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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: 1036265-CCC (Child Care Center) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was picked up by the wrong parent. The parent brought the AV to the parent’s home before realizing the error and returning the AV to the facility, unharmed. The AV was away from the facility and without staff supervision for about 26 minutes. Date of Incident(s): June 29, 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 July 17, 2023; from documentation at the facility; and through interviews conducted with the AV’s family member (FM), another child’s parent (P1), facility staff persons (S1-S4), and a supervisory staff person (S5). At the time of the incident, the AV was five months old, and another child (C) involved in this investigation was eight months old. Both were enrolled in the facility’s infant classroom. The AV and the C each had documentation regarding who was authorized to pick them up from the facility. The AV’s authorized pick-up list did not include any members of the C’s family. The facility provided childcare services to children, infant to school age. The facility was a stand-alone building that upon entering had a staff desk (S4’s desk) and a sign-in and -out computer for parents/guardians. When a parent/guardian used the computer to sign their child in or out, they had their back turned to S4. The infant classroom was down a short hallway from the entryway. The facility had cameras in common areas recording movement but not audio. P1 and the facility’s camera footage provided the following information: · On the day of the incident, at 4:14:14 p.m. P1 arrived at the facility to pick up the C. · P1 walked directly to the infant classroom and saw his/her “favorite caretaker,” S2, sitting on a rocking chair holding a child whom P1 believed was the C but was later determined to be the AV. P1 made eye contact with S2 and walked over to him/her. S2 handed the AV to P1. P1 “noted [my child] seemed off” or “wasn’t excited to see me” as s/he had been during previous pick-up times. P1 “didn’t want to overthink it” and decided to head home and ask the C’s other parent (P2) his/her thoughts on the child’s demeanor. The facility’s camera footage showed P1 entering the infant classroom, walking up to S2, and bending down in front of S2. S2 then handed the child s/he was feeding to P1. P1 stood and held the child against his/her chest with the child’s face against P1’s chest or toward P1’s back. P1 walked out of the classroom at 4:15:46 p.m. P1 did not take a car seat or bottle with the child. · P1 carried the child out to his/her car, placed the child in a car seat, and drove home. The facility’s camera footage showed P1 leaving the building, carrying a child, at 4:16:49 p.m. · Upon arriving home, and after discussion with P2, they discovered that P1 had accidentally picked up the AV, not the C. P1 and P2 immediately called the facility and drove back with the AV. The facility’s camera footage showed P1 and P2 entering the building, carrying the AV in a car seat, at 4:43:34 p.m. · P1 said that P2 was the typical pick-up person for the C; however, P1 had done so about 15 times prior and believed the staff knew who s/he was. No one had asked to see P1’s photo identification when s/he arrived on the day of the incident to pick up the C. · P1 said that the C and the AV looked “quite a bit alike.” The incident was “an honest mistake” and P1 had no concerns with the facility’s overall care and supervision. S1-S5 provided the following information: · S1-S3 each said that around 4 p.m., on the day of the incident, they were working in the infant classroom with eight children, including the AV and the C. S1 was sitting on the floor interacting with a child; and S2 and S3 were each sitting in a rocking chair holding or feeding a child. S2 was feeding the AV with a bottle. They could not recall exactly where the C was in the room at that time. · S1 said that it was a “busy pick-up time,” and S3 called it a “mad house” at that time of day. Most parents were arriving around this same time to pick up their respective children. · S1-S3 each saw P1 enter the classroom and walk “directly to” S2. S2 said that P1 walked “close to me” and reached for the AV, which prompted S2 to hand the AV to P1. · S2 and S3 each recognized P1 as being a parent of a child in the classroom. S2 and S3 did not ask P1 for his/her photo identification. P1 did not state his/her child’s name, and no one asked P1 for this information; however, “We knew that [P1] was a kid’s parent.” P1 did not pick up his/her child “very often.” That said, according to S2 and S3, P1 walked “confidently” up to S2 and looked “comfortable and natural” picking up the AV. S3 said, “It didn’t register” that P1 might be getting the wrong child. “We’ve seen these parents so many times.” S3 “didn’t question” P1’s actions because s/he seemed “too natural” picking up the AV. S2 said that P1 seemed “very