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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): Gessner Rivas/Alice Percy 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a chemical irritant to subdue an alleged victim (AV) who was not complying with requests to return to his/her room. Date of Incident(s): February 26, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); subdivision 18, paragraph (a); and subdivision 23, paragraph (a): 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. "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 March 26, 2026; from documentation at the facility; and through six interviews conducted with two facility staff persons (P1 and P2), a supervisory staff person (P3), the SP, the AV, and the AV’s family member (FM). The facility was a secure 24-hour detention facility for youth 18 years of age or younger who were waiting for court appearances or placement. Residents at the facility slept in living units called pods which had individual bedrooms for residents. Residents were able to participate in a variety of programming while they resided at the facility including health services and schooling. 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. The AV was 15 years old at the time of the incident. The facility’s Deploying Oleoresin Capsicum (OC) policy stated that the OC was effective in an enclosed area, such as a bedroom. The OC was a nonlethal chemical irritant aerosol that caused temporary blindness and intense burning of the skin and mucous membranes. OC was only to be used after it was determined that other means of controlling the resident’s behavior were not effective. OC was used to protect the resident from self-inflicted injury, to protect others from the “assaultive actions” of the resident, to prevent “riot, escape, and or significant property damage,” or to maintain the safety of the institution. The use of OC as a punishment or retaliation was prohibited. The AV provided the following information: · On the day of the incident, the staff persons kept the AV in his/her bedroom all day, which frustrated the AV. At one point, the SP and the facility’s social worker (SW) opened the AV’s bedroom door and asked to talk to the AV. The AV told them s/he did not want to talk and just wanted some free time outside of his/her bedroom. The AV then left the room and sat in a chair outside his/her bedroom. The AV refused to return to his/her bedroom. The AV “was just saying things, but didn’t physically fight them” as s/he sat in the chair. The SP asked if the AV wanted to go to his/her bedroom and the AV said that s/he did not. The SP showed the AV a spray can and told the AV that if s/he did not go to his/her bedroom, s/he would spray the AV. When the AV did not go to his/her bedroom, the SP sprayed the AV in his/her face and eyes. The AV stood, blinked his/her eyes, tried to swing at the SP, and walked around. The SP again sprayed the AV in his/her eyes. · The AV “didn’t feel the burn at first,” but became angry. The AV walked toward the bathroom, but the SP and another staff person “boxed [the AV] in.” The AV then tried to walk upstairs, but the SP and the other staff person “tackled” the AV, put him/her in handcuffs, and took him/her to the health care professional (HCP), who put water on the AV’s face before they put the AV in the holding cell. When the AV tried to wash his/her face, they turned off the water in the sink. The AV started to do push-ups to distract him/herself and then walked around the holding cell with his/her eyes closed. The AV’s eyes were burning and the AV asked for a wet towel, but the staff persons “did nothing.” The AV stated that s/he must have accidentally walked into a wall and the staff persons said that the AV was trying to hurt him/herself, so they put the AV in a “wrap.” · The AV took a shower, but his/her face began to burn again. The staff persons put the AV back in the holding cell, where s/he had to sleep on the concrete floor. When the AV woke, his/her whole body was burning so s/he asked to take another shower. The AV told the staff persons that his/her face was still burning and they gave water to the AV. P1 and P2 provided the following information: · P1 stated that prior to the incident, the AV had repeatedly covered the window in his/her bedroom door, so the SW went to talk to the AV. The AV agreed to talk to the SW in the day room, but once the AV went to the day room and sat in a chair, s/he swore at the staff persons and told them that s/he was not willing to talk and only wanted to get out of his/her bedroom. · P1 stated that when the AV was told to return to his/her bedroom, the AV told the staff persons that s/he was having a bad day and was ready to fight, was ready to “rumble,” and that if anyone came near him/her, s/he was going to “swing on them.” P2 stated that the AV was directed to return to his/her bedroom “numerous times,” but kept refusing and saying s/he would assault the staff persons. The SP warned the AV multiple times that s/he would use OC spray, but the AV told them that it did not scare him/her. The AV stood and clenched his/her fists and the SP sprayed the AV with OC spray. P1 stated that the first spray did not seem to affect the AV. The AV moved toward P1 and one of the staff persons told P1 to move away from the AV, which s/he did. · P1 believed the SP sprayed the AV with OC spray a second time during the incident. The AV went down the steps to the