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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: 1036881-CRF (Children’s Residential Facility/Department of Corrections) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was found unresponsive, on the floor, in his/her bedroom. Staff persons waited approximately 20 minutes before checking on the AV and at that point, discovered something tied around his/her neck. The item was untied and additional care was sought at that point. The AV was unharmed. Date of Incident(s): November 4, 2022 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 December 29, 2022; from documentation and camera footage at the facility; and through interviews conducted with the AV, the AV’s family member (FM), facility staff persons (SP1-SP3), a staff person (P1) who was a facility nurse, and a supervisory staff person (P2). According to the facility’s website, www.hennepin.us, “The Hennepin County Juvenile Detention Center is a secure 24-hour pre-adjudication facility housing 10- to 17-year-olds while their cases are assessed by the court … The facility has a capacity of 87 beds with a nine-day average length of stay.” The facility had more than one unit to house the residents. There were staff assigned to each unit, who were also able to respond to other units if additional staff were needed. The AV’s unit was multi-level with the communal areas being on the middle floor, including dining room and staff office; and then stairs going up and down to the bedroom areas. The AV’s bedroom, of which the AV was the sole occupant, was on the lower level. Each bedroom door had a window approximately 4 by 18 inches allowing visibility in and out of the room. The facility had cameras mounted in the communal areas, not inside bedrooms or bathrooms, which recorded activities, but not audio. On November 1, 2022, the AV arrived at the facility pending court proceedings. The AV was 16 years old. The AV did not have a history of attempting to “hurt or kill” him/herself. The staff person, who completed the AV’s intake assessment, did not observe any signs the AV was suicidal and documented that the AV appeared “mentally stable, focused, responsive, and alert.” The facility’s policies and procedures, including Visual Well-Being Checks and Medical Emergencies, stated the following: · All staff persons were required to carry a two-way radio when working. There were various types of radio calls a staff person might use. A “back-up” radio call indicated the need for an immediate response to the stated location by all available staff; a “medical back-up” included a request for medical staff. · Unit staff conducted well-being checks of every resident at irregular intervals not to exceed 30 minutes between checks. Staff conducted checks at more frequent intervals when they believed a resident’s well-being might be in question. · Regarding how to conduct a well-being check: o “When conducting well-being checks of residents in their rooms, staff will stop at each resident door/window and postion [sic] themselves to visually observe either the skin of, and/or movement by a resident in the room. In addition, staff will ensure the resident’s head is uncovered, check for respiration and/or movement and perform a quick check of the room to look for obvious damage or potential security and safety concerns.” o If the resident cannot be seen through the window, a verbal command will be given telling the resident to make themselves visible. If the resident does not comply, it is necessary to obtain assistance and enter the room to complete the check.” o Staff persons documented the well-being checks on the facility’s Well-Being Record. · Any facility staff certified in first aid and/or cardiopulmonary resuscitation (CPR), who encountered an “injured person” within the facility, responded immediately by checking the scene safety; checking the person for responsiveness; checking the person’s airway, breathing, and circulation; and administering first aid as needed. The staff person then radioed a “medical back-up,” and/or whatever other resource was needed. The AV told this investigator that at the time of the incident, s/he was upset about being restricted to his/her bedroom. The AV tied a sheet around his/her neck to “act like” s/he was “dead.” The AV then lay on the floor and waited for the staff to respond. However, over the next 20 to 30 minutes, staff checked on the AV three separate times, but “didn’t care at all” about the AV’s condition. In response, the AV “tied [the sheet] a little tighter,” which caused him/her to “pass out.” When the AV woke up, s/he saw P2 standing over him/her. This investigator spoke with the FM over the phone. The facility previously told the FM