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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: 1102022-CCC (Child Care Center) Investigator(s): Danielle Morrison Suspected Maltreatment Reported: It was reported that a staff person (SP) was changing an alleged victim’s (AV’s) diaper, when the SP bent down to retrieve necessary supplies, and the AV fell off a changing table. The AV sustained a fractured skull and a hematoma (a solid swelling of clotted blood within the tissues). Date of Incident(s): October 18, 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 November 3, 2022; from documentation at the facility, medical records, and through five interviews conducted with the staff person (SP), two supervisory staff persons (P1 and P2), one facility staff person (P3), and the AV’s family member (FM). The AV was seven months old at the time of the incident and was enrolled in the infant room. The infant classroom had a sectioned off crib area, an area for infants who were eating solid foods, an open area for infants to play. The changing table was located in a bathroom inside the classroom. The changing table was approximately three feet off the floor. There was a covered plastic bin on the floor to the left of the changing table that contained exam paper that staff persons were to use to cover the top of the changing table as a barrier to the child. The SP, P1, P2, and P3 provided consistent information that the diaper changing policy included for staff persons to keep a hand on a child while changing the child’s diaper. There was a Dutch door (a door divided into two parts horizontally, allowing one half to be shut and the other left open) in the infant classroom that led to an open concept toddler and preschool classroom. The FM provided the following information: · On October 18, 2022, at approximately 2:45 p.m., the FM received a telephone call from P1 that the AV had fallen off of the changing table. P1 said that the SP did not keep his/her hand on the AV as the SP reached down to grab the “liner pad” and the AV “flipped” him/herself off the changing table. · The FM picked the AV up from the facility and took the AV to the hospital. The AV was admitted as soon as s/he and the FM walked through the door. The FM was told “good news the brain [was] not bleeding, but [the AV had] a skull fracture.” · The FM was told the skull would heal on its own, and so far the AV had been “acting normal.” Medical Records dated October 18, 2022, stated that the AV arrived to the emergency room for evaluation after a fall from a three foot high counter while being changed at the facility. A head computed tomography (CT) scan was done and the AV was diagnosed with a skull fracture and a 1.5 inch scalp hematoma. There was no intracranial hemorrhage (bleeding within the skull). The AV was admitted to the pediatric floor for overnight observation. Neurosurgery was consulted and it was determined that the AV did not require surgery. The next day the AV was discharged and prescribed acetaminophen every four hours as needed and was to follow-up with neurosurgery in one month. P3 provided the following information: · On October 18, 2022, P3 was “off the clock” at the end of his/her day in the infant classroom when the SP came out of the bathroom and said that the AV had fallen off of the changing table. P3 said the SP looked “really nervous” and was crying · P3 took the AV from the SP while the SP went to get P2. Initially the AV cried, but then calmed, seemed “fine,” and smiled at P3. P3 said the AV’s head was a little red, but P3 did not see any bruises. · P3 said that P2 notified the FM and then P1 came into the classroom. P1 provided the following information: · On October 18, 2022, approximately 2:30 p.m., P1 was not at the facility and received a call from P2 that the AV fell off the changing table. P1 immediately went to the facility to evaluate the AV. When P1 saw the AV, s/he seemed “good,” s/he was not crying, and his/her pupils were not dilated. · After seeing the AV, P1 called the F< and then the FM arrived “probably” 15 minutes later. · The SP told P1 that prior to the incident, s/he brought the AV into the bathroom and had gotten supplies ready, but forgot to grab the exam paper to lay the AV on. The SP then lay the AV on the changing table and bent down to grab the paper. When the SP stood up, the AV was on the floor in front of the SP. · P2 and the SP each told P1 that the AV cried, but not very much, had no obvious swelling, and was drinking regularly. P2 was in the preschool room when P2 hear the SP say that the AV rolled off the changing table. P2 went to see the AV and the AV was sitting with P3, smiling, laughing, and acting fine. There was a red mark that was starting to appear. P2 called P1 to come back to the facility as this was the “scariest thing ever.” The SP provided the following information: · The SP did not remember the date, but on a Tuesday in October 2022, s/he worked in the toddler classroom in the morning and the infant classroom in the afternoon. Sometime between 2-3 p.m., P3 was in the room, but “not on the clock,” when the SP took the AV into the bathroom to be changed · The SP realized s/he did not have a sheet of exam paper, so s/he lay the AV on the table while s/he bent over to get the paper, and the AV rolled off. The SP stated s/he did not keep his/her hand on the AV as was the policy. The AV was face up on the floor and was not crying. The SP picked up the AV right away and gave him/her to P3 and “yelled” to the preschool room for P2 to come over. . The SP said the AV was “acting normal.” · P2 told the SP to leave the room so s/he was not sure what steps were taken after that, but knew P1 and the FM came to the facility. The facility’s Diaper Changing Policy outlined that staff persons were to “gather necessary supplies so that they are easily accessible during diaper change and within reach” and were to “keep one hand on the child the entire time.” This policy was posted in the bathroom next to the changing table. The facility’s Risk Reduction Plan stated “to keep one hand on child at all times and never leave a child on the changing table.” The SP, P1, P2, and P3 were all trained on the facility’s Diaper Changing Policy, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. Conclusion: A. Maltreatment: Information was consistent that on October 18, 2022, sometime between 2-3 p.m., the SP took the AV into the bathroom to be changed. The SP bent down to get exam paper, taking his/her hands off the AV, at which point the AV rolled off the changing table falling approximately three feet onto the floor, sustaining a skull fracture and a hematoma. Given the AV’s age and that the SP did not keep a hand on the AV after placing the AV on the changing table which was approximately three feet high, the AV was at risk for a fall. 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 seriously endangered his/her physical health when reasonably able to do so. 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. 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. The SP was responsible for the care and supervision of the AV at the time of the incident and was trained on the Diaper Changing Policy, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. 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 neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious. It was a single incident and although the AV suffered a fractured skull, the AV was admitted overnight at the hospital solely for observation and did not receive medical treatment other than for diagnostic purposes. 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 and found their policies and procedures were adequate, but were not followed by the SP. The SP no longer worked at the facility. 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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