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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: 1104003-CCCC (Certified Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised in a facility bathroom and found by a staff person. Date of Incident(s): January 27, 2023 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 February 9, 2023; from documentation at the facility; and through five interviews conducted with four facility staff persons (SP1, SP2, SP3, P), and the AV’s family member. The AV was three years old at the time of the incident and enrolled in the preschool classroom. The facility was located inside an elementary school building. Through the main entrance to the left was a long hallway. Along the hallway were the facility classrooms including the AV’s classroom. Right in front of the main entrance was a bathroom, which had two large sinks on either side. Each side had a door through which was several bathroom stalls. To the right of the main entrance down the hallway was the cafeteria.
The P provided the following information: · When the classrooms used the bathroom, the staff persons lined the children up after they were finished on a silver line that ran on the floor right outside the bathroom. One staff person stood in front and counted the children from front to back while the other staff person stood in back and counted the children from back to front. Once the children had been counted, they walked to their destination. · At approximately 8:30 a.m. on the date of the incident, the P heard crying while s/he sat in his/her office. The P’s office shared a wall with the facility bathroom. The P went to the bathroom and found the AV in a stall. · The P cued the AV to unlock the door and come out of the stall. The AV needed assistance buttoning his/her pants. The P helped the AV wash his/her hands and then brought the AV to the cafeteria to join the rest of the classroom children who were eating breakfast. SP1, SP2, and SP3 provided the following information: · On the day of the incident, there was inclement weather and the facility had a two-hour late start. The typical staff persons in the AV’s classroom had not yet arrived at the facility as they lived further away. SP1, SP2, and SP3 started their day in the AV’s classroom. · There were 16 children in the classroom at the time of the incident and this number was documented on a white board in the classroom. When it was time for the class to use the bathroom and have breakfast, SP1, SP2, and SP3 lined the children up in the classroom and counted them. There was a bathroom in the classroom, but the AV’s class used the larger bathroom in the hallway for when the whole classroom used the bathroom to start to practice for the transition to the older classroom. They walked down to the bathroom and waited outside while the children went into the bathroom several at a time. When each child was finished, they washed their hands and got back in line in front of the bathroom on the silver line on the floor. · SP1 stood at the front of the line and counted the children. Some of the children were in and out of line so SP1 “may have miscounted.” SP1 said s/he asked a second staff person (likely SP2 or SP3 but SP1 did not specify who) to count the children but could not remember if s/he got confirmation from the staff person. · SP2 was at the end of the line leaving the classroom and was helping a child with his/her watch. The children went to the bathroom and were lining back up. The child still needed assistance with his/her watch. SP1 knew SP2 was waiting on that child and asked if the child was done. SP1 then started heading down the hallway to the cafeteria and SP2 did not get a head count. Typically, the classroom ate breakfast in their room but due to the late start, they were eating in the cafeteria on that day. · SP3 said that s/he was off to the side of the line during bathroom time. SP1 was at the front of the line and SP2 was next to SP3. Before the children were counted SP1 started to walk away so SP3 assumed SP1 had counted all the children. SP3 said s/he did not count the children when they were in the cafeteria because they were lined up and staff persons were watching them the entire time they walked down to the cafeteria. · Once the classroom arrived in the cafeteria, the children went through the cafeteria line and sat down with their breakfast trays at a table. SP1 thought s/he counted 17 children after sitting down in the cafeteria as another child arrived when the class was in the cafeteria. · After approximately 10 minutes, the P brought the AV to the cafeteria. SP1, SP2, and SP3 were not aware that the AV was not with the other children in the cafeteria.
The FM had no prior concerns with the facility. The P had no previous concerns with SP1, SP2, or SP3. The Risk Reduction Plan indicated that staff persons waited in the sink area to monitor both female and male restrooms. Head counts were required during all transition activities. Staff persons positioned themselves in front and behind the children to ensure an accurate head count. The counts were communicated verbally to all staff persons in the classroom. Facility documentation showed that all staff persons were trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245H.13, subdivision 10 states that staff must supervise each child at all times. Staff are responsible for the ongoing activity of each child, appropriate visual or auditory awareness, physical proximity, and knowledge of activity requirements and each child's needs. Staff must intervene when necessary to ensure a child's safety. In determining the appropriate level of supervision of a child, staff must consider: (1) the age of a child; (2) individual differences and abilities; (3) indoor and outdoor layout of the child care program; and (4) environmental circumstances, hazards, and risks. Conclusion: Information was consistent that on the date of the incident, there was a late start and SP1, SP2, and SP3 were each in a classroom that they did not normally work in. Although the classroom typically ate breakfast and used the bathroom in their room, due to the late start, the classroom used the larger bathroom outside of the classroom and then went to the cafeteria for breakfast. After using the bathrooms, the children lined up outside of the bathroom and walked down the hall to the cafeteria. The AV was left in the bathroom unsupervised for approximately 10 minutes, which was a violation of Minnesota Statutes, section 245H.13, subdivision 10. The P heard the VA crying through his/her office wall and went to get the AV and took him/her down to the cafeteria. SP1 said s/he counted the children before leading the children down the hallway and had the correct number. Although some of the children were in and out of line so s/he may have miscounted. SP1 told SP2 or SP3 to count as well but could not remember if s/he received confirmation of the count. SP2 said SP1 headed down the hallway before SP2 could get a head count of the children. SP3 said before the children were counted SP1 started to walk down the hallway so SP3 “assumed” SP1 had counted. Minnesota Statutes, section 260E. 30, subdivision 3 states that rather than making a determination of substantiated maltreatment by an individual, the commissioner of human services shall determine that a nonmaltreatment mistake was made by the individual. A nonmaltreatment mistake occurs when: (1) at the time of the incident, the individual was performing duties identified in the center's child care program plan; (2) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; (4) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; and (5) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing requirements relevant to the incident. Consistent information was provided that SP1, SP2, and SP3 were assisting multiple children using the restroom, cueing the children to line up, and supervising the children during the time of the incident. SP1, SP2, and SP3 did not normally work in the classroom but were there due to the late start. The late start also caused the routine to be different including that the children used the larger bathroom and went down to the cafeteria for breakfast. SP1, SP2’s, and SP3’s actions or conduct were determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, SP1, SP2, and SP3 were each performing job related duties, as require by the facility’s policies; (2) Neither SP1, SP2, nor SP3 had been determined responsible for any previous incident that resulted in a finding of maltreatment; (3) Neither SP1, SP2, nor SP3 had been determined to have committed a nonmaltreatment mistake under this paragraph; (4) The AV was uninjured and did not require medical care after the incident; and (5) Except for the period when the incident occurred, the facility, SP1, SP2, and SP3 were each in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake to the AV by SP1, SP2, and SP3 was not maltreatment. It was not 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.) Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility completed an internal review and determined that policies were adequate but not followed. All staff persons were retrained on the counting policies within the Risk Reduction Plan. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were not determined as perpetrators of maltreatment of the AV because the Department of Human Services found that the incident for which each was responsible met the criteria to be determined a nonmaltreatment mistake. SP1, SP2, and SP3 were each notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which each is responsible might not be considered a nonmaltreatment mistake. On March 10, 2023, the facility was issued a Correction Order for the violation outlined in this report. 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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