sure” the AV was his/her child. · S1 did not routinely work in the infant classroom and said that s/he allowed S2 and S3 to interact with parents as they arrived at pick-up time. S1 did not ask P1 for his/her photo identification. · As P1 was leaving the classroom with the AV, S3 said, “Bye [the AV’s first name].” [Note: Later, and in hindsight, P1 said that s/he heard S3 say the AV’s first name but believed S3 was calling P1 by that name and that S3 had forgotten P1’s name.] · P1 walked out of the classroom carrying the AV against his/her shoulder. P1 did not take a car seat or bottle, rather just the AV. · S4 was sitting at his/her desk in the entryway when P1 entered carrying a child and stopping at the sign-out computer. S4 could not see P1’s face or the child’s face but recognized the child as being the AV. S4 said, “Goodbye [the AV’s first name].” P1 gave S4 a “funny look” but kept signing-out on the computer. As P1 was leaving, S4’s computer showed that P1 had signed-out the C, not the AV. S4 then said sorry and that s/he had misidentified the child P1 was holding. P1 continued out the door looking “puzzled” at S4. · S1-S5 each said that the AV and the C “look a lot alike” or “remarkable similar,” and own the same outfit as the one worn by the AV on the day of the incident. “The only difference is that [the C] has a rounder head and [the AV] has a more narrow head.” The C also had “bigger” or “more open” eyes. [Note: The facility provided photographs of the AV and the C, which appeared consistent with the staffs’ descriptions.] · The AV and the C also did not have set pickup times; they were not always picked up by their parent at the same time every day or at times that were significantly apart from one another. P1’s arrival time did not alarm the staff. · About 20 minutes after P1 left the facility, S4 answered an incoming facility phone call. P2 was on the other line “yelling” that P1 took home the wrong child, and that they were headed back to the facility. S4 looked up P1’s and P2’s address and determined it would take them about nine minutes to drive back to the facility. · Upon hanging up the phone, S4 and S5 “ran” to the infant classroom to check on the C and inform staff of what happened. · About ten minutes later, P1 and P2 arrived carrying the AV in a car seat and walked directly to the infant classroom. The AV was unharmed. · S4 said that P1 looked “pretty shocked … pretty panicked,” and repeated, “Everything is fine now.” P2 repeatedly apologized and asked if s/he should wait around for the AV’s parent/guardian to arrive to explain what happened; staff told P2 that s/he did not have to wait around. · In addition to the AV and the C looking similar, S5 said that P1 and the FM looked similar and neither of them picked up their child often. However, P1 and the FM each picked up their child “enough that you knew they were a parent but not so infrequent that you would [check their photo identification].” · S1-S5 each said that they were trained to check a parent’s photo identification if the person did not regularly pick up the child, or the staff did not recognize the parent. [Note: P1 said that a few weeks prior to this incident, s/he brought a different family member with him/her to pick up the C and the staff in the classroom recognized P1 but questioned who the other person was.] · S5 said that it was common for a parent/guardian to enter the classroom, locate their child, and pick their child up, whether from the floor or crib; and then upon leaving, they signed their child out for the day. P1 followed these same steps at the time of the incident but happened to grab the wrong child. · S5 said that from when P1 left the front door to when they returned, the AV was unsupervised (outside of the facility’s supervision) for 26 minutes. · S5 did not have prior concerns with S1’s-S3’s conduct. The facility’s policies and procedures provided the following information: · “New Horizon Academy only releases children to their parents or other adults designated on the Enrollment Agreement and Emergency Card in the child’s file. When picking up children, we require families to log out on the computer system and exit through the front lobby of the building … If an unauthorized individual attempts to pick up your child, we will contact you for permission to release your child to their care.” · “If there are any concerns or doubts regarding a person’s identity, it is our policy that you must ask to see photo identification … Individuals who have never previously picked up a child need to be asked for photo identification before the child can be released.” The FM did not have previous concerns with the facility’s overall care and supervision. Facility documentation stated that S1-S5 received training on the facility’s policies and procedures and the Reporting of Maltreatment of Minors Act.