lower tier and said that the OC spray was “sweet.” P2 stated that the AV told the other residents that the OC spray was not affecting him/her. P1 stated that s/he believed the AV posed a threat to the staff persons because s/he was having a bad week and was “ready to fight.” P1 and another staff person placed the AV in a wall pin for the safety of both the AV and the staff persons. They then placed handcuffs on the AV and took him/her to the holding cell. · P1 stated that s/he stayed with the AV for the next hour, removed the handcuffs, took the AV to take a shower, and got the AV’s personal items. The AV was taken to the HCP, who rinsed out the AV’s eyes. The AV asked P1 to wipe his/her eyes several times. The AV was returned to the holding cell and then began banging his/her head against the wall. P2 stated that the AV was agitated and hitting his/her head on the door. P1 sat outside the AV’s room with the door open to provide supervision to the AV. The AV was placed in a “wrap” for approximately an hour. · P1 stated that the facility’s policy stated that OC spray would be used when it was necessary to maintain the safety of both the resident and the staff persons. P1 and P2 each believed that during the incident the SP followed the facility’s policies and training. · P1 stated that after OC spray was used on a resident, the staff persons would take the resident to the HCP to “decontaminate.” The SP provided the following information: · On the day of the incident, the AV was not supposed to leave his/her bedroom. The AV was angry and the SW opened the door of the bedroom because s/he was trying to “de-escalate” the AV. When the door was opened, the AV pushed past the SW and the SP. The AV pointed at the staff persons and threatened to spit in their faces. The AV said, “I’ll spit in your face and I’ll fuck you up and make you pay.” For approximately 11 minutes, the SP talked to the AV to help him/her process what was making him/her angry. The SP asked the AV to return to his/her bedroom and told the AV that if s/he did, the SP would “pass the shift,” which meant that the AV would earn a treat. · The AV told the SP that s/he “better pepper spray” him/her in order to get the AV to move. The SP told the AV that s/he did not want to use OC spray or “go hands on” and continued to urge the AV to return to his/her bedroom. The SP attempted to de-escalate the AV for longer than usual, but the AV refused to return to his/her bedroom. The first time the SP used the OC spray, the AV blocked most of the spray with his/her arm and stood up clenching his/her fist, “roared,” and charged toward the staff persons. The SP continued to tell the AV to get down on the floor and place his/her hands behind his/her back, but the AV refused and the SP used the OC spray again. The SP believed that s/he sprayed the AV with OC spray three or four times during the incident because the AV continued to say that s/he wanted to hurt the staff persons. The SP believed that during the incident, his/her actions were consistent with the facility’s policies and training. The AV had a history of making threats and assaulting the staff persons and other residents. · The SP received training each year on the use of “restrictive procedures,” including the use of OC spray. The staff persons were to use the OC spray as a tool to defuse a potentially dangerous situation or when a resident posed a threat of harm to themselves, other residents, or the staff persons. Before using the spray, a staff person should consider different factors such as the size of the resident, types of threats being made, or verbal or physical cues. Implementing a manual restraint without first using OC spray often meant that the residents had “a lot more injuries.” P3 provided the following information: · After each incident involving a resident, the staff persons had to complete paperwork that explained what efforts were made to de-escalate the situation, the level of force used, who was involved, and why the SP used OC spray. The facility’s policy was to use the least amount of force needed to ensure compliance. · When P3 reviewed the SP’s documentation of the incident, P3 had concerns about the SP’s use of force because there were several staff persons available to intervene and escort the AV if necessary. Also, the AV was in a seated position when the SP first used OC spray. Although the AV verbally threatened the staff persons, s/he did not act on those threats. Once a staff person used the OC spray, the procedure was to see if the resident would comply and then take them to the HCP, who would wash the spray off the resident’s face and “decontaminate” them. The residents typically complied after being sprayed one time. During the incident, the SP sprayed the AV five or six times. Although the AV remained non-compliant, P3 believed there were enough staff persons present to escort the AV to where s/he needed to go. P3 did not believe the SP followed the facility’s procedures regarding the use of OC spray. The FM stated that the AV did not tell him/her about the incident and s/he had no information about what occurred. The facility had five video cameras that showed the control center, dayroom, stairs, lower tier, and holding cell areas of the facility. Videos from two body cameras were also provided. Videos from the facility video recording system and audio/video recordings from staff persons’ body cameras dated February 26, 2026, provided the following