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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: 800379-CCC (Child Care Center) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that a staff person (SP1) interacted with children, including alleged victims (AV1-AV5), in a manner that was “aggressive,” “forceful,” and/or “hurt.” It was also reported that a staff person (SP2) failed to adequately intervene with SP1’s conduct in a manner necessary to protect children, including AV1-AV5. Date of Incident(s): Ongoing between March 29 and May 24, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); subdivision 18, paragraph (a); and subdivision 23, paragraph (a): 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. "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 June 7, 2023; from documentation at the facility; and through ten interviews conducted with AV1’s-AV4’s family members (FM1-FM4, respectively), facility staff persons (P1, P2, and SP1), and supervisory staff persons (SP2, P4, and P5). AV1-AV5 were not interviewed due to their ages. Attempts via telephone to contact and interview AV5’s family member (FM5) and a staff person (P3) were not answered by the completion of this investigation. P3 provided information to the facility regarding the allegations and that was included in this report. At the time of the incidents, AV1-AV5 were each between 18 and 31 months old and enrolled in the facility’s toddler classroom. The facility provided childcare services to children, infant to preschool. The facility’s policies and procedures, including Behavior Guidance, included the following: · The facility did not allow the use of physical punishment or emotional abuse by staff. Prohibited actions included: rough handling, shoving, hitting, spanking, shaking, and/or using language that threatens, humiliates, or frightens a child. · “Child Garden has an open-door policy and suggests employees share their questions, concerns, suggestions or complaints with someone who can address them properly. In most cases, an employee's supervisor is the best person to address an area of concern. However, if an employee is not comfortable speaking with his/her/their supervisor or is not satisfied with the supervisor's response, the employee is encouraged to speak with the Director. If the employee believes the issue is not resolved, they may contact the President. Managers are required to report suspected violations of local, state or federal law, or Child Garden's policies to Child Garden's President, who is responsible for investigating all reported violations.” · “If you work in a licensed facility, you are a ‘mandated reporter’ and are legally required (mandated) to report maltreatment. You cannot shift the responsibility of reporting to your supervisor or to anyone else at your licensed facility … Mandated reporters must make a report to [the Department of Human Services] immediately (as soon as possible but no longer than 24 hours).” P1, P2, and P4, and facility documentation provided the following information: · Consistent information was provided that on or shortly after March 29, 2023, SP2 asked SP1 to switch classrooms and fill an open position in the toddler classroom. The open position was responsible for overseeing the classroom management and held a greater responsibility than the other staff in the classroom. SP1 agreed to the change and began working in the toddler classroom with P1 and P3. This was a “temporary” change until a permanent replacement for the open position was hired. [Note: Just prior to this change, SP1 had been working in the infant classroom in a position that was not responsible for overseeing classroom management.] · P4 said that when s/he learned that SP2 asked SP1 to fill the open position in the toddler classroom, s/he was concerned and expressed his/her concerns to SP2 more than once. “[It] was warned against.” P4 explained that SP1 had previously been in a position, overseeing classroom management, in a different classroom and had previously stepped down from that position due to struggling with the responsibilities. The position had been “stressful” to SP1. SP1 had previously struggled with communication with children and “getting a handle on” the children. SP1’s communication with the children had been described as “disrespectful.” SP1’s previous conduct also reportedly included unsanitary practices like not immediately throwing soiled diapers away and unsafe conditions like leaving items, like a toilet plunger, accessible to children. P4 did not believe SP1 was “qualified” to fill the open position in the toddler classroom. · P1 said that when s/he learned that SP1 was filling the open position in the toddler classroom, s/he talked to SP2. “I didn’t want [SP1] in there. [S/he] was not a good fit.” P1 was familiar with SP1 and was aware of how s/he had struggled with the responsibility of this position previously. · P4 said that SP2’s position at the facility included