about the incident, herein. The FM did not have anything to add about this specific incident, but said that s/he had concerns about previous incidents. The FM told this investigator that s/he was not in an appropriate spot to vocalize these concerns, but that s/he would email this information to this investigator on a later day. The FM did not reach out or email this investigator with additional information or concerns by the completion of this investigation. SP1-SP3, P1, P2, and facility documentation and camera footage provided the following information: · The facility’s Incident Reports stated that on November 1, 2022, the AV was involved in a physical altercation with another youth. This, resulted in the AV being placed on disciplinary room time (DRT) until November 4, 2022. [Note: Consistent information was provided that DRT meant the AV was restricted to his/her bedroom for most hours of the day.] · The facility’s Staff Assignments stated that on November 4, 2022, SP1-SP3 were assigned to work on the AV’s unit. P1 and P2 were assigned to work in other areas of the facility. · The AV’s DRT had expired allowing him/her to leave his/her bedroom. P1, P2, and SP1-SP3 were each not aware of indications or statements the AV was suicidal or contemplating self-harm on November 4, 2022. · The facility’s Incident Reports stated that at 10:23 a.m., on November 4, 2022, the AV was out of his/her bedroom for an undisclosed reason. The AV started yelling and swearing at SP3. When SP3 prompted the AV to return to his/her bedroom, the AV declined and threw orange peels at SP3. SP3 radioed for a “back-up,” and the responding staff convinced the AV to go into his/her room. Around 10:26 a.m., the AV’s bedroom door was secured, and the AV was placed on “awaiting due process” (ADP) status, which, again, meant the AV was not allowed to leave his/her bedroom. · SP1-SP3 each said that the AV was “upset” about being restricted to his/her bedroom. SP1 said that the AV was “pissed.” SP2 and SP3 each described how the AV repeatedly pounded on his/her bedroom door. · The facility’s Well-Being Record stated that at 11:13 and 11:35 a.m., SP3 completed well-being checks of the residents, including the AV, who remained in his/her bedroom. SP3 did not document concerns for anyone’s well-being. [Note: The Well-Being Record did not document what each resident was doing at the time of a check.] · The facility’s Well-Being Record stated that at 12 p.m., SP2 completed a well-being check of the residents. SP2 told this investigator that at the time of this check, the AV was lying on his/her bed and appeared unharmed. · Also around 12 p.m., SP1 and SP2 prepared lunch trays in the dining room while all of the residents remained in their respective bedrooms with doors secured. Information was provided that at each meal, staff delivered prepared lunch trays to residents, who were restricted to their bedrooms for disciplinary reasons; and that once these trays were delivered, the remaining residents were allowed out of their rooms to eat in the dining room. · The facility’s camera footage showed that at 12:04:25 p.m., SP1 walked down the stairs into the lower bedroom area towards the AV’s bedroom, carrying a prepared lunch tray. At 12:04:37 p.m., SP1 stood outside the AV’s bedroom looking into the room through the window. At 12:04:50 p.m., SP1 keyed open the AV’s bedroom door. SP1 stood in the door threshold and did not appear to be moving. At 12:05:24 p.m., SP1 backed out of the threshold, closed the door behind him/her, and then carried the same lunch tray back to the dining room. · SP1 said that when s/he looked into the AV’s room, s/he saw the AV lying face-down on the floor with his/her head near the door and his/her feet going away from the door. SP1 called the AV’s name and asked if the AV wanted lunch but the AV did not respond or move. According to SP1, the AV’s face was towards the wall, not visible to SP1, and about four to five feet from the door. The AV’s arms were outstretched above his/her head. SP1 saw the AV’s chest rise and fall, which indicated to SP1 that the AV was breathing. SP1 did not see anything around the AV’s neck, and did not see “blood” or “weapons” in the room, or other cause for concern. SP1 said that if s/he had observed something tied around the AV’s neck, s/he would have radioed a “medical backup,” went into the room, and alleviated the pressure or restriction on the AV’s neck. [Note: At the time of the site visit, this investigator observed the AV with short head hair wearing facility-issued attire, which did not contain a hood. This investigator believed that if the AV’s hair length was the same or similar on November 4, 2022, it was unlikely the AV’s hair played a factor in SP1’s