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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: 1093613-CCC (Child Care Center) Investigator(s): Kimberly Huettl Anderson Suspected Maltreatment Reported: It was reported that a staff person (SP) grabbed an alleged victim’s (AV) arm to redirect the AV causing a dislocated elbow. Date of Incident(s): March 31, 2022 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 May 13, 2022; from documentation at the facility; and through four interviews conducted with the AV’s family member (FM), and facility staff persons. Attempts to were made to contact and interview the SP via telephone and US mail, but the SP did not respond to the request. The AV’s New Student Checklist stated that the AV was two years old at the time of the incident. The AV was enrolled in one of the facilities preschool classrooms. The AV’s family member (FM) stated that on March 31, 2022, at approximately 3 pm., s/he received a telephone call from a facility management person (P1) stating that “something” was wrong with the AV’s arm. The FM arrived at the facility a short time later and spoke directly with P1. At that time, P1 stated that s/he had reviewed the facility’s video surveillance and saw the SP “pull” the AV arm. Later that evening, the FM took the AV to a local medical center where the AV was diagnosed with a left elbow dislocation. Facility documentation and interviews with staff persons provided the following information: · Facility documentation, including the facility’s Ouch Report, stated that on March 31, 2022, the AV was playing with other children, the SP grabbed the AV’s arm and pulled him/her until the AV began crying and stating that his/her arm hurt. · Approximately one hour after the incident, a staff person (P2) informed P1 that the AV might be hurt because the AV was crying “a lot.” P1 asked the SP about the AV, and the SP stated that s/he thought the AV hurt him/herself while playing with his/her friends. Later that day, P1 reviewed the facility’s video surveillance and observed the SP “aggressively” pulling the AV’s arm when the AV was running away from the SP. P1 contacted the FM and explained the incident. · After P1 reviewed the video, s/he spoke to the SP again. At that time, the SP did not have an explanation for the incident, but stated that s/he “might be” the reason that the AV was hurt. At that time, the SP turned in his/her resignation and left the facility. · On April 1, 2022, the FM told P1 that the AV had been to the doctor the night before and that the AV sustained a dislocated elbow as a result of the SP’s actions. · Prior to the incident, P1 had concerns regarding the SP’s tone of voice with the children, but no concerns regarding his/her physical interactions with the children. · P2 told this investigator that s/he was in the classroom at the time of the incident, and s/he heard the AV start to cry, but did not see the interaction between the SP and the AV. However, P2 stated that the SP was “a little upset” with the AV because the AV was not listening at the time of the incident. · Video surveillance of the incident showed that the SP entered the camera view holding the AV’s left arm and the AV was pulling away from the SP. Then the AV dropped to his/her knees as the SP continued to hold and pull the AV’s left arm to lift the AV off the floor and to his/her feet. The SP held on to the AV’s left arm and walked approximately five steps holding the AV’s left arm in the air before stopping and releasing the AV’s arm. The facility’s Risk Assessment and Reduction Plan stated all staff persons were trained with on proper handling of children with an emphasis on the prevention of dislocated elbows. The facility’s personnel files showed that P1, P2, and the SP were each trained on the facility’s Risk Assessment and Reduction Plan and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0055, subdivision 3, item A, states that the license holder must have and enforce a policy that prohibits the subjection of a child to corporal punishment. Corporal punishment includes, but is not limited to rough handling, shoving, hair pulling, ear pulling, shaking, slapping, kicking, biting, pinching, hitting, and spanking. Conclusion: A. Maltreatment: On March 31, 2022, video surveillance showed the SP holding the AV’s left arm, the AV pulled away from the SP, dropped to his/her knees, and the SP pulled the AV’s left arm to lift the AV off the floor. The AV sustained a dislocation of his/her left elbow. Given that the SP’s actions of pulling the AV’s arm to lift him/her off the floor was inconsistent with the standards of a professional caregiver licensed by the Department of Human Services and a violation of Minnesota Rules, chapter 9503.0055, subdivision 3, item A; that there was no information provided that the AV was a danger to him/herself or others and therefore did not require physical intervention; that grabbing, pulling, and moving a child by their arm was not accidental; and that the AV sustained an injury as a result of the SP’s actions, there was a preponderance of the evidence that the SP’s action were not accidental and caused injury to the AV. It was determined that 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. The SP was responsible for the care of the AV at the time of the incident and was trained on the facility’s Risk Assessment and Reduction Plan and the Reporting of Maltreatment of Minors Act 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” because this was a single incident but was “serious” because the AV sustained a serious injury, dislocation of his/her elbow. 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 conducted an internal review and determined that their policies and procedures were adequate and followed at the time of the incident. Additional training to staff persons was provided on a continuous basis, but all staff persons were reminded of the facility behavioral guidance policy. The SP no longer worked at the facility. 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. On April 19, 2023, the facility was issued a Correction Order for the violation outlined in this report and for failing to report maltreatment as required. 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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