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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: 830172-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left the classroom and was unsupervised in the facility for six minutes. Date of Incident(s): April 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 May 10, 2023; from documentation at the facility; and through six interviews conducted with five facility staff persons (SP, P1, P2, P3, P4), and the AV’s family member (FM). Due to the AV’s age, s/he was unable to provide any information about the incident. The facility was a large building with eight classrooms along a long hallway. On left side of the hallway there were four classrooms; two infant classrooms followed by two toddler classrooms (Twos classroom and Toddler classroom). At the end of the hallway was the Pre-k classroom. An adjacent hallway went down from the Pre-K classroom to a door that exited to the fenced playground. The facility had several strollers and buggies that were stored in this hallway near the playground door. Each classroom had at least one window that looked out into the hallway. The Toddler classroom was a large open classroom with a changing station near the back of the room which faced the door. There were two windows that looked out into the hallway next to the door. The AV was 30 months at the time of the incident and enrolled in the Twos classroom. P1, P2, and P4 provided the following information: · On the date of the incident, P1 was in the toddler classroom with the SP. The number of children in the classroom had dropped to seven so P1 left to go assist with another classroom. A while later as P1 was taking children from another classroom to the gross motor room s/he noticed that the toddler door was ajar. · P1 peeked into the room and saw the SP changing a diaper and a parent stood next to the SP waiting for his/her child to be changed. P1 looked down and saw a child (C) holding the door open. P1 said something like, “We don’t hold the door open, it is not safe,” and closed the door. P1 turned back to the children that s/he was assisting. · P1 looked back into the classroom through the window and saw the SP trying to say something through the window. P1 opened the door and the SP said that s/he could not find the AV. P1 asked if the AV might be in the bathroom but the SP said, “No.” P1 said s/he would go look for the AV. · P1 walked down the hallway while keeping an eye on his/her children and saw the AV at the end of the adjacent hallway standing by a stroller. P1 looked into the Pre-K classroom and had P2 who was working in that classroom come to his/her door and watch the AV while P1 went to alert P4. P2 stood at the doorway of the Pre-K classroom and supervised the AV. · P1 walked down the hallway to the front entrance keeping an eye on his/her children and found P4 at the front desk talking to a parent. P1 was not able to get P4’s attention, so P1 went back and grabbed the AV and brought him/her back to the classroom. · P4 had no previous concerns with the SP. Although there was video footage of the incident, this investigator was not able to view the footage. P3 provided the following information about the footage: · On the date of the incident, sometime after 5 p.m., a parent came into the toddler classroom. The parent walked in and stood in the doorway for approximately one minute. It appeared the door to the classroom was resting on the parent’s back. The SP was at the diaper station changing a diaper. The parent went to the diaper station and talked with the SP while s/he finished changing the child’s diaper. · The parent talked with the SP for approximately three minutes and during this time, a child (C) pushed the door open and the AV walked out of the door. The parent then left the classroom with their child. The SP then went and got another child and took them to the changing station and started changing that child. At one point, the SP appeared to be looking around the classroom. · P3 was able to see P2 leave his/her classroom six to seven minutes after the AV left the classroom. The SP provided the following information: · The SP and P1 were in the toddler classroom on the date of the incident with 10 children. A number of the children had loose stools that day so there were a lot of diaper changes. At approximately 4:30 p.m. as some of the parents started picking up their children, the SP asked P1 to do diaper changes before they went down to one staff person for the evening. · P1 completed the diapers changes and shortly after left the classroom. Sometime around 5 p.m., the SP saw a child’s family member through the window, so s/he went to grab the child. The SP could smell that the child needed a diaper change so the SP brought the child to the changing table and changed the diaper as the family member came into the classroom. · The SP finished changing the child’s diaper and gave the child to his/her family member. The SP then noticed the classroom seemed too quiet and s/he looked around. The SP noticed the AV was not in the classroom. At that moment, another family member came in to pickup a child. That child also smelled like s/he needed a diaper change and so the SP flagged down P1 to tell him/her that the AV was missing. P1 went to look for the AV while the SP changed the child’s diaper. · Approximately 30 seconds later, P1 came back and said s/he had found the AV by the stroller area. P2 was keeping an eye on the AV until staff persons could bring him/her back to the classroom. P1 went and brought the AV back to the classroom. · Staff persons did a count of the children each hour and counted the children multiple times during transitions. The FM had no previous concerns with the facility or any staff persons. The Child Supervision Procedure indicated that children were supervised in the direct line of sight and within earshot of staff persons at all times. 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 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, stated that a child must have supervision at all times and that supervision was 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: Information was consistent that on the date of the incident, at approximately 5 p.m., a family member came into the classroom likely leaving the door ajar. The family member spoke with the SP while the SP changed a child’s diaper. At that time the C opened the door and the AV walked out the door and into the hallway. The family member left and the SP changed another diaper while interacting with another family member that came into the classroom. The SP noticed the AV was missing and alerted P1 who went down the hallway and found the AV playing near the stroller and buggies at the end of the adjacent hallway. The AV was unsupervised for approximately six to seven minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. 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 the SP was changing diapers for multiple children and interacting with famiy members during the time of the incident. The SP’s actions or conduct was determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, the SP was performing job related duties, as require by the facility’s policies; (2) The SP had not been determined responsible for any previous incident that resulted in a finding of maltreatment; (3) The SP had not 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, the SP was in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake to the VA by the SP 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 and procedures were adequate but not followed by staff persons. Staff persons were retrained on unplanned departures and classroom supervision. Action Taken by Department of Human Services, Office of Inspector General: The SP was not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which the SP was responsible met the criteria to be determined a nonmaltreatment mistake. The SP was notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which the SP was responsible might not be considered a nonmaltreatment mistake. On June 21, 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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