have” hit his/her head during the incident. The facility’s video surveillance dated May 14, 2026, from 7:35 to 7:40 p.m. (five minutes) was reviewed by this investigator. The video did not include audio and opened with the AV and a youth standing and facing P6. SP3 was standing on the opposite side behind a quarter-wall near the walkway between the two sides. At one point, P6 turned his/her head towards the other side of the room, and the AV and the other youth ran towards the other side of the room. The AV towards the walkway/SP3 and the youth towards the quarter wall. As the AV neared SP3, SP3 turned to face the AV, took a step forward towards the AV, raised his/her left arm, and used his/her left shoulder/arm to block and push the AV. This caused the AV to fall into wooden chairs that were placed against the wall and onto the floor. The AV stood and turned and walked away from SP3. At this time, the AV had his/her left hand on his/her lower back near his/her buttocks. Conclusion for Allegation Two: Consistent information from all sources showed that the AV engaged in a verbal/physical altercation with another youth during the evening on May 14, 2026. The next day, the AV provided information to P8 that SP3 “body slammed” him/her to the floor during the incident. However, information provided during interviews was that SP3 did not “body slam” the AV at any point during the incident and P3, P6, P8, SP2, and facility documentation stated that the AV “ran into” SP3’s body while the AV aggressed towards the Y, causing the AV to fall to the floor. However, video showed that as the AV ran towards SP3, SP3 turned to face the AV, took a step forward towards the AV, raised his/her left arm, and used his/her left shoulder/arm to block and push the AV causing the AV to fall into wooden chairs that were placed against the wall and onto the floor. Although SP3’s actions as viewed on video were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and not therapeutic conduct or necessary because SP3 could have taken actions other than pushing the AV, given that there was no information provided that the AV sustained an injury as a result of the incident, there was not a preponderance of the evidence that SP3’s actions caused or threatened any physical injury to the AV.
It was not 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. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by SP1 and SP2 in delaying the AV’s medical treatment. SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On September 23, 2026, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine 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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