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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 Minnesota Department of Human Services 651-431-3676 Suspected Maltreatment Reported: It was reported that a staff person (SP) allowed an alleged victim (AV) to use the SP’s THC vape, and the AV got high. Date of Incident(s): Unknown 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 July 9, 2026, from documentation at the facility and through five interviews conducted with a facility supervisory staff person (P1), a facility staff person (P2), a facility resident (R), and the AV’s family member (FM), and the AV. The AV was fifteen years old and was diagnosed with major depressive disorder, generalized anxiety disorder, and a history of substance use. The AV was motivated, a good advocate for him/herself, enjoyed spending time with friends, cheerleading, and helping others. The AV’s Diagnostic Assessment said the AV had a history of emotional dysregulation, physical and verbal aggression, and used substances as “coping mechanisms.” The AV said that s/he gave the SP money and the SP gave the AV his/her “cart.” Five other residents witnessed this happen, but the AV did not provide the names of those individuals. The AV did not think s/he would get his/her money back from the SP and did not provide additional information relevant to the investigation. P1, P2, and the facility’s Internal Review provided the following consistent information: · On an unknown date, in May 2026, the AV told a staff person, who no longer worked at the facility, that the SP gave the AV a vape, and that the AV gave the SP money to purchase a vape and cartridges. · P1 spoke with the AV who said that on an unknown date, in April or May of 2026, the SP allowed the AV to “hit” the SP’s THC vape, let the AV keep the vape “all shift,” and that the AV got “high.” The AV hung out in his/her bedroom, used the vape, and returned it to the SP at the end of the SP’s shift. The AV asked the SP if s/he would purchase the AV a vape and cartridges, and the SP said s/he would. The AV gave the SP money, but the SP did not purchase the AV a vape and did not return the money. · P2 said the AV had a history of having vapes in his/her bedroom and had to be watched “constantly.” On an unknown date, the AV said s/he gave the SP $67 to purchase the AV a vape, and the SP took the AV’s money, but did not purchase him/her a vape. The AV also said that the SP let the AV “borrow” the SP’s vape when s/he worked. · On an unknown date, the R and other unidentified residents saw a vape fall from the SP’s pocket while s/he worked. · The facility had a designated smoking area where staff persons could smoke cigarettes and/or vapes, but when finished, the vape had to be “locked up” in a separate area. Staff persons could not have vapes on their person when they worked and were trained on these expectations. · Neither P1 nor P2 thought the AV was an accurate provider of information because the AV had a history of “lying” and a lot of “behaviors.” The R provided the following information: · The R “heard” that the AV got vapes from the SP, and another resident told the R that the SP let him/her “hit” the SP’s THC vape when they went on nature walks. The R witnessed this one time and told a staff person who no longer worked at the facility. · The R did not see the SP let anyone else use his/her vape, but on one occasion, the R jumped from his/her window, and on one occasion when the SP followed, a nicotine vape fell out of the SP’s pocket. A resident, who was no longer at the facility, took the vape and “smoked it” in his/her bedroom. The other resident then gave the R the vape, and the R provided it to an unidentified staff person. · The SP’s nicotine vape was rectangular and black with red writing and the THC vape was round with a white lid and looked like a “long usb drive.” · The R saw the AV write down flavors s/he wanted for the vape and provide that information to the SP. The R did not see the SP give the AV any vapes, but on an unknown date, saw the SP come to the facility with “five different vape flavors.” · The AV’s bedroom sometimes smelled like “mangoes” and “weed,” and the R thought it was the AV using the vape in his/her bedroom. The R thought the AV got the vape from the SP but did not have information to verify that. The FM was aware of the allegations and had some concern about things that happened following the AV’s discharge from the facility but were unrelated to this investigation and were not considered possible maltreatment so they were not included in this report. The facility’s Smoking/Tobacco Policy said that smoking tobacco or “tobacco-like” products was not permitted in any part of the facility, or in facility vehicles. Use of these products was permitted in a designated outdoor area, and tobacco-like products included e-cigarettes. The facility’s Drug-Free Workplace Policy said that staff persons were “prohibited” from using, distributing, dispensing and/or purchasing a controlled substance when they worked. This included being under the influence of alcohol, illegal drugs, prescription medication, marijuana or “any substance” that impaired their ability to perform duties. Personnel files showed that P1-P3 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 the SP was seen with a vape at the facility, which did not follow the facility’s Drug-Free Workplace Policy and Smoking Tobacco Policy. The AV told P1 and P2 that the SP allowed the AV to use his/her vape, and that the AV gave the SP money to purchase the AV a vape. The R said that s/he saw the SP let the AV “hit” the SP’s vape on a nature walk, saw the AV write down vape flavors that s/he wanted and give it to the SP, and smelled “weed” from the AV’s bedroom. Another unidentified resident told the R that the SP allowed him/her to use the SP’s vape. Although the SP did not provide information for this investigation, given that all individuals interviewed, and the facility’s Internal Review provided consistent information that the SP was seen with a vape, that the AV and the R said that the SP let the AV use the SP’s vape, that the AV asked the SP to buy him/her a vape, and that the AV’s bedroom sometimes smelled like “weed,” it was likely that the AV had been given access to and/or was able to use the SP’s vape. Given that nicotine and THC was illegal for the AV to possess and/or use and that the AV had a history of using substances as “coping mechanisms,” and that the SP gave the AV access and/or bought the vapes for the AV there was a preponderance of the evidence that the SP failed to provide the AV with reasonable care or services. 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.) 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 of Maltreatment of Minors Act. At the time of the incident(s), the SP was responsible for providing necessary cares to the AV to ensure his/her 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 neglect for which the SP was responsible was recurring maltreatment because the AV had access to a vape on more than one occasion. The SP was disqualified from providing direct contact services. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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