overseeing facility management. “[SP2] made all the decisions … [SP2] was the final call … It was out of our hands.” SP2 did not listen to P4’s or P1’s concerns about SP1 and continued to have SP1 fill the open position in the toddler classroom. [Note: P4’s responsibilities at the facility included supporting the overall operation. P4 was not a supervisory staff person and had no responsibility overseeing the management of staff.] · P1 said that as soon as SP1 started in the toddler classroom, “almost immediately,” P1 had concerns. SP1 was preoccupied with his/her personal cellphone during times when s/he was supposed to watch the children. SP1 left soiled diapers around the classroom and left urine or feces unflushed in the children’s toilets. · P1 began reporting his/her concerns to SP2 on a “weekly” basis. SP2 responded to P1 by “brushing it off.” SP2 told P1 that they needed to “communicate and work as a team.” SP2 also reminded that SP1’s placement in the classroom was “temporary” until the position was permanently hired. P1 explained, “[SP2] didn’t address the issue and wasn’t concerned at all.” One time, SP2 told P1, “Bite your tongue,” regarding his/her concerns with SP1’s conduct. · Facility documentation included a screenshot of an email from P3 to SP2, dated April 30, 2023, included the following: Over the past month I have noticed [conduct of SP1] that you should be aware of. I started recording them this past week as these are things I do not feel comfortable with correcting …. 4/24 [P1] was left alone with 10 children on the playground for 20 minutes while [SP1] said [s/he] was using the bathroom 4/25 [SP1] was aggressively and forcefully “patting” [AV2’s] and [AV1’s] backs to the point of them crying and [AV1] begging [him/her] to stop at this point I offered to take over 4/27 Pee left in the potty … Every day while I do the after-nap bathroom shift [SP1] sits by the kids on [his/her] phone instead of watching them. Younger new kids to the class are wandering down the hall or out the open door and coworkers are walking by asking whose cell phone is laying on the ground. Disappearing throughout the day under the guise of work or personal matters, increased aggression and decreased patience with the children, laziness around modeling and maintaining a clean environment and sitting on their phone are not attributes I look for in [SP1] or any coworker I am supposed to be learning from. · P3 forwarded this same email to P4 on May 1, 2023, and said, “I emailed [SP2] yesterday regarding my concerns and wanted to send it to you as well to ensure all bases are covered!” On May 2, 2023, SP2 responded to P3’s original email by saying, “THANK YOU.” (Emphasis in original.) · P4 said s/he had not previously been made aware of the staffs’ concerns until they started forwarding or copying him/her on their emails to SP2. P4 said that s/he met with SP2 more than once regarding what was being done, and each time, SP2 responded that s/he was “handling it.” [Note: There was no documentation in SP1’s personnel record regarding the incidents reported on April 30, 2023, and/or corrective action.] · Facility documentation included a screenshot of an email from P1 to SP2 and P4, dated May 8, 2023, which included the following: The following is a continuation of notes over the last week or so. 5/1 [SP1] left poop covered underwear sitting out on top of the trash can in the bathroom 5/2 [SP1] yanked [a child] out of [his/her] chair and shoved [him/her] into [a corner] because [s/he] was playing with [his/her] spoon before food was served 5/5 [A child] woke up from nap with poop stains on [his/her] underwear. [SP1] said [the child] wipes on [his/her] own. I also encourage most of the kids to wipe on their own, but always do a final wipe before sending them on their way. 5/8 Ripped [AV3’s] cup out of [his/her] hands, yanked [him/her] out of [his/her] chair and shoved [him/her] away from the table because [AV3] was holding [his/her] cup after [SP1] had asked [him/her] not to … 5/8 Toilets were left with pee in them after lunchtime bathrooming I’ve approached [SP1] several times to have conversations about bathrooming and cleanliness, and there hasn’t been much, if any, improvement … Pulling children out of their chairs and shoving them away is not acceptable … I know there are so many different and more appropriate ways to handle these situations …. · P4 said that following the email from P1 on May 8, 2023, s/he met with SP2. During this meeting, SP2 “got defensive” and said that staff were “just bitching” about SP1. P4 told SP2 that s/he needed to take the concerns “seriously” and do something about it. According to P4, SP2 abruptly left the room during this conversation and “slammed” the door behind him/her. [Note: There was no documentation in SP1’s personnel record regarding the incidents reported on May 8, 2023, and/or corrective action.] · P4 began checking-in with SP2 on a weekly basis. P4 repeatedly asked, “Are