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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: 1066817-CCC (Child Care Center) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised for several minutes in the facility’s bathroom by two staff persons (SP1 and SP2). Date of Incident(s): May 11, 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 25, 2023; from documentation at the facility; and through six interviews conducted with two facility staff persons (P1 and P2), an administrative staff person (P3), SP1, SP2, and the AV’s family member (FM). The AV was 17 months old and enrolled in the toddler classroom at the time of the incident. The AV’s classroom was located at the intersection of two of the facility’s hallways. One hallway led to the main entryway, where a desk for administrative staff persons was located. The second hallway led to other classrooms and the children’s bathroom, which was several feet from the door to the AV’s classroom. The bathroom area did not have a door, but had an outer area where a sink was located and then areas to the left and to the right that each contained two enclosed toilet stalls with doors. Consistent information was provided that all of the doors leading outside of the facility were locked and/or had door alarms that sounded when the door was opened. P1, P2, P3, SP1, SP2, and the facility’s documentation provided the following information: · On May 11, 2023, SP1, SP2, and P1 worked in the toddler classroom. Information regarding how many children were in attendance at the time of the incident varied: SP1 stated they had 12-13 children, SP2 stated that had 14 or 15 children, P1 could not recall how many children but typically they had two staff for 14 children and there were three staff at the time, and P3 could not recall how many children were in attendance but later looked at the attendance sheet and stated there were 14 children. At approximately 9:10 a.m., P1 remained in the classroom to change a child’s diaper while SP1 and SP2 took the remaining children, including the AV, to the bathroom. SP1 stated that after the children used the bathroom and washed their hands, they had the children sit in a line against the wall. SP1 then did a “head count” before they had the children walk back to the classroom and saw the AV sitting at the wallSP1 stated that the AV was with the group when s/he counted the children prior to returning to the classroom. SP1 followed the line of children into the classroom. SP1 stated that s/he usually counted the children again as they entered the classroom, but did not do so that day because s/he was at the end of the line. SP2 believed that one of the other staff persons counted the children when they returned to the classroom, but did not know which staff person and SP2 did not count the children him/herself. P1 stated that s/he did not count the children when they returned to the classroom because s/he believed SP1 or SP2 counted the children. · SP1 stated that once they were back in the classroom, s/he made sure “everything was settled” and s/he left the classroom to go to the office, leaving SP2 and P1 in the classroom with the children. SP1 stated that s/he shut the classroom door when s/he left the classroom. None of the staff persons heard or saw the door to the classroom open after SP1 left the classroom. · At approximately 9:25 a.m., a family member of a preschool child was dropping off his/her child and was walking down the hall when s/he heard the AV playing in the bathroom. The family member told P2, who went to the bathroom and found the AV alone in the bathroom crying and playing in one of the toilets. The AV’s clothing was wet. P2 returned the AV to his/her classroom and told the staff persons in the classroom that s/he found the AV unsupervised in the bathroom. SP2 believed that P2 returned the AV to the classroom within “maybe four or five minutes” of when the other children returned to the classroom. None of the staff persons in the AV’s classroom realized the AV was not in the classroom until P2 brought the AV into the classroom. · P2 then told P3 about the incident and P3 then talked to SP1, SP2, and P1 about what occurred and each provided information that was consistent with the information each provided to this investigator. After talking to the staff persons, P3 telephoned the FM and told him/her about the incident. · P1, SP1, and SP2 each thought differently regarding how the AV was in the bathroom unsupervised. P1 stated that s/he remained in the classroom changing a child’s diapers while SP1 and SP2 took the other children to the bathroom and believed the AV left the group prior to when they returned to the classroom. SP1 stated that after s/he, SP2, and the children returned to the classroom after using the bathroom, SP1 went to the office to make copies. SP1 was in the office for approximately 10 minutes. Shortly after s/he returned to the classroom, P2 brought the AV into the classroom after finding the AV in the bathroom. SP1 believed the AV left the classroom after SP1 went to the office.SP2 stated that all three staff persons took the children to the bathroom that day and s/he believed that the AV “slipped past” the staff persons as they returned to the classroom. P1 stated that it typically took ten minutes for all of the children to use the bathroom. · SP1 stated that prior to the incident, the AV had not previously attempted to open the classroom door, but that most of the children could reach the door handle. SP1 had not seen any of the children open the door. Neither SP2 nor P1 saw the AV open the door and leave the classroom. SP2 stated that the staff persons always checked the bathroom stalls before returning to the classroom with the children. · After the incident, the staff persons ensured that a gate was placed in the doorway so that even if a child opened the classroom door, s/he would be unable to get past the gate. The FM stated that the facility did not notify him/her about the incident until “hours” after the incident occurred. The FM believed the staff persons need more training. According to the facility’s Risk Reduction Plan, the staff persons were to supervise the children while they were in the bathroom. The staff persons were to ensure that no child was ever left without supervision. The staff persons were to conduct head counts after each transition from one area to another. All doors leading outside of the facility were locked or had an alarm that sounded when the door was opened. According to the facility’s Supervision Policy, all children were to be supervised at all times while at the facility, including in the classrooms, gym, playgrounds, hallways, and bathrooms, and were to be within sight and hearing of all children at all times. Facility documentation showed that P1, P2, P3, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies 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, state that “supervision” means 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; and that children are required to be supervised at all times. Conclusion: A. Maltreatment: On May 11, 2023, at approximately 9:25 a.m. a family member of another child at the facility discovered the AV unsupervised in the bathroom which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart1, item A; and inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. SP1, SP2, and P1 worked in the toddler classroom. At approximately 9:10 a.m., it was unknown exactly how many children were in the classroom but between 12 and 15. P1 remained in the classroom to change a child’s diaper while SP1 and SP2 took the other children to the bathroom. After the children used the bathroom, the children lined up in the hallway and SP1 did a “head count” of the children. At that time, the AV was sitting against the wall. SP1 and SP2 then took the children into the classroom but neither counted the children upon their return to the classroom. Shortly after, SP1 went to the office for several minutes. After SP1 returned to the classroom, P2 brought the AV into the classroom and told the staff persons that s/he found the AV unsupervised in the bathroom. The AV was unsupervised for between five and fifteen minutes. Although SP1 believed the AV left the classroom while SP1 was in the office, given that SP2 and P1 each did not see or hear the door open, it was more likely than not that the AV left the group while in the hallway prior to returning to the classroom. None of the staff persons were aware that the AV was not in the classroom until P2 brought the AV to the classroom after s/he was discovered in the bathroom by the family member. The AV, who was 17 months old, was unsupervised for up to 15 minutes in the facility’s bathroom and was found playing in a toilet, which exposed the AV, to danger. Therefore, 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 the AV’s physical or mental health when reasonably able to do so. 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 and/or 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. Facility documentation showed that P1, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. P1’s responsibility for the incident was mitigated because it was determined that it was more likely than not that the AV left the group while in the hallway prior to returning to the classroom and P1 was in the classroom while SP1 and SP2 took the children, including the AV, to the bathroom. SP1 and SP2 were each responsible for the care and supervision of the AV when the group went to the bathroom and returned to the classroom. SP1 and SP2 were 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 and SP2 were each responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not sustain an injury that required the care of a physician. 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 completed an internal review and determined that the facility’s policies were adequate, but was not followed by the staff persons. After the incident, all of the staff persons were retrained on the facility’s policies. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each 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 disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal. On August 4, 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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