information: o On February 26, 2026, the AV entered the dayroom and sat in a chair along one wall. Five staff persons followed the AV and another staff person walked down the stairs from the upper level. The SP walked up to the AV and could be seen talking to the AV. The other staff persons walked around the edges of the dayroom. o Approximately eight minutes after the AV entered the dayroom, the SP walked toward the AV and pulled a OC spray canister out of his/her pocket as s/he continued to talk to the AV. The AV remained sitting in the chair. The SP then walked quickly up to the AV and sprayed the OC spray in the AV’s face. The AV covered his/her face with his/her hands. Eight staff persons stood around the room and several moved closer to the AV as s/he stood. The AV stood and walked away from the SP and other staff persons and the SP sprayed the back of the AV’s head. The AV stopped walking while the SP continued to talk to him/her. o The AV moved toward the door of the dayroom, walking through the staff persons standing in the middle of the room. The SP pointed the canister at the AV at least twice, but it was unclear if s/he sprayed the AV. The AV wiped his/her face, bent over, and then moved to the back of the dayroom. The SP followed the AV and the other staff persons moved away from the AV. o The AV held his/her shirt over his/her face and walked to the door of the dayroom. The SP followed the AV, but the other staff persons stepped back. The AV gestured toward the SP and the SP sprayed the AV with OC spray again. The AV wiped his/her face with his/her shirt and stood in the doorway facing the staff persons. The AV gestured and walked down the stairs to the lower tier, with all of the staff persons following him/her. o The AV knocked on some of the bedroom doors and looked in the door windows. The AV walked toward the staff persons and talked to them before turning and walking away from them. Three staff persons followed the AV, grabbed his/her arms, placed handcuffs on him/her, and walked the AV up the stairs and out of the unit. o The staff persons took the AV to the holding cell, removed the handcuffs, and left the AV in the holding cell. The AV took off his/her shirt and sweat pants and walked around the holding cell, bounced off the wall several times, and then hit his/her head on the wall several times before sitting on the floor and rocking. After approximately ten minutes, several staff persons entered the holding cell, placed the AV in a body wrap and placed the AV on a cart. P1 sat outside the holding cell and watched the AV until the AV was taken out of the wrap and walked out of the holding cell. Facility documentation showed that the SP, P1, P2, and P3 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. Conclusion: A. Maltreatment: On February 26, 2026, the AV walked out of his/her bedroom, went to the day room and sat in a chair, and refused to return to his/her bedroom even though the SP repeatedly asked the AV to go to his/her bedroom. Consistent information was provided that the AV threatened the staff persons, but the AV was still sitting in a chair when the SP approached the AV and sprayed OC spray in the AV’s face. The AV wiped his/her face with his/her hands, stood, and walked away from the staff persons. The SP sprayed the back of the AV’s head with OC spray. Information was provided that the AV verbally threatened the staff persons, but the video recording did not show the AV physically aggressing toward the staff persons. The SP sprayed the AV with OC spray several more times before the AV walked to the lower tier of the facility and was physically restrained by the staff persons. While the SP, P1, and P2 each believed that during the incident the SP followed the facility’s policies and training, P3 had concerns about the SP’s use of force after watching the video recordings of the incident because there were several staff persons available to intervene and escort the AV if necessary and the AV was in a seated position when the SP first used OC spray. Given that at the time of the incident, the AV was not engaging in actions that were endangering him/herself or others, but was repeatedly sprayed in the face with OC spray instead of the SP first trying other means of controlling the AV’s behavior, there was a preponderance of the evidence that the SP’s actions were not accidental and represented a substantial risk of physical or mental harm to the AV and that the SP failed to protect the AV from actions that seriously endangered the AV’s physical or mental health when reasonably able to do so. 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). 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 and/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. 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 and neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because the SP’s pattern of behavior was considered a single incident and the AV did not sustain a serious injury requiring the care of a physician during the incident. 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 and was not required to complete an internal review. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was 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 the disqualification of the SP. The determination that the SP was responsible for maltreatment is 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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