you having a meeting with [SP1]?” and each time, SP2 responded, “Of course I am.” · On May 10, 2023, P1, P3, SP1, and SP2 had a meeting to discuss the classroom concerns. During this meeting, P1 heard SP1 remind SP2 that s/he had previously stepped down from a similar position in a different classroom because s/he “wasn’t safe around the children.” P1 believed that if SP1 had previously said this SP2, then SP2 should not have put SP1 back in the same position in the toddler classroom. “Everyone was aware of this capability that [SP1] wasn’t able to do this job without the possibility of harming someone.” · P1 and P2 each said that on May 24, 2023, they were in the toddler classroom with SP1 and were helping children settle on their individual cots for naptime. AV1 was refusing to lie down. P1 and P2 each saw SP1 grab AV1’s arm and leg and “flip” AV1 over so that s/he was on his/her stomach on his/her cot. SP1 started patting AV1’s back “aggressively.” SP1 then picked AV1 up and shook him/her, up and down. It all happened “very fast.” AV1 was crying and saying, “You’re hurting me. You’re hurting me;” and SP1 responded, “You’re hurting yourself by moving.” · P1 and P2 approached SP1 and stopped his/her interaction with AV1. They told SP1 that s/he should leave on break and that P2 would take over the care of AV1. SP1 agreed and left the room. AV1 continued to cry but soon stopped and fell asleep on his/her cot. AV1 did not sustain an injury. · At some point after naptime, P1 and P2 went to SP2’s office to report what they witnessed. P1 asked SP2 about their reporting requirements per the Reporting of Maltreatment of Minors Act, and SP2 told them, “You don’t report. I will do it. You don’t have to talk to anybody.” · P2 said, “We said [to SP2] we were going to report it and [SP2] told us not to because that was [SP2’s] job.” · P2 had not worked with SP1 prior to or after May 24, 2023, and this was their first and only shift working together. P2 said, regarding SP1’s conduct toward AV1 on that day, “You could hear the thud of [SP1] smacking [AV1’s] back. You could tell it was not a gentle pat.” P2 believed that s/he needed to intervene because “[SP1] was becoming aggressive” toward AV1. · P1 said that s/he saw SP1 “aggressively and forcefully patting” other children’s backs on other days, not just AV1 on May 24, 2023. P1 described this as, “The children were definitely expressing discomfort. Verbally, if they were verbal. It was clear to tell … it was obvious that (SP1’s conduct) was not to comfort. [S/he] was past that point.” Specifically, regarding the incident with AV1, P1 said, “It was really, really horrifying to watch. I was shaking when I left the room. It was so obviously over the line.” [Note: P1’s additional information regarding other instances of SP1 “aggressively and forcefully patting” the children’s backs is included in the forthcoming paragraphs.] · Facility documentation included an undated document titled “P3’s Testimonial,” and included the following: Leaving staff with more children than licensing allows over 15 minute periods Using phone during times [s/he] should be watching and interacting with the children Aggression during nap time to get kids to sleep Yelling at children to the point of other staff and parents hearing in the halls Pee and poop left on the potty’s/ not properly wiping the kids and not properly cleaning after toileting Physically removing children instead to talking to them and asking them to move their bodies 4/25 aggressively and forcefully “patting” [AV2’s] and [AV1’s] backs to the point of them crying and [AV1] begging [him/her] to stop 4/26 – 5/12 always on phone sitting next to children during [P3’s] bathroom shift – switched with [P1] to resolve 4/27 pee left on the potty 5/9 threw [AV3] down on [his/her] cot 5/9 poop residue in the potter [sic] 5/17 physically restrained [AV4] to keep [his/her] legs from moving during nap 5/22 nap time yelling and aggressively patting [AV2, AV4, and AV5] 5/23 [a child] poop in butt, [a child] poop in undies [Note: P3 did not respond to this investigator’s requests for an interview. There was no information regarding whether P3 had reported these concerns as they occurred and, in the moment, or whether this list of concerns was provided all-at-once at some point after “5/23.” It was also not known who the intended recipient of this list was.] · On May 25, 2023, P2 approached SP2 and questioned why “nothing was being done on [SP2’s] end.” SP2 responded to P2, “Lose the tone,” in his/her voice when speaking to SP2. SP2 then asked P2 if s/he wanted to continue to work at the facility and P2 said, “I don’t know.” P2 told SP2 that s/he had been “unhelpful and dishonest” throughout SP1’s time in the toddler classroom. · Facility documentation included an undated, untitled document, signed by P1, which included the following: 4/25 aggressively and forcefully “patting” [AV2] and [AV1’s] backs to the point of them crying and [AV1] begging [him/her] to stop 4/26 – 5/12 always on phone sitting next to children during [P3’s] bathroom shift – switched with [P1] to resolve 4/27 pee left on the potty 5/9 threw [AV3] down on [his/her] cot 5/9 poop residue in the potty 5/17 physically restrained [AV4] to keep [his/her] legs from moving during nap 5/19 pinned [AV4] down on [his/her] cot with [his/her] leg so [s/he] could fill out the daily sheets 5/22 yelled at kids in the classroom and could be heard from the bathroom and by teachers at the opposite end of the hall 5/22 nap time yelling and aggressively patting [AV2, AV4, and AV5] 5/23 [a child] poop in butt, [a child] poop in undies [SP1] was sitting next to [AV1’s] cot and pulled [him/her] off at [sic] [his/her] cot by [his/her] leg and arm. [S/he] then held [AV1] in [his/her] arms and shook [AV1] up and down. [SP1] then put [AV1] back on [his/her] cot and flipped [him/her] onto [his/her] stomach and forced [his/her] head down and started hitting [his/her] back. [AV1] start [sic] yelling and crying and told [SP1] [s/he] was hurting. [SP1] said, “You’re hurting yourself because you won’t stop moving.” [Note: This incident allegedly occurred on May 25, 2023.] [Note: P1 provided information that s/he had been reporting his/her concerns to SP2 on a “weekly” basis. These weekly concerns were not documented to show which concerns were reported and when, or whether this list of concerns was provided all-at-once at some point after May 25, 2023.] · P1 explained SP1’s “yelling” that if a child was not lying down for naptime, SP1 “yelled, across the room, ‘Lay down. Be quiet.’” · P1, P2, and P4 were each not aware of any children, including AV1-AV5, sustaining injuries from SP1’s conduct. · P4 added regarding the aforementioned incidents, “This was preventable. Multiple people were documenting. It is unfortunate. So many people were documenting, and it was neglected. All-in-all, it was definitely preventable, but it was stopped at the top by [SP2].” P4 stated that SP2 should have been addressing each concern. SP2 should have observed in the classroom, provided additional support or extra training, or created a corrective action plan. “To ignore the warning signs is dangerous.” FM1 stated that s/he was contacted by the facility regarding SP1’s interaction with AV1; however, this contact occurred 72 hours after the incident occurred and FM1 believed that s/he should have been notified immediately. FM1 was not aware of AV1 sustaining injuries specific to SP1’s conduct on May 24, 2023, or any other days. FM2-FM4 were not contacted by the facility regarding concerns with SP1’s conduct toward their respective child and were made aware when this investigator contacted each. FM2-FM4 each believed they should have been immediately contacted when each concern was raised. FM2-FM4 were not aware of their respective child sustaining injuries from a staff person’s conduct. SP1 provided the following information: · SP1 explained that the open position in the toddler classroom had previously been filled by a staff person, who “was very mean and not kind to any of” the children. [Note: See Maltreatment Investigation Memorandum # 202302780.] After this staff person was no longer employed and SP1 took over, there was “tension” in the classroom. The children were “quiet … very, very timid,” and the staff persons were “triggered” by any conflict. SP1 believed “the tension in the classroom, from before, came into play” with the allegations made against him/her, herein, this investigation. · SP1 said that s/he did not “aggressively or forcefully pat” a child’s back. However, SP1 described him/herself as “a large person with big hands.” SP1 might pat a child’s back “firmly and slow,” and this “might sound louder” to others. SP1 also did not typically pat a child’s back to comfort them, but rather typically rubbed the child’s back or played with their hair. · SP1 denied stating that s/he “wasn’t safe” around children. · SP1 denied shaking a child but did sometimes “cradle” children in his/her arms to help them “calm down.” · SP1 denied throwing any children on their cots or using his/her legs to hold a child against their cot. · SP1 denied yelling at the children but might have “spoke loudly if the child was on the other side of the room.” · SP1 said that no one (e.g., other staff persons) ever intervened or told him/her that s/he was being too aggressive or forceful. In addition, no children ever cried or said they were “hurt” from SP1’s contact with them, except AV1 (explained in the forthcoming paragraphs). If a child had cried or said something, SP1 would have changed the child’s positioning or set the child back on their cot. · SP1 had “a lot of concerns” with SP2’s facility management. SP1 said that s/he approached SP2 more than once for help in the toddler classroom. “We needed extra people.” One time, SP2 facilitated a meeting with SP1, P1, and P3. However, during this meeting, it was “evident” that SP2 was “pitting us against one another.” SP2 told them, “I can’t babysit you guys all the time.” In addition, SP2 might have visited the toddler classroom for 15 minutes at a time, but otherwise, “[S/he] was not there.” SP1 said that s/he needed to “learn from watching others, but when you don’t have anyone to watch, how do you learn? I didn’t learn from [SP2].” · Regarding the incident on May 24, 2023, involving AV1, SP1 said that AV1 was struggling to settle for naptime. SP1 cradled AV1 in his/her arms, which did not work. SP1 set AV1 down on his/her cot. AV1 rolled onto his/her stomach. SP1 was “gently patting [AV1’s] back a little bit.” AV1 was “thrashing all around.” SP1 tried to cradle AV1 again in his/her arms, but AV1 “wiggled back onto [his/her] cot.” AV1 was again on his/her stomach. AV1 was lifting his/her legs and at one point, lifted his/her head up. SP1 placed his/her hand on the back of AV1’s head to lower it back to the cot and AV1 said, “Ow.” SP1 immediately removed his/her hand from AV1’s head and started patting his/her back again. At that point, P1 and SP1 left on their lunchbreaks, and P1 remained to calm down AV1. SP2 provided the following information: · When the position opened in the toddler classroom, SP2 posted the vacancy on various job search websites; however, s/he also needed to temporarily fill the position until it was filled through the hiring process. SP2 asked one staff person to take the position, but s/he declined. “[SP1] was the only one qualified and willing to take the role.” · SP1 had been in a similar position a few years prior and stepped down voluntarily. At that time, SP1 was dealing with unrelated personal matters. SP1 had approached SP2 about stepping down because s/he wanted to focus on his/her personal matters and wanted a position at the facility with less responsibility. SP1 never told SP2 that s/he “wasn’t safe around the children.” Instead, SP1 had been concerned that his/her focus might not be fully on the children. SP1 was worried that “something might happen” but this was not in reference to SP1 potentially causing harm to the children. In addition, at the time SP1 stepped down from his/her previous position, SP2 was not made aware of anyone having that SP1 was unsafe or had a potential to cause harm to the children. · When SP1 took the open position in the toddler classroom in March 2023, P1 had immediate concerns and began relaying his/her concerns to SP2 on a “daily” basis. P1 said that SP1 was not organized, that SP1 was “not super hygienic” (e.g., smelled like cigarette smoke), and that SP1 was “loud.” In addition, P1 said that SP1 made changes in the classroom without consulting the other staff. P1 said, “I don’t like [SP1] in that role,” and “[SP1] is not good for that role.” SP2 believed there was a “personality conflict” between SP1 and P1. SP2 believed that P1 was relaying his/her “annoyances” with SP1’s personality. · Likewise, P4 approached SP2 with concerns about SP2’s management of the toddler classroom and staff; however, P4 refused to help SP2 create a corrective action plan. SP2 believed that P4 was seeking to take SP2’s position at the facility and so was not always helpful when SP2 asked for help. · Despite P1’s and P4’s concerns, when SP1 temporarily filled the open position in the toddler classroom, “No one ever said anything (to SP2) about [SP1] being unsafe or hurting the children.” · SP2 told P1 and other staff to document their concerns with SP1’s conduct and send them to him/her. Twice, SP2 received lists of “back-dated incidents,” like SP1 left underwear on the hamper or took a cup out of a child’s hand. These lists also included concerns with SP1’s method of patting the children’s backs during naptime, which were also “back-dated” and “intermixed” with concerns about SP1 “not always wearing gloves” when changing a diaper. SP2 believed that if the staff were concerned in the moment, they would have notified SP2 immediately and not via a back-dated, emailed list. · SP2 responded by having conversations with, and “coached,” SP1 and the other staff. SP2 encouraged them to “work together and be a team.” These conversations were not documented as they were mostly “spot conversations.” · SP2 never told staff not to report suspicions of maltreatment per their reporting requirements in the Reporting of Maltreatment of Minors Act. SP2 never told staff to “bite their tongue” regarding SP1’s conduct. · SP2 said that s/he checked-in with the toddler classroom “daily.” Sometimes, this was a 45-minute visit and sometimes it was “passing by and pausing … and spot coaching.” SP2 attempted to interact with the toddler classroom whenever s/he had “any free time.” · On May 24, 2023, P1 and P2 came to SP2’s office to tell them about SP1’s interaction with AV1 during naptime. However, this was an hour and a half after the incident occurred. P1 and P2 said that SP1 was “holding [AV1] down and rocking [AV1] aggressively like a baby;” and that SP1 