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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: 1036942-CRF (Children’s Residential Facility) Investigator(s): Gessner Rivas 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) grabbed an alleged victim (AV) and threw her/him to the ground and the AV sustained a cut lip. Date of Incident(s): May 11, 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 June 1, 2023; documentation from the facility, medical records, and law enforcement records: and through three interviews conducted with supervisory staff persons (P1 and P2) and the AV. This investigator contacted the SP to request an interview, but the SP did not respond. The facility was a 24-hour detention facility for youth up to the age of 18 waiting for an initial hearing, trial, court disposition, or placement. Residents at the facility slept in living units called pods which had individual rooms for residents. Residents were able to participate in a variety of programming during their stay including health services and schooling. The AV was residing at the facility awaiting certification for adult court. The facility’s policies and procedures provided the following information: · The Safety and Emergency Procedures Use of Force stated that staff persons should use the minimum amount of force necessary. The policy had a Use of Force Model which placed residents into a number of categories depending on their actions, such as: Cooperative, Resister (Active or Passive), and Assailant (Low, Mid or High). · The policy also had a Use of Force Continuum to guide staff persons on the appropriate response depending on the classification of a resident under the Use of Force Model. · The facility’s Response to Code Calls policy stated that a “Code 2” was a call for all available staff persons to assist in incidents that could be life threatening, acts that could result in serious physical harm or injury to staff persons, residents, or visitors. P1 stated that on May 11, 2023, while the AV was secured in her/his room, the AV and the SP exchanged words through the AV’s door window. The SP then opened the door to the AV’s room, and grabbed the AV and forcibly took her/him to the floor. The SP called for a “Code 2” on her/his radio, requesting assistance from other available staff persons. The Superintendent of the facility sent the SP home after having the SP write up a report about the incident; the SP’s employment with the facility was later terminated. The AV provided the following information: · The AV was in her/his room and asked the SP if s/he could get some water from the water fountain outside of the room, and the SP told her/him, “No.” The AV said s/he told the SP, “Fuck you,” but did not threaten the SP. The AV stated that the SP then walked to her/his room and said, “Fuck you, I’ll break your neck,” and dared the AV to do something when the SP returned from taking another resident to school. · When the SP returned, s/he said it was the AV’s turn to clean. The SP opened the door and grabbed the AV, ripped her/his shirt and slammed her/him to the ground, punched her/him the mouth and grabbed the AV’s hair and slammed her/his head against the ground, grabbed her/his left arm and pulled it behind her/his back. The AV stated that the SP mocked the AV for crying and called “the code.” · The AV stated that s/he got a bloody lip but at first did not want to be checked out because s/he did not think anything was wrong. The AV further stated that s/he was passing out afterwards but did not know that until staff persons told her/him and the last couple of time s/he woke up with a bloody nose. The AV recalled that s/he was taken to the hospital twice. Video footage of the incident provided the following information: · The video footage did not have audio. The timestamp showed that the incident began on May 11, 2023, at 10:14 a.m. The SP approached the AV’s room, words were exchanged through the glass window of the AV’s door. The SP walked away from the door five times but returned each time and continued to exchange words with the AV. The SP appeared to be agitated, flailed her/his arms in an aggressive manner and pointed at the AV. At 10:16:06 a.m. the SP walked out of camera view but returned at 10:16:38 a.m. to the AV’s room. · The SP unlocked the door to the AV’s room, the AV stepped forward and the SP reached with both arms toward the AV’s neck and then grabbed the AV’s t-shirt and swung her/his arm backwards forcing the AV to the floor next to the AV’s room. The AV landed on her/his left side and the SP got on top of the AV, the AV’s head can be seen bouncing up and down a number of times; twice, the AV’s head can be seen hitting the floor. The AV was turned over to her/his right side, and the SP could be seen putting her/his knee on the AV’s back, and the SP pinned the AV’s left arm behind the AV’s back towards her/his right shoulder. · While the SP was on top of the AV, the SP could be seen pushing the AV