view of the AV’s neck. However, that said, this investigator did not know the AV’s hair length at the time of the incident and did not know if the AV was wearing something other than facility-issued attire without a hood.] · SP1 explained that s/he had a history with the AV, and knew that when the AV was “upset,” s/he would sometimes “ignore” staff. For instance, the AV would lay on his/her bed and not respond to staff. SP1 had no experience of observing the AV lying on the floor. · At the time of this incident, SP1 was aware that the AV had been placed on ADP and was “pissed” because of this. SP1 did not observe anything in the room or with the AV that led him/her to believe there was a medical emergency, or a need to radio a “backup.” SP1 believed that AV was intentionally ignoring him/her and was “playing opossum.” SP1 decided to leave and check on the AV at a later point. · SP2 said that SP1 approached and told him/her, “[The AV] is laying on the floor. Just laying there.” SP1 asked that SP2 join him/her for a second well-being check of the AV. SP1 did not say anything about there being something tied around the AV’s neck. · The facility’s camera footage showed that at 12:09:07 p.m., SP1 and SP2 walked down the stairs into the lower bedroom area arriving outside the AV’s bedroom door at 12:09:16 p.m. SP1 keyed the door open. SP1 and SP2 each stood outside the open door on either side of the doorframe and did not appear to be moving. At 12:09:38 p.m., SP1 and SP2 closed the door and walked back to the dining room. · SP1 said that between his/her first check on the AV and now this second check with SP2, the AV’s arms had changed position. The AV was still lying in the same manner, but the positioning of his/her arms looked different to SP1. · SP2 said that the AV was lying face-down on the floor with his/her head towards the door. SP2 could not see the AV’s face because it was towards the wall. SP2 saw the AV’s chest rise and fall, which indicated to SP2 that the AV was breathing. SP2 did not see any blood or anything tied around the AV’s neck. SP1 and SP2 repeatedly knocked on the door and yelled the AV’s name, but the AV did not move or respond. · SP2 said that according to his/her training, if s/he came across an unresponsive person lying on the floor, s/he was supposed to call a medical back-up. Regarding this incident, SP2 did not call a medical back-up because the AV had been “active” and “wound up” earlier in the day and when SP2 checked on the AV at 12 p.m., the AV was lying on his/her bed, unharmed. Given that only a few minutes had passed since that, SP2 did not believe there was a need for immediate medical services. SP2 could see the AV breathing. SP2 was aware, based on the facility’s medical slips, the AV did not have a medical conditions that might cause an emergency situation. SP2 believed it was appropriate to continually check on the AV and prompt him/her to respond to them. SP2 did not believe the situation “add[ed] up” to a medical emergency. · SP3 said that SP1 approached and told him/her that the AV was lying on the floor and not responding. SP3 believed SP1 also mentioned the AV having “something on [his/her] neck,” but SP3 was not positive if or when this was told to him/her. · The facility’s camera footage showed that at 12:20:01 p.m., SP1 and SP3 walked down the stairs into the lower bedroom area towards the AV’s bedroom. SP1 arrived outside the room at 12:20:05 p.m., looked through the window and then stepped away to give space to SP3. SP3 looked through the window at 12:20:10 p.m. At 12:20:17 p.m., SP3 turned to leave and SP1 removed his/her two way radio from his/her belt and appeared to be speaking into it. SP1 and SP3 walked out of the bedroom area and returned to the dining room. · SP3 said that upon arriving at the AV’s bedroom, SP3 saw the AV lying on the floor with a towel around his/her neck. SP3 told SP1 to radio a medical back-up “right away.” SP3 recalled that at some point prior to 12 p.m., the AV had been “bouncing” (pounding) on his/her bedroom door. The AV was “upset” with staff for being placed on room restriction. However, according to SP3, despite this, even if the AV was sleeping on the floor, they needed to radio a medical backup to ensure the AV was okay. · SP1 said that the staff, who responded to the medical backup, discovered the item tied around the AV’s neck. SP1 did not see anything tied around the AV’s neck at any point when s/he checked on the AV; and SP2 and SP3 never told SP1 that they saw anything tied around the AV’s neck. SP1 believed that if SP2 and/or SP3 had seen something tied around the AV’s neck, they would have told SP1 right away. SP1 also believed that s/he, SP2, and SP3 would have taken immediate action if