was “holding [AV1] tight enough that [AV1] was saying, ‘You’re hurting me.’” Upon receiving this information, SP2 removed SP1 from having direct contact with children. This was the first time P1, P2, or any other staff came to SP2 with this level of concern. “Nothing that came to me prior out of concern compared to that concern” on May 24, 2023. “To me, if something had happened as severe as that day, they would have come to me about it,” or completed an incident report. · SP2 was never informed of any children sustaining injuries from SP1’s conduct. · On May 25, 2023, SP2 helped in the toddler classroom and heard P1 patting a child’s back “too hard.” SP2 could hear it across the classroom. SP2 told P1 to stop. After witnessing P1 patting a child’s back “too hard,” SP2 further questioned the back-dated lists that had been previously provided by P1. SP2 said, “What is going on in here?” · Regarding why the allegations were made about SP2’s conduct, SP2 explained that P1 had previously asked to fill the open position in the toddler classroom, but s/he was not qualified. SP2 attempted to help P1 become qualified, but P1 grew “more and more impatient” with the process. SP2 believed P1 wanted SP1 removed from his/her position in the toddler classroom, so that P1 could take the position. · SP2 provided a typed timeline for this investigation. According to this timeline, SP2 contacted P5 in “mid/end-April” 2023. SP2 recorded that s/he told P5 that s/he “wasn’t doing well, felt alone, and needed help.” SP2 told P5 that s/he “felt unsupported and had no one to lean on at the school.” According to SP2, P5’s responded that s/he was available “by phone whenever I need [him/her].” No additional support was provided at that time. SP2 did not have documentation of this conversation or any other conversations with P4 or P5. In addition, any emails exchanged at the time were on SP2’s work computer, which s/he no longer had access to at the time of this investigation. · SP2 said that s/he asked P4 and/or P5 for help more than once. SP2 wanted help managing the staff in the toddler classroom. SP2’s typed timeline for this investigation included, “I expressed to [P4] and [office assistant] throughout April and May (2023) that I needed help. They did not. I asked them multiple times what they would do in my position, and they said they ‘didn't know.’” P5 provided the following information: · Following the incident involving SP1 and AV1 on May 24, 2023, P5 received a phone call from a facility office assistant describing the ongoing concerns with SP2’s facility management and the ongoing concerns with SP1’s classroom management. P5 had not previously been contacted about these matters. P5’s position with the facility included significant authority over the facility’s operation. · P5, who was out-of-state at the time of this call, facilitated a video conference with SP2, P4, and the office assistant. P4 raised concerns regarding SP2’s handling of ongoing concerns with SP1’s conduct. P4 told SP2, “You didn’t go [to the toddler classroom] and visit. You weren’t there.” SP2 responded, “Yes, I did. Yes, I did.” P4 repeatedly shock his/her head in disagreement as SP2 explained what steps s/he had taken to address the concerns. · P5 said that SP2 should have contacted P5 much sooner about the ongoing concerns. P5 said that SP2 never reached out to him/her seeking assistance with managing or handling situations, and SP2 never informed P5 of the ongoing concerns with SP1’s conduct. · P5 told this investigator, “If [SP2] had reached out asking for help or support, I wouldn’t have held that back.” Facility documentation stated that P1-P5, SP1, and SP2 received training on the facility’s policies and procedures, including Behavior Guidance, and the Reporting of Maltreatment of Minors Act. Relevant Minnesota Statutes and Rules: Minnesota Rules part 9503.0055, subpart 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: Regarding SP1: A. Maltreatment: Regarding SP1’s interactions with children including AV1-AV5: Although SP1 denied being “aggressive or forceful” with children, P1 and P3 each provided typed lists that included more than one example of what they described as “aggressive and forceful” conduct, and P1 and P2 each said that they saw SP1 shaking up and down, and patting AV1 in a manner that caused AV1 to state that s/he was hurting. SP1 also heard AV1 say, “Ow,” in response to SP1’s conduct. P2 described the incident with AV1 as, “You could hear the thud of [SP1] smacking [AV1’s] back. You could tell it was not a gentle pat.” P2 believed that s/he needed to intervene because “[SP1] was becoming aggressive” toward AV1. P1 said “It was really, really horrifying to watch. I was shaking when I left the room. It was so obviously over the line.” Although P1 might have been motivated to provide inaccurate information about SP1, P2 had never worked with SP1 prior to witnessing the incident involving AV1 and did not have a known