Relevant Minnesota Statutes and Rules: 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. Minnesota Rules, chapter 9503.0125, item D, states that the license holder must ensure that a record is maintained on each child and must contain the names and telephone numbers of any persons authorized to take the child from the center. Minnesota Statutes 245A.04, subdivision 14, paragraph (b), clause (3), states the license holder shall monitor implementation of policies and procedures by program staff. Conclusion: A. Maltreatment: On June 29, 2023, the AV was released from the facility to P1 who was not the AV’s parent and was not on the AV’s authorized pick-up list, which was a violation of Minnesota Rules, chapter 9503.0125, item D. The action was also inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and inconsistent with facility’s policies and procedures regarding authorized pick-up lists which was a violation of Minnesota Statutes 245A.04, subdivision 14, paragraph (b), clause (3). The AV remained with P1, without supervision by a staff person, for 26 minutes before being returned to the facility, unharmed. The conduct of failing to provide supervision to the AV was in violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. At the time of the incident, S1 was sitting on the floor interacting with a child; and S2 and S3 were each sitting in a rocking chair holding or feeding a child. S2 was feeding the AV with a bottle. S1-S3 each said that they recognized P1 as being a parent of a child in the infant classroom who did not pick up their child often but did not know whose child P1 belonged to. P1 walked “confidently” and “directly to” S2 who was holding the AV. P1 bent down in front of S2 to be handed the AV. S2 said that P1 seemed “very sure” the AV was his/her child. S3 “didn’t question” P1’s actions because s/he seemed “too natural” picking up the AV. P1 did not state his/her child’s name and no one asked P1 for their information including name or photo identification. S1-S5 each said that they were trained to check a parent’s photo identification if the person did not regularly pick up their child, or the staff did not recognize the person. Although staff recognized P1, they did not recognize him/her well enough to identify which child was his/hers; and although staff believed the AV and the C looked “similar,” they were not family or related in any way and did not have the same people on their respective authorized pick-up lists. Unfortunately, the AV was not old enough to identify him/herself or identify his/her parent, and instead, the AV was relying on staff persons to make these identifications on his/her behalf; however, this was not done on the day of the incident. The staffs’ failure to verify identification allowed an unrelated community person (P1) to remove the AV from the facility without the legal authority to do so, and given that the AV was five months old at the time, there was a preponderance of the evidence that there was a failure to supply the AV with care or services when reasonably able to do so and was 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. S1-S5 were responsible for the AV’s care and supervision at the facility and received training on the facility’s policies and procedures and the Reporting of Maltreatment of Minors Act. S4 and S5 were not in the classroom when the incident occurred and did not release the AV to P1. S4’s and S5’s responsibilities were mitigated. S1, S2, and S3 were in the classroom when the incident occurred and each were responsible for ensuring that each child was picked up by an authorized person. S1, S2, and S3 were responsible for 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 S1, S2, and S3 were responsible did not meet statutory criteria to be determined as recurring or serious. It was a single incident for which the AV did not sustain a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought. 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 and followed. “New Horizon Academy has very solid policies on dropping and picking children off for care at our centers. All the staff that cared for the two families knew that both [P1 and P2] and [the FM] were authorized to pick their [child] up and there were no stipulations or conditions for the pickup process … [P1] followed the process and clocked who [s/he] believed was [the C] out on the check out system. The staff caring for the children had no concerns or alarming warning that an unintentional/mistake had been made. Everyone that was involved had no reason to believe that our standard pick up process was being followed and this was an unfortunate incident that took place.” Action Taken by Department of Human Services, Office of Inspector General: S1, S2, and S3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, S1, S2, and S3 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 S1, S2, and S3 were each responsible for maltreatment is subject to appeal. On September 22, 2023, the facility was issued a Correction Order for the violations 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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