any of them saw something tied around a youth’s neck. · SP1 believed that when the AV overheard the radio call for a medical backup, at that point the AV “decided to turn it up a notch” by tying something around his/her neck. [Note: SP1 and SP3 walked out of the bedroom area upon calling the medical backup and did not continue to watch the AV or see if the AV moved positions.] · The facility’s camera footage showed that at 12:21:08 p.m., several additional staff persons, including P1 and P2, arrived and went to the AV’s bedroom. The bedroom door was opened and staff entered the room. · P2 said that there was a sweatshirt tied around the AV’s neck and the AV was not responding to the staffs’ verbal and/or physical prompts. P2 tried to untie the item around the AV’s neck but was unable. P2 called out for someone to retrieve a “seatbelt cutter” from the staff office. The item was retrieved and the sweatshirt was cut away from the AV’s neck. The AV was breathing, and staff found a pulse on the AV’s wrist. The AV was rolled onto his/her side. P2 completed a “sternum rub” by rubbing his/her knuckles along the AV’s ribcage, and the AV responded by waking up. The AV was helped into a sitting position and moved so that his/her back was against the wall. · P1 also responded to the AV’s bedroom. P1 observed the AV having a shirt tied around his/her neck. The AV had a “weak pulse” and was breathing. The AV’s limbs were “kind of limp.” Once the shirt was removed, the AV became responsive and had a “strong pulse.” The AV’s oxygen saturation (O2 stats) was 100%. The AV’s neck had “some redness” and the AV was “really sweaty.” P1 believed that the shirt was tied “quite tight” in order to leave redness on the AV’s neck; however, P1 also expected that had the shirt been restricting the AV’s oxygen intake, the AV’s O2 stats would not have been 100%. Within minutes the AV was “completely alert, oriented.” P1 and a nursing supervisor determined that the AV did not require emergency medical services and could remain at the facility under constant supervision. P1 also called the facility’s medical doctor who agreed with this assessment. · P2 said that the AV was placed on “suicide risk,” which meant that s/he would be continuously observed by a staff person until a time when the AV was cleared or removed from suicide risk. · The facility’s camera footage showed that at 12:27:43 p.m., all staff exited the AV’s bedroom and the door was closed. One staff person remained standing outside the door looking continuously through the window into the room. · Following this incident, the AV made comments to SP2 that s/he tied the sheet around his/her neck to get a response from staff because the AV was not allowed to make a phone call earlier in the day. The AV told SP3, “You guys would have been in real trouble had it been this was real.” · P2 said that following the incident, s/he met with SP1-SP3 about what happened. P2 was told that staff saw the AV lying on the floor and they could tell the AV was breathing. P2 said that staff were trained to watch for signs of breathing (e.g. chest rising and falling) and to see skin. P2 added that it was not uncommon for a youth to ignore staff or act “unresponsive” to get attention. P2 told SP1 that, in the future, if s/he did not know if a situation required a medical back-up, s/he could call P2 to get assistance. Facility documentation stated that SP1-SP3, P1, and P2 were certified in first aid and CPR, and received training on the Reporting of Maltreatment of Minors Act. SP1-SP3 and P1 also received training on the facility’s policies and procedures, including Visual Well-Being Checks and Medical Emergencies. P2 was not required to receive this training due his/her role at the facility. Conclusion: A. Maltreatment: The AV told this investigator that on November 4, 2022, s/he was upset about being restricted to his/her bedroom. The AV tied a sheet around his/her neck to “act like” s/he was “dead.” The AV then lay on the floor and waited for the staff to respond, but the staff “didn’t care at all.” In response, the AV “tied [the sheet] a little tighter,” which caused him/her to “pass out.” When the AV woke up, s/he saw P2 standing over him/her. The AV was ultimately unharmed. SP1-SP3 provided information that on November 4, 2022, the AV was “upset” or “pissed” about being restricted to his/her bedroom. At 12 p.m., SP2 checked on the AV, and the AV was lying on his/her bed, unharmed. At 12:04 p.m., SP1 checked on the AV and found him/her lying on his/her bedroom floor. The AV did not respond to SP1. SP1 saw that the AV was breathing and did not see anything restricting the AV’s breathing or other hazards in the AV’s bedroom. SP1 explained that the AV had a history of