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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/Department of Corrections) Investigator(s): Gessner Rivas/Carla Harvieux Minnesota Department of Human Services carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) told an alleged victim (AV) to get off the phone several times, but the AV declined to end his/her phone call. The SP attempted to hang up the phone and the AV cursed at the SP and slapped him/her. The SP punched and slapped the AV’s face. Date of Incident(s): February 14, 2024 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 February 28, 2024; from documentation and information at the facility; and through interviews conducted with facility staff persons (P1, P2, P5, and the SP) and the AV. The facility was a secure 24-hour detention facility for youths 18 years of age or younger who were waiting for court appearances. At the facility, youths participated in discussions led by staff persons, and education, health, and mental health services. There was a video recording system which recorded common areas of the facility and staff persons at the facility wore body cameras that video and audio recorded. Interviews with a Department of Human Services investigator, facility documentation, videos from the facility’s video recording system, and audio/video recordings from staff persons’ body cameras provided the following information: · The AV said that at about 12:15 p.m., on February 14, 2024, s/he was making a phone call using the facility’s phone affixed to a wall in the unit in which s/he resided. The SP instructed the AV and other youths to go to their bedrooms, but the AV initially did not hear the SP because s/he was focused on the call and not paying attention. The SP grabbed the AV’s wrist, which hurt the AV and upset him/her, and began pulling the phone away from the AV. The AV pulled back, and the phone slipped and hit the AV’s face. The AV slapped the SP, who then punched the AV’s face. When staff persons observed physical contact between the AV and the SP, they moved between them and held the AV down. The incident occurred quickly and lasted about 30 seconds. After the incident, the AV had bruising and swelling to his/her forehead and neck, but s/he received no medical care for his/her injuries and resided overnight in another unit at the facility before returning to the unit where the incident occurred. · Body camera audio/video recordings from the cameras worn by the SP, P1, P2, P3, and P4 on the time/date of the incident showed that they each responded to a call for assistance (code 2) at the AV’s unit. Inside the unit, another youth was upset and being redirected by staff persons, the AV was seated in a chair beside the wall phone to the SP’s left, and another youth was walking away from P1 and P2, who were to the AV’s left but in front of the SP. Several staff persons were heard telling the AV to get off the phone and asking the youths to go to their bedrooms. The AV continued the phone call and was smiling and gesturing with his/her hands. · The SP approached the AV, told him/her to get off the phone, and attempted to take the phone receiver from the AV with his/her right hand, while disconnecting the call with his/her left hand. The SP pulled the receiver from the AV and told the AV to get off the phone and go lie down in a loud voice. The AV raised his/her voice to the SP, cursed him/her, and then slapped the SP. The SP hit the AV several times with his/her right fist, at times reaching over and around P1 and P2, who had grabbed the AV’s arms and were attempting to separate him/her and the SP. The SP followed P1 and P2 as they escorted the AV and continued to swing at the AV. The SP moved away from the AV, P1, and P2, and P3 and P4 stepped between the AV, P1, P2, and the SP. P1 and P2 verbally redirected the AV to go to his/her bedroom and asked the AV to calm, but s/he cursed the SP and said that s/he would “beat” the SP’s ass. The AV did not calm and was placed in a WRAP, which was a restraint system used at the facility for the protection of youths and staff persons when a youth posed a danger to him/herself or others. · The SP said that s/he went to the unit in which the AV resided because there was a call for assistance with the code 2. Protocol specified that when there was a code 2, youths were to go to their bedrooms, and the SP instructed the AV to end the phone call and go to his/her bedroom. However, the AV declined, cursed the SP, and hit the SP’s face. The SP “reacted” and hit the AV once or twice, but P1 and P2 intervened. The SP realized what s/he had done and left the unit, then the facility. Everything happened very quickly, and the SP was unsure why s/he hit the AV. · At 1:12 p.m., on February 14, 2024, the AV was assessed by a facility health care professional (HCP) after s/he was released from the WRAP. The HCP documented that the AV had good circulation and vital signs, but the AV told the HCP that s/he had knee and wrist pain. There was redness around one of the AV’s knees that the HCP thought came from pressure of the AV’s pants leg inside the WRAP. The AV had swelling at his/her left eye, and bruising to his/her forehead and temple, but s/he denied that s/he had a headache or changes to his/her vision. The AV was given an ice pack for swelling and a topical ultra strength muscle rub for aches and pains and instructed to tell staff persons if anything changed. The AV voiced no other concerns and there were no other visible injuries. · P5, a supervisory staff person, said that youths at the facility could have eight telephone calls each day. The SP did not follow protocol when s/he attempted to remove the phone from the AV and should have continued attempting to verbally de-escalate the AV during the incident. The facility’s Use of Force policy showed that staff persons were to use the minimum amount of force necessary when responding to perceived threats and were to never use force as “punishment.” Staff persons were to attempt to disengage from any situation that might result in physical harm to themselves or others, but if disengagement was not possible, staff persons were to use reasonable response to control and defend against threats or aggressive behaviors. The facility’s Controlled F.O.R.C.E (First Official Response in a Critical Environment) training showed that staff persons’ responses to the youths’ actions were to be defensive/reactive. Staff persons were not to respond offensively but were to use a reasonable amount of force to control the youths, and not take the youths’ actions personally. Allowed physical holds were described in the Controlled F.O.R.C.E training, but hitting a youth was not listed as an acceptable action. Facility documentation showed that staff persons interviewed for this report were trained on the facility’s policies and procedures upon hire and the Reporting of Maltreatment of Minors Act prior to the incident. The SP began working at the facility in 2016 and completed a policy review refresher in early 2024. Conclusion: A. Maltreatment: At about 12:15 p.m. on February 14, 2024, several staff persons including the SP responded to the AV’s unit and began redirecting the AV and other youths to their bedrooms. When the SP entered the unit, the AV was making a phone call and declined to follow the SP’s instructions to end the call. Information was consistent from interviews with the SP and the AV and from audio/video recordings made by the body cameras worn by P1, P2, P3, P4, and the SP, that the AV cursed at the SP and slapped him/her. The SP responded by hitting the AV’s face/head area several times with his/her fists. P1 and P2 moved quickly between the AV and SP, and held the AV’s arms to prevent him/her from hitting the SP. However, the SP continued to swing at the AV, at times reaching over and around P1 and P2, before realizing what s/he had done, and leaving the unit. The SP said that s/he “reacted” and was unsure why s/he hit the AV, but everything happened very quickly. The SP’s actions of hitting the AV’s face/neck hard enough to cause swelling to his/her left eye and bruising to his/her temple were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Corrections and was a violation of the facility’s policies and procedures. Given that the AV had bruises and swelling to his/her face and head after the incident, 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 received training 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 maltreatment because it was a single incident but was serious maltreatment because it resulted in bruises on the AV’s face/head which were visible 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 was licensed by the Department of Corrections was not required to complete an internal review. However, the SP was suspended immediately following the incident and s/he had no further contact with the AV. 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 Minnesota Department of Corrections, a copy of this report was provided to them for their review of the maltreatment determination and to take any necessary licensing actions. 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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