down into the floor a number of times, the AV did not appear to be fighting back. At some point during the altercation the SP called a “Code 2” over the radio and other staff persons began to arrive at 10:17:55 a.m. One staff person tapped the SP on the back and the SP stood up and walked away from the AV, a staff person checked on the AV who then stood up and was placed back in her/his room at 10:18:40 a.m. The SP submitted a report regarding the incident and provided the following information: · The report submitted by the SP stated that the AV was shouting through her/his door. While the SP escorted another resident to a classroom, the SP stopped at the AV’s door and asked the AV to stop and calm down and upon the SP’s return, the AV would get a chance to come out and clean. The SP returned and opened the AV’s door and the AV “acted as if [s/he] was going to lunge and attack me.” · The SP then noted that before the AV had a chance to do so, s/he took the AV down to the ground and held [her/him] down there,” and called a Code 2 holding the AV there until support arrived. Facility records regarding the incident provided the following information: · Other staff persons responding to the Code 2 noted that the AV was secured on the floor next to the AV’s room, was not resisting, and was walked back into her/his room. · A facility nurse (N) noted that the AV was yelling and threatening staff persons, the N was informed that the AV was bleeding, The N noticed there was a minimal amount of blood on the floor outside of the AV’s room. The AV did not allow the N to make an assessment through the door window and the AV stated, “I am fine. I didn’t get hurt... my lip was bleeding [it’s] not bleeding anymore.” · After the AV was deescalated, the N was able to observe the AV through the window and noticed a small wound on the inside of the AV’s upper lip, approximately 0.5 centimeters. The N did not observe any other signs of injuries, as s/he observed the AV walk around in the room without a shirt. · Later in the day, the AV had fallen asleep on the floor of her/his room and was awoken at 3:15 p.m. by a staff person after calling out the AV’s name several times. The AV was evaluated by an N later that evening. The AV stated that s/he had been hit by a car “not too long ago,” from which s/he had pain in her/his back and legs. The AV noted that the SP had punched her/him in the upper lip, twisted her/his left arm back and above her/his right shoulder, landed her/him on the ground and grabbed her/his hair, and knocked her/his head on the floor two to three times. The AV denied having any headaches, neck pain, or dizziness, but was experiencing pain in her/his back, left arm and lower right leg. The AV stated that s/he was “seeing stars.” · Later that evening around 7:15 p.m., the AV was again found on the floor, did not how s/he got there, and was confused. A Code 2 Medical was called for the AV. The AV was taken to the hospital and admitted at 8:29 p.m. · In the following days, on numerous occasions the AV was found “unresponsive” in her/his room, staff persons tried to wake the AV by calling her/his name and/or tapping her/him on the shoulder and the AV would not respond. Each time the AV was found like this, the N checked in on the AV and found the AV’s vitals to be within normal limits. On May 12, 2023, the AV was moved to a room with a camera and placed on 15-minute overnight checks. On May 13, 2023, after being found “unresponsive” to staff persons calling the AV’s name and or tapping the AV on the shoulder, with dried blood by on his face, the AV was moved to a different room with a camera. On May 14, 2023, the AV was again found in her/his room “unresponsive” with dried blood near her/his face. On May 15, 2023, at 1:00 a.m. the AV was again found “unresponsive,” with blood on the floor next to the AV. Paramedics were called, and the AV was taken to the hospital for evaluation. The AV was cleared at the hospital and returned to the facility around 4:14 a.m. Medical records provided the following information: · The AV was admitted to Regions Hospital on May 11, 2023, at 8:29 p.m. for evaluation after the altercation with the SP. The AV expressed s/he was experiencing pain in the right shin and mild pain in the jaw, and left forehead. A physical exam noted that the AV had a small hematoma (bruise) and tissue swelling in the right shin. A neurologic exam showed no cause for concern, a computerized tomography (CT) scan was normal, an electrocardiogram (EKG) did not reveal any cause for concern, and a thoracic spine x-ray was performed due to the AV’s complaints of tenderness after the altercation; x-ray results were normal. · On May 15, 2023, the AV was again admitted at 1:45 a.m. for repeated episodes of syncope (fainting). Medical professionals noted a small amount of blood coming from the AV’s nose. The AV noted that s/he had pain in her/his left clavicle, left shoulder, and neck pain since “falling” in her/his room (hospital