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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: 1082346-CCC (Child Care Center) Investigator(s): Kimberly Huettl Anderson/Judith Schwanke Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left in the classroom without supervision for approximately 34 minutes when staff persons (SP1 and SP2) put their infants into a stroller and took a walk outside. Date of Incident(s): June 1, 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 July 8, 2022; from documentation at the facility; and through three interviews conducted with a facility management person (P1), SP2, and the AV’s family member (FM). Several attempts were made via telephone and US mail to contact and interview SP1 but SP1 did not respond. The facility’s infant classroom had an area for cribs that separated the classroom with a half-wall. The crib area was visible from classroom. There were two rows of cribs with six cribs on each side. The AV’s crib was in the far back corner of the classroom. The facility’s enrollment records showed that the AV was approximately 16 months old at the time of the incident. The facility’s Incident Report stated that on June 1, 2022, the AV was left unattended for approximately 20 minutes. The facility’s video surveillance showed that SP1 and SP2 left the classroom at 3:38 p.m. and at approximately 4:05 p.m., the AV awoke in his/her crib. At approximately 4:12 p.m., another staff person (P2) entered the classroom and saw the AV in his/her crib. P2 picked the AV up and left the classroom with the AV. (Note: The facility’s Weekly Attendance Report showed that there were seven children present on the time of the incident.) The FM stated that s/he was notified of the incident and was “sad” that his/her child was not supervised for that length of time, but did not have any other concerns about the program. P1 provided the following information: · On June 8, 2022, a staff person (P3) told P1 that the AV had been left in the classroom on June 1, 2022, when SP1 and SP2 took the other children outside for a walk. P1 immediately contacted the FM about the incident and notified his/her supervisors. · On June 8, 2022, P1 talked to SP1 and SP2. SP1 told P1 that s/he told SP2 that the AV was sleeping in his/her crib and that SP2 needed to wake him/her up for the walk. SP2 told P1 that s/he did not hear SP1 tell him/her that the AV was sleeping and that s/he “assumed” all the children were awake because the classroom lights were on when s/he returned from his/her break. SP2 also told P1 that they did not tell P1 about the incident because s/he was “afraid” s/he would lose his/her job. SP1 told P1 that s/he did not know about the incident until P1 asked him/her about it because s/he left for the day when they were on the walk. · P2 and P3 each told P1 that they did not tell P1 about the incident right away because they did not want to “snitch” on his/her coworkers, but P3 realized that it was something P1 needed to know about. · P1 believed the AV was “as safe as s/he could possibly be” in his/her crib, but said that there were other potential dangers, like falling out of his/her crib, from being left alone in the classroom without a staff person’s supervision. · P1 said that all staff were trained on Safety and Supervision and Daily Education policies and the reporting requirements at orientation and within the first five days of employment. Name to face attendance during transitions was covered in those trainings. P1 stated that usually the staff persons wrote the number of children down on a white board but SP1 and SP2 did not follow the policy on the day of the incident. SP2 provided the following information: · On June 1, 2022, SP1 and SP2 worked in the infant classroom together. SP2 did not remember how many children were present on the day of the incident. Around 2:30 p.m., SP2 returned to the classroom from his/her break and began changing children’s diapers. At that time, SP2 “assumed” that all of the children were awake because the lights were on so s/he did not look into the cribs to see if any children were still sleeping. SP1 told her that they were going to take the children outside and started putting children into the buggy while SP2 continued to change diapers. Six children fit in a buggy and when SP1 and SP2 went on walks they typically put four children in each buggy and on the day of the incident there were children in the two buggies. SP2 stated that s/he felt rushed by SP1 because SP1 was putting the children in the buggy and wanted to take the children outside. · Sometime between 3:50 and 4 p.m. while they were on their walk, a staff person replaced SP1 because it was time for SP1 to leave for the day. · When SP2 returned inside, P2 told SP2 that s/he found the AV in his/her crib when they were outside on the walk. At that time, the AV was content and happy. SP2 stated that P1 was not in so s/he continued on with his/her day. · An iPad was used to track counts and was used throughout the day and when a child was sleeping it was indicated with a “Z”. SP1 had placed the iPad in the buggy when SP2 left the classroom and SP2 did not remember how many children were present. SP2 did not look at the iPad when they were on the walk. · SP2 did not believe that the AV could have gotten out of the crib but said that the AV was alone and scared and received trauma from that. The facility’s Safety and Supervision policy states that all children must be within sight and sound at all times. Infant and toddler children were to be supervised at all times when they were sleeping; staff persons supervising sleeping infants and toddlers were to position themselves so they could hear and see any sleeping children. The facility’s personnel files showed that the SP1, SP2, P1, P2, and P3 were trained on the Reporting of Maltreatment of Minors Act and SP1 and SP2 were each trained in Safety and Supervision policy prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, state that a child must have supervision at all times and that supervision is defined as occurring when a program staff person is within sight and hearing of a child at all times so that the program staff person can intervene to protect the health and safety of the child. Conclusion: A. Maltreatment: Information showed that on June 1, 2022, the AV was left in the infant classroom without SP1’s and SP2’s knowledge and supervision for 34 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was in his/her crib in the classroom, and was not injured during that time, it was more likely that no staff person would have been aware that the AV was in the crib in the event of an emergency. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that could seriously endanger the AV’s physical 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 and 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. SP1 and SP2 were each responsible for the supervision of the AV when they left the classroom and went on a walk. SP1 and SP2 were each trained on the facility’s Safety and Supervision policies and on the Reporting of Maltreatment of Minors Act prior to the incident. SP1 and SP2 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 the SP1 and SP2 were each responsible did not meet statutory criteria to be determined as recurring because this was a single event and was not serious because the AV did not require the care of a physician. However, information obtained by the Department of Human Services, in combination with this report, resulted in SP1 being disqualified for recurring maltreatment. SP1 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 conducted an internal review and determined that their policies and procedures were adequate but not followed. All staff persons were retrained on the Reporting of Maltreatment of Minors and SP2 was also retrained on the Safety and Supervision policy. SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 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 SP1 was responsible for maltreatment and the disqualification of SP1 are each subject to appeal. SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 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 SP2. The determination SP2 was responsible for maltreatment is subject to appeal. On November 18, 2022, the facility was issued a Correction Order for the violation outlined in this report. Minnesota Statutes, section 260E.06, subdivision 1, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that two staff persons failed to report suspected maltreatment as required. A letter from DHS was sent to each of these individuals regarding their failure to report the suspected maltreatment and potential consequences for future such failures. 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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