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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: 1002181-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was in a locked office without staff persons (SP1 and SP2) supervision or knowledge. Date of Incident(s): April 4, 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 April 21, 2023; from documentation at the facility; and through five interviews conducted with a supervisory staff person (P1), three facility staff persons (SP1, SP2, and P2), and the AV’s family member (FM). When entering the facility, there was a small entryway and then an infant classroom was on the left and a toddler classroom on the right. There was a short hallway that opened up to a common area where there were two tables for activities and eating. There were two preschool rooms to the right and a kitchen to the left. There was a laundry room off of the common area behind the infant classroom. Outside of the laundry room door there were paper “construction zone cones” taped to the floor for children to sit on as a visual que while getting ready to transition back to the classroom. Past the common area was a short hallway to the outside and an office was on the left side of that hallway. The office door locked automatically when shut. The AV was 19 months old at the time of the incident and enrolled in the toddler classroom. Due to his/her age, the AV was not able to provide information for this investigation. P1, P2, SP1, and SP2 provided consistent information that SP1 and SP2 were working in the toddler classroom that day while P1 and P2 were at the facility in other roles and assisted SP1 and SP2 with the children in the common area as they began the transition of heading back to the toddler classroom on the day of the incident. P1 said s/he was out in the common area helping get the children organized sitting down on the cones while SP1 and SP2 were cleaning up the tables after a craft activity. P1 stated that the AV was with him/her at the cones. SP1 started walking towards the toddler classroom with the children while SP2 finished cleaning up and then SP2 followed after SP1 and the children so P1 left the area. P1 then walked to the infant room, the toddler room, and the two preschool rooms to grab some papers and lastly went to the office and noticed it was locked. P1 looked inside to see if the keys were in there when s/he saw the AV, through a window in the door, standing in the office behind a plastic basketball hoop. P1 saw P2 and asked P2 to stand at the door and watch the AV while P1 left the facility and went two office doors down to grab an extra set of keys from another staff person. P1 stopped at the toddler classroom on the way out to let SP1 and SP2 know that the AV was in the office. P1 stated it took him/her about a minute to run and grab the keys. When P1 returned and unlocked the office, s/he checked the AV over to see if there were any injuries and did not see anything. The AV was not crying. P1 was not sure when the AV went into the office and shut the door. P1 said a headcount should be done before walking to the classroom. P2 said the children had been out painting in the common area and it was very “chaotic” as some of the children were upset. P1 and P2 were in the common area trying to help calm the children as they began their transition back to the classroom. The toddler class lined up and walked back to the toddler classroom, and as SP1 started counting the children as they went into the toddler classroom, a couple of children were pushing and shoving so SP1 tried to break it up. P1 and P2 went back to what they were doing in other areas of the facility. Soon after, P1 asked P2 to come to the office to watch the AV as s/he had locked him/herself inside while P1 ran to grab the extra set of keys. P2 said s/he waved at the AV to keep his/her attention on P2. P2 said the AV stood in one spot laughing and fidgeting with his/her hands. After about two minutes P1 came back, unlocked the door, talked to the AV, and brought him/her back to the toddler classroom. P2 said they should be counting “as they go.” SP2 stated that the toddler class was in the common area cleaning up and getting ready to go back to the toddler classroom. P1 and SP1 were with the children on the cones on the floor trying to get the children lined up. SP1 started to walk the children back to the toddler classroom and P1 went to another classroom. SP2 went to throw the smocks from the activity in the laundry room. SP2 heard SP1 counting the kids when SP1 called for him/her for help. Two children were at the front door pushing on the handle and not coming into the toddler classroom. SP2 went and stood at the toddler classroom door while SP1 went and got the two children at the front door and brought them back to the classroom. SP2 went back to start the laundry and then returned to the classroom. It was a couple seconds after SP2 returned to the toddler classroom that P1 opened the door to say that the AV was in the office and the door was locked. SP2 said it was normal to count the children before we bring them back to the classroom. SP1 said the toddler class was doing an art project in the common area and was getting cleaned up and had lined up against the wall on the cones when kids started running around. SP1 said that P1 and P2 were out there helping sing songs. SP1 started to walk the children back to the toddler classroom and was counting the children as they went into the toddler classroom. SP2 was finishing cleaning a table when two children from the line went towards the front door. SP1 had SP2 stand in the toddler classroom while SP1 went to get the two children by the door. SP1 said s/he just started to count the children when P1 came in to say that the AV was in the office. SP1 thought it was about two minutes. The AV came back into the classroom and was acting like his/her normal self. SP1 called the FM to let him/her know what had happened. SP1 did not count the children as they were