records were not clear if this meant during the incident with the SP or a different incident). A physical exam noted that the AV had tenderness in her/his cervical spine but was otherwise normal. EKG results were unchanged from the previous one conducted on May 11, 2023. A CT scan of the cervical spine and head showed no abnormalities. An x-ray of the AV’s shoulder was normal. An ultrasound of the AV’s inferior vena cava showed normal respiratory variation. The AV was discharged from the hospital at 3:31 a.m. P1 provided the following information: · At the time of the incident, P1 was an administrative staff person at the facility. When the Code 2 call came over the radio P1 was in a meeting with other management level staff persons, which included P2. P1 pulled up the video footage from the pod where the incident occurred and saw that the situation had been resolved. P1 then rewound the video footage to when the incident began. · P1 watched the incident from beginning to end and went to the pod, found the SP sitting at her/his desk, the AV was in her/his room and other staff persons were trying to calm her/him so that medical staff persons could look at her/him. The SP was removed from the area and escorted out of the pod and was informed s/he would be sent home but first s/he was instructed to write a report. · The video of the incident was reviewed again to determine if the level of force used was appropriate. The following Friday May 12, 2023, the SP was informed that her/his employment was terminated. P1 stated that the SP did not follow policies and practices because the AV was secured in her/his room and was not posing a threat to self or others, the SP’s actions were “way outside the use of force” policy. P2 provided the following information: · P2 stated that staff persons were trained to recognize the various subject types of residents to guide staff persons on the appropriate force to use. The AV appeared to be cooperative and in the “Use of Force Continuum, the use of hands on a cooperative [person] is not within the appropriate use of force.” · P2 stated that in review of the video, “It was apparent that the action was extreme, shocking, and it was going to be a problem.” Conclusion: A. Maltreatment: Information showed that the AV was secured in her/his room and did not pose a threat to self or others when the AV and the SP had an exchange of words. Video footage showed that the SP then opened the AV’s door and the SP reached with both arms toward the AV’s neck and then grabbed the AV’s t-shirt and swung her/his arm backwards forcing the AV to the floor next to the AV’s room. The AV landed on her/his left side and the SP got on top of the AV, the AV’s head can be seen bouncing up and down a number of times; twice, the AV’s head can be seen hitting the floor. The AV was turned over to her/his right side, and the SP could be seen putting her/his knee on the AV’s back, and the SP pinned the AV’s left arm behind the AV’s back towards her/his right shoulder. The SP was on top of the AV and was pushing the AV down on the floor while the AV did not appear to be fighting back. Video footage of the incident and statements provided by P1 and P2 corroborated that SP acted outside of the facility’s policies and practices regarding the use of force because there was no need for the SP to open the AV’s door and the SP’s use of force was inappropriate. The AV sustained a cut lip. Later that day, the AV was found more than once “unresponsive” to staff persons calling the AV’s name to wake up. The VA went to the hospital. The VA had a bruise and swelling on his/her shin. The VA then returned to the facility. Three days later, the AV retuned to the hospital for repeated episodes of syncope (fainting) which occurred several times in the days following the incident. The AV was given testing and then returned to the facility. Given that the facility’s policies and practices to use the minimum amount of force necessary were not followed by the SP when s/he engaged the AV, that the testimony provided by staff persons that the SP’s actions were “way outside the use of force,” “extreme,” and “shocking,” and that the AV sustained physical injuries, there was a preponderance of the evidence that the SP’s conduct was not accidental and caused the AV physical injury. It was determined that physical abuse occurred (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. The SP was trained on the facility’s relevant policies and the Reporting of Maltreatment of Minors Act 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 maltreatment because it was a single incident but was serious maltreatment because the AV sustained physical injuries. 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 reviewed the actions of the SP and determined that the SP’s actions were not within policies and practices and terminated the SP’s employment. 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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