motivation to provide inaccurate information regarding what s/he witnessed. Given this, and that SP1 had reason to minimize his/her actions due to the potential repercussions, it was determined that P1’s-P3’s accounts were more credible than SP1’s account. The conduct of shaking, “aggressively and forcefully patting” a child, “throwing” a child onto their cot, and/or “pinning” a child against their cot was not accidental, was inconsistent with the facility’s policies and procedures, and in violation of Minnesota Rules part 9503.0055, subpart 3, item A. Although there was no information provided that AV1-AV5 sustained any injury, given that AV1-AV5 were between the ages of 18 and 31 months old at the time of the incidents, there was a preponderance of the evidence that SP1’s conduct included overt acts that represented a substantial risk of physical injury to AV1-AV5. It was determined that physical 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). Regarding SP2’s intervention with SP1’s conduct: Although SP2 said that s/he was having daily check-ins with the toddler classroom and/or SP1; these conversations were not documented and there was nothing in SP1’s personnel file to show any corrective conversations or action occurred. In addition, P1, P2, P4, and SP1 each said that SP2 was “not there” in the classroom, and that SP2 did not provide additional support or extra training. Although it was unclear when P3’s Testimonial list of concerns and P1’s list of concerns were provided and to whom; P1 said that s/he was checking-in with SP2 about SP1’s conduct “weekly” and SP2 said these check-ins were occurring “daily.” In one email, dated April 30, 2023, P3 told SP2 about at least one incident when, “[SP1] was aggressively and forcefully patting [AV2’s] and [AV1’s] backs to the point of them crying and [AV1] begging [him/her] to stop at [which] point [P3] offered to take over.” In another email, dated May 8, 2023, P1 told SP2 about two incidents where SP1 “yanked” and “shoved” a child. Given that there was no documentation or additional witnesses that these incidents were ever addressed; and that the incidents continued to occur leading up to the incident with AV1 being “hurt” by SP1 on May 24, 2023, there was a preponderance of the evidence that there was a failure to supply the children with necessary care required for their physical or mental health and a failure to protect the children from conditions or actions that seriously endangered their 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; 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. Regarding SP1: SP1’s position at the facility included overseeing the toddler classroom management. SP1 was responsible for the care and supervision of the children. SP1 received training on the facility’s policies and procedures, including Behavior Guidance, and the Reporting of Maltreatment of Minors Act. SP1 was responsible for maltreatment of AV1-AV5. Regarding SP2: Emails showed that SP2 was notified of concerns with SP1’s conduct by multiple people. SP2’s position at the facility included overseeing facility management and was therefore responsible for the care and supervision of the children. SP2 received training on the facility’s policies and procedures, including Behavior Guidance, and the Reporting of Maltreatment of Minors Act. SP2 was responsible for maltreatment of AV1-AV5. 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. Regarding SP1: It was determined that the substantiated physical abuse for which SP1 was responsible was not “recurring” or “serious” maltreatment because SP1’s pattern of behavior was considered a single incident and AV1-AV5 did not sustain injuries. Regarding SP2: It was determined that the substantiated neglect for which SP2 was responsible was not “recurring” or “serious” maltreatment because SP2’s pattern of behavior was considered a single incident and AV1-AV5 did not sustain injuries. 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 policies and procedures were adequate, but not followed. The facility reviewed existing policies with all staff “to address best practices and Child Garden standards.” SP1 and SP2 were no longer employed at the facility. 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 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 and/or SP2. The determinations that SP1 and SP2 were responsible for maltreatment are each subject to appeal. On August 23, 2023, the facility was issued a Correction Order for the violation outlined in this report. Minnesota Statutes, section 260E.06, subdivision 1, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that one staff person failed to report suspected maltreatment as required. A letter from DHS was sent to this individual regarding their failure to report the suspected maltreatment and potential consequences for future such failures. 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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