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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: 1054231-CCC (Child Care Center) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: It was reported that a staff person (SP) incorrectly strapped an alleged victim (AV) into a highchair. The AV then fell out of the highchair and hit his/her head on the floor. Date of Incident(s): April 24, 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 medical records; and through four interviews conducted with a facility staff person (P1), an administrative staff person (P2), the SP, and the AV’s family member (FM). The AV was eleven months old and enrolled in the infant classroom at the facility. The infant classroom was a large square room with carpet on one half and a tile floor on the other half. Two tables and chairs were set up on the tiled floor. At the time of the incident, there was a highchair near the tables in the classroom that had a removable tray that snapped into place and safety straps that held a child in the chair. The high chair was an Ikea Antilop high chair with a bucket seat approximately 21 inches from the floor and had a depth of approximately eight and a half inches. A tray was approximately 28 inches above the floor and when the tray was removed, there were edges around the chair that were not removeable that were also approximately 28 inches from the floor. The FM stated that after the incident, s/he took the AV to be seen by a physician, who told the FM to watch the AV for signs of concussion. No additional care was needed for the AV. P1, P2, the SP, and the facility’s documentation provided the following information: · The AV was transitioning into the older infant classroom from the young infant classroom. After lunch, the children had naptime. P1 washed the dishes and the SP mopped the floor. At approximately 1 p.m., the AV woke, so P1 asked the SP to prepare the AV’s bottle since the AV was probably hungry. The SP went to the young infant classroom and brought the AV’s bottle and bottle warmer back to the older infant classroom. · The SP put the bottle in the bottle warmer and then took the AV out of his/her crib and sat him/her in the highchair. The SP did not fasten the safety strap around the AV’s waist. The SP then placed the tray on the highchair and turned around and walked five or six steps to reach for the bottle. The SP and P1 each heard the tray fall to the floor and then the AV began to cry. The SP said that when s/he heard the noise and turned to look at the AV, the AV was lying on the floor near the tray. · The SP picked up the AV and the SP and P1 each checked the AV for injuries. The AV had a small bump on his/her forehead so they placed an ice pack on the AV’s forehead. The SP stated that the AV also had a small cut on his/her tongue. P1 then told P2 about the incident and P2 telephoned the FM, who arrived at the facility a short time later and took the AV to see a physician. · Consistent information was provided that the staff persons in the classroom rarely used the highchair and the children typically sat in chairs at the table. The SP stated that s/he did not have the AV sit at the table that day because s/he woke up crying, all of the other children were napping, and the tables were put away after lunch. P1 stated that s/he usually reminded the staff persons to use the strap on the highchair when they placed a child in the highchair. P1 stated that it was necessary to push the tray “down hard” to ensure that it was locked in place. A sound machine was running while the children napped so neither the SP nor P1 was certain whether the tray “clicked” into place. There were no previous incidents involving a child falling from the highchair. After the incident, the facility replaced the highchair. · The SP stated that s/he did not usually use the strap because it was “rare” that the highchair was used because children typically sat in chairs at the table. Three to four days prior to the incident, the SP was told that s/he needed to use the strap for children who sat in the high chair, but she “didn’t even think” to do so on the day of the incident because s/he was “literally just grabbing the bottle, so didn’t even think.” According to the hospital’s Pediatric Clinic Notes, on April 24, 2023, the AV was seen by a physician, who documented that the AV had a circular contusion on his/her right forehead that measured approximately three centimeters across. The area was “mildly swollen.” The AV did not sustain any loss of consciousness. The physician provided the FM with symptoms of possible complications to watch for. According to the facility’s Employee Handbook, all of the children were to be supervised at all times and the staff persons must be able to see and hear infants and toddlers at all times. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies at the time of the incident.
Conclusion: On April 24, 2023, the SP and P1 worked in the older infant classroom with eight children. At approximately 1 p.m., the AV woke in his/her crib so P1 asked the SP to prepare the AV’s bottle since the AV was probably hungry. The SP put the AV’s bottle in the bottle warmer and then took the AV out of his/her crib and sat him/her in the highchair. The SP did not fasten the safety strap around the AV’s waist but placed the tray on the highchair and turned around and walked five or six steps to reach for the bottle. The SP and P1 each heard the tray fall to the floor and then the AV began to cry. When the SP turned to the AV, the AV was on the floor crying. The AV sustained a small bump on his/her forehead during the fall. The AV was seen by his/her physician, but did not require any medical care. Minnesota Statutes 260E.30, subdivision 3, states that rather than making a determination of substantiated maltreatment by the 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 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 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. Although the SP failed to secure the safety strap on the AV or ensure the tray was snapped onto the highchair completely causing the AV to fall out of the highchair, the SP’s actions or conduct were determined to be a nonmaltreatment mistake for the following reasons: · At the time of the incident, the SP was performing job-related duties as required by the child care program plan including preparing a bottle for the AV; · The SP had not been determined responsible for any incident that resulted in a finding of maltreatment; · The SP had not been determined to have committed a nonmaltreatment mistake under this paragraph; · The AV sustained no injury during the incident; and · Except for the period when the incident occurred, the facility and the SP were in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake by the SP to the AV 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 the facility’s policies were adequate, but were not followed by the staff person. All of the staff persons were retrained on using the highchairs and ensuring that the children were strapped in the highchairs. After the incident, the highchairs in the facility were replaced with new highchairs. 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 is responsible might not be considered a nonmaltreatment mistake. 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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