ignoring staff when s/he was upset. SP1 believed this was what the AV was doing. At 12:09 p.m., SP1 and SP2 checked on the AV, who remained lying on the floor and not responding to staff. SP2 saw that the AV was breathing and did not see anything restricting the AV’s breathing or other hazards in the AV’s bedroom. SP1 believed the AV’s arms had changed positions since his/her initial check five minutes prior. At 12:20:17 p.m., SP1 and SP3 checked on the AV. SP1 still did not see anything tied around the AV’s neck. SP3 told this investigator that s/he saw something tied around the AV’s neck and instructed SP1 to radio a “medical backup.” SP1 and SP3 did not enter the AV’s bedroom at that time, and instead waited for the responding staff. At 12:21:08 p.m. responding staff arrived including P2 who tried to untie the item from the AV’s neck but was unable and called for a “seatbelt cutter.” When that was brought to P2, the items was cut from the AV’s neck. The AV was breathing, and staff found a pulse on the AV’s wrist. The AV was rolled onto his/her side. P2 completed a “sternum rub” by rubbing his/her knuckles along the AV’s ribcage, and the AV responded by waking up. The AV was helped into a sitting position and moved so that his/her back was against the wall. The AV did not require emergency medical services. Information regarding what was tied around the neck varied. The AV said s/he used a sheet; SP3 said it was a towel; P1 said it was a shirt; and P2 said it was a sweatshirt. Therefore, it was not determined what was tied around the AV’s neck. P1 said that the item tied around the AV’s neck was tight enough to leave redness on the AV’s skin. However, P1 believed that had the AV’s breathing been restricted, his/her O2 stats would have been lower than what they were, which was 100%. Although ultimately the AV was unharmed and throughout the incident, SP1 believed that the AV was “playing opossum,” the staff did not know this outcome while the incident was unfolding. Between 12:04 and 12:21 (17 minutes), SP1-SP3 each observed the AV unresponsive on the floor, and SP3 observed something tied around the AV’s neck. However, despite this, no one entered the AV’s bedroom or immediately called for help to ensure the AV was unharmed until 12:20 p.m. (16 minutes after the AV was initially observed on the floor). This conduct was inconsistent with the facility’s Medical Emergencies, which stated that staff should respond immediately by checking the scene safety; checking the person for responsiveness; checking the person’s airway, breathing, and circulation; administering first aid as needed; and radioing a “medical back-up.” Given this, and that the item tied around the AV’s neck was tight enough to leave redness and make it so the AV was not immediately awoken by staff and required a “sternum rub", the failure of the staff to act immediately placed the AV at an increased risk of harm or even death, and as such, there was a preponderance of the evidence that there was a failure to provide the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV's physical or mental health. 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. On November 4, 2022, SP1-SP3 were assigned to work the AV’s unit. SP1-SP3 were certified in first aid and CPR; and received training on the Visual Well-Being Checks and Medical Emergencies, and on the Reporting of Maltreatment of Minors Act. SP1, SP2, and SP3 each failed at certain points to immediately provide care for the AV. SP1-SP3 were each 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 SP1-SP3 were responsible did not meet statutory criteria to be determined as recurring or serious. SP1’s-SP3’s actions were considered a single incident of maltreatment for which there was no information the AV sustained 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’s professional standards and conduct division was conducting an investigation concurrently with this investigation, and would determine any needed corrective actions, including additional trainings. At the completion of this investigation, the professional standards and conduct division had not yet completed their investigation. Action Taken by Department of Human Services, Office of Inspector General: SP1-SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1-SP3 were each 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 disqualification. The determination that SP1-SP3 were each responsible for maltreatment is subject to appeal. The facility is licensed by the Minnesota Department of Corrections. A copy of this report was forwarded to them for their review of possible licensing violations. 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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