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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: 1056393-CRF (Children’s Residential Facility/Department of Corrections) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a rolling chair to push an alleged victim (AV) and pin him/her against a wall, which bruised the AV’s left side. Date of Incident(s): March 22, 2023 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 on April 17, 2023; from documentation at the facility; and through interviews conducted with facility staff persons (P1 and the SP), and the AV. The facility provided residential services to adolescents though the use of individualized programs that might incorporate the use of addiction recovery, truancy support, and pet, individual, group, and family therapies. The length of stay for each youth and the supports offered to him/her were based on the needs and age of the youth and tailored to his/her needs. There were video cameras at the facility that recorded many of the facility’s common areas. The incident between the SP and the AV was video recorded. The AV resided in a non-secure residential program at the facility when the incident occurred. Attention deficit hyperactivity disorder and anxiety were included in the AV’s diagnoses, and s/he was admitted to the facility in the fall of 2022. The AV was active and liked to stay busy. Interviews with this investigator, facility documentation, and a video recording from the facility provided the following information regarding the incident: The AV said that on March 22, 2023, s/he walked behind a desk at which the SP was seated in a common area of the facility and picked up a dry erase marker then walked away from the desk. The SP asked the AV for the marker, but the AV declined. The SP then rolled his/her chair into the AV, pushing the AV into a wall behind the desk. The AV was upset and knocked a printer off the desk then left the area. Later the AV observed that s/he had a bruise on his/her left side that s/he thought was from being pushed into the wall. A copy of the video recording obtained by this investigator showed that at 7:43 p.m., on March 22, 2023, the AV, several youths, the SP, and another staff person (P2), were in a common area on the facility. The SP was seated in a rolling chair behind an L-shaped desk with his/her back toward the wall behind the desk. One end of the desk was against wall but there was an opening between the other end and the wall behind the desk that allowed staff persons to walk behind the desk and sit in the rolling chair. There was a dry erase board on a wall behind the desk on which staff persons wrote assignments for the youths. P2 was seated to the left of the L shaped desk at a small table with his/her back toward the SP, who was seated behind the desk at the time of the incident. The recording showed the AV walk toward the desk, look at the dry erase board, and walk behind the desk. The SP was seated behind the desk and rolled backward in the chair to block the AV, then spoke with him/her. The SP gestured toward the opening between the desk and the wall, but the AV walked around the SP to the dry erase board, then erased information written near the top of the board. The SP remained seated in the chair, spoke with the AV, and then rolled forward toward the desk. The AV walked behind the SP to exit the desk area, and then the SP pushed his/her chair backward into the AV’s right side, which pushed the AV’s left side into the wall. The AV immediately pushed the SP’s chair forward toward the desk and the AV and SP gestured toward each other and talked. The AV pointed his/her finger at the SP, stood over the SP, and knocked a piece of office equipment from the desktop onto the floor, then exited the room. During the incident, P2 remained seated at the table, and at some point, looked over his/her right shoulder toward the AV and the SP. The incident lasted about one minute and showed that the AV was not pinned against the wall. The SP said that on the date of the incident, the AV was dysregulated and went behind the desk to erase the dry erase board, so s/he “stepped up” to prevent the AV from erasing it, but the AV wiped everything down, then started to take all the markers. The SP said that s/he was seated in the chair and tried to move it out of the AV’s way because s/he thought that the AV was going to walk in front of him/her. However, the AV continued behind the SP, who was not “100 % sure” whether his/her chair made contact with the AV. P2 was also present when the incident occurred, but might not have seen the incident because s/he was completing documentation and his/her back was to the SP and the AV. It was a “violation” for the AV to go behind the desk and “technically” the SP could have “put [his/her] hands on” the AV to remove him/her, but the SP was never comfortable putting his/her hands on anyone. The incident happened quickly according to the SP and his/her actions were not malicious. The SP was unaware that the AV sustained a bruise during the incident. P1, a supervisory staff person, said s/he learned of the incident a couple of days after it occurred when the AV told him/her about it. P1 assessed the AV for injuries and observed a bruise on the AV’s left side which was at a location on the AV’s body that was consistent with an injury the AV might have sustained, based on his/her description of the incident and the video recording. P1 reviewed the video recording of the incident and talked with the other youths who were present when it occurred. The youths’ accounts of the incident varied and might have been affected by their previous interactions with the AV and SP. P1 thought that the video showed a power struggle between the AV and the SP, and that the SP took the AV’s actions personally instead of walking away from the AV or switching out with another staff person. The AV might be difficult to redirect and there had been numerous conversations with staff persons about successful interventions to use with the AV. There were no previous concerns regarding the SP’s work, but s/he might be impatient or “unsympathetic” with the youths. The facility’s Restrictive Procedures Policy was reviewed. However, using a chair to block, push, or pin a youth was not an approved technique described in the policy. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Minors Act and the facility’s Restrictive Procedures Policy prior to the incident. Conclusion: A. Maltreatment: The AV said that on March 22, 2023, the SP pushed him/her into a wall with the SP’s chair, which caused a bruise on the AV’s left side. The AV told P1 about the incident. P1 watched a video of the incident from the video recording system at the facility and gave this investigator a copy of the recording. The video recording showed the AV walking behind the SP who was seated in a rolling chair at a desk in a common area. The AV erased information on a dry erase board then walked behind the SP again. The SP pushed his/her chair backward into the AV, which pushed the AV into the wall behind the desk. The AV then pushed the SP’s chair forward and there was a conversation between the SP and AV which included gestures. The SP stated that the AV was dysregulated on the date of the incident and violated the facility’s expectations for the youths by going behind the desk. The SP moved his/her chair and attempted to prevent the AV from taking markers out of the area. However, the SP was unsure whether the chair made contact with the AV and was unaware that the AV sustained an injury during the incident. The SP said that his/her actions were not malicious. P1 stated that the AV had a bruise on his/her left side that was consistent with injuries that might result from being pushed into the wall. The video showed a power struggle between the AV and the SP according to P1, which might have been avoided if the SP walked away from the AV or switched out with another staff person. Using a chair to block or push a youth was not an approved technique in the facility’s Restrictive Procedures Policy. Although the SP said that his/her actions were not malicious and the AV should not have been behind the desk, given that the video recording showed the SP push his/her chair into the AV which pushed him/her into the wall but did not pin him/her, that P1 saw the AV’s bruise and said that it was consistent with an injury that might result from being pushed into the wall, and that the SP would have reason to minimize his/her actions, 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). 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 the SP was trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. 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 was not recurring because it was a single incident but was serious maltreatment because it resulted in a bruise on the AV’s side that was visible a couple of days after the incident. 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 which determined that its policies and procedures were adequate but were not followed. The SP was suspended after P1 became aware of the incident and his/her employment with the facility was ended after P1 viewed the video recording of the incident. 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. Because this facility was licensed by the Department of Corrections, a copy of this report was provided to them. 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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