lined up on the cones that day, but that was his/her normal procedure to then count the children when entering the classroom. The FM was told by SP1 what had happened and P1 followed up letting the FM know that the AV was happy and smiling. The FM stated that the AV liked to close doors at home as well and was glad that staff persons noticed it and told the FM. The AV enjoyed it at the facility. The facility’s Risk Reduction Plan stated that staff persons “will be aware of the children in their care at all times during a transition.” Facility records showed that P1, P2, SP1, and SP2 were trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Licensing Rules and Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states 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: On April 4, 2023, the toddler class was preparing to transition back to their classroom from the common area. It was busy time, and some children were shoving, pushing, and running. SP1 led the children back to the toddler classroom and started counting the children as they entered the classroom. SP2 was cleaning up the common area. Two children started to go towards the front door, so SP1 had SP2 watch the children already in the toddler classroom. At some point, the AV went into the office and shut the door. SP1 got the two children back into the classroom and SP2 went to throw laundry in. SP1 began counting the children as SP2 returned to the toddler classroom. P1 came in shortly after and told SP1 and SP2 that the AV was in the office unsupervised, and it was locked. This was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. P1 had P2 watch the AV while P1 went to retrieve keys from a staff person working in another office space two doors down. P2 said the AV just stood there and fidgeted with his/her hands. When P1 returned, s/he unlocked the office, checked the AV, and saw the AV had no injuries. P1 thought it was about one minute from when the children headed back to the toddler classroom to when s/he went to enter the office and found it was locked with the AV inside. P1 then had P2 watch the AV and it took about two minutes for P1 to run to the other office building to get an extra set of keys, return, and unlock the office door. Minnesota Statues 260E.30, subdivision 3, paragraph (b), clause (1-5) states that a “non-maltreatment mistake” occurs when: (1) At the time of the incident, the individual was performing duties identified in the center’s child care program plan required under Minnesota Rules, part 9503.0045; (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 non-maltreatment 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. Regarding SP2: Although the AV was unsupervised for an unknown length of time without staff persons’ knowledge and when the AV was found, s/he was in a locked office and staff persons were not able to intervene if necessary, SP2’s actions and conduct were determined to be a non-maltreatment mistake for the following reasons: (1) At the time of the incident, SP2 was performing job related duties, as required by the facility’s policies; (2) SP2 had not been determined responsible for a previous incident that resulted in a finding of maltreatment; (3) SP2 had not been determined to have committed a non-maltreatment mistake under this paragraph; (4) There were no injuries to the AV as a result of this incident; and (5) Except for the period when the incident occurred, the facility and SP2 were in compliance with all licensing requirements relevant to the incident. The non-maltreatment mistake to the AV by SP2 was not maltreatment. Regarding SP1: A. Maltreatment Although SP1 was performing job related duties at the time of the incident, the AV was not injured, and the facility and SP1 were in compliance with all licensing requirements relevant to the incident, SP1 had been determined responsible for a similar incident that resulted in a finding of a non-maltreatment mistake. Therefore, SP1 was not able to be considered under a non-maltreatment mistake for this report. Given that the AV was unsupervised without staff persons’ knowledge, and when the AV was found, s/he was in a locked office and staff persons were not able to intervene if necessary, 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 or mental 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. 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 trained on the facility’s Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. SP1 and SP2 were both responsible for the AV’s supervision because it was unknown when the AV left; when in the classroom or when in line to enter the classroom. However, given that SP2’s conduct met the requirements for a non-maltreatment mistake, SP2 was not responsible for maltreatment of the AV. SP1 did not meet the requirements for a non-maltreatment mistake, therefore SP1 was responsible for the 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 SP1 was responsible in this report was not serious or recurring maltreatment because it was a single incident and the AV did not sustain an injury.
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 found their policies and procedures adequate but not followed by SP1. SP1 no longer worked at the facility. The facility added to the Risk Reduction that “headcounts will be made before, during, and after transition times” and “if a count is interrupted, the staff person will restart.” Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. SP2 was not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which SP2 was responsible met the criteria to be determined a nonmaltreatment mistake. SP2 was notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP2 is responsible might not be considered a non-maltreatment mistake. On June 2, 2023, the facility was issued a Correction Order for the violation outlined in this report and for failure to comply with background study requirements. 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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