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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: 1049970-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on a diaper changing table and fell over the side to the floor sustaining a mild concussion. Date of Incident(s): September 22, 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 October 4, 2023; from documentation at the facility; and through five interviews conducted with four facility staff persons (SP, P1, P2, P3), and the AV’s family member (FM). Due to the AV’s age, s/he was not able to provide any information about the incident. The facility was located inside a church. The toddler classroom was located off a hallway that had several other classrooms. The toddler classroom was a large open room. On the left side of the room was a large open area with some rugs. There were several tables and shelves in the middle of the classroom. On the right side of the room was a changing table and sink area. The changing table was across from a sink. There was a wall to the left of the changing table. The AV was 28 months old at the time of the incident and enrolled in the Toddler Classroom. The FM provided the following information: · The FM was notified that the AV fell off the changing table so s/he came to the facility to observe the AV. The AV threw up at the facility, so the FM took the AV to the emergency department (ED) to get checked out. At the ED the AV threw up twice more. · The AV had a visible bump on the back of his/her head that was initially red and turned purple. After the fall the AV did not seem like him/herself and s/he was “clingy” and did not have an interest in food. The AV was diagnosed with a possible mild concussion. Later that evening, the AV started to return to his/her normal baseline. P1-P3 provided the following information: · At approximately 12-12:30 p.m., P1, P2, and the SP were in the classroom and had started to transition from lunch to naptime. P1 was at the far end of the room helping a child fall asleep when s/he heard a sound of contact between two objects. When P1 looked up, s/he saw the AV curled up on the floor crying near the changing table. P2 was putting a child to sleep and heard the AV fall but did not witness the fall. · The SP picked up the AV and consoled the AV. At approximately 12:30 p.m., P1 text P3 to inform P3 of the situation and then P1 brought the AV to P3 who was in another classroom. When P3 asked the AV what hurt, the AV tapped the side of his/her head. P3 checked the AV’s head and eyes and asked the AV to follow some simple directions. The AV was able to follow simple directions. · P3 called the FM who came to observe the AV. The FM was going to take the AV to his/her home but then the AV threw up. The FM decided to get the AV checked out at the ED and left the facility at approximately 2 p.m. At approximately 6 p.m., the FM called to say that the ED was treating it as a mild concussion and sent the AV home for some rest. · The SP told P3 that the AV slipped on the paper that was used to cover the changing table. When changing a diaper, staff persons were to underarm lift the child onto the changing table or have the child walk up the stairs. Staff persons changed the child’s diaper while keeping one hand on the child at all times. · P3 said s/he thought it was an accident and unintentional. The SP was one of the most caring staff persons at the facility. The SP provided the following information: · On the day of the incident at naptime, the SP was changing diapers. The AV had a bowel movement, so the SP put a paper liner down on the changing table and grabbed the AV’s diapers and wipes. The SP put on gloves and assisted the AV up the stairs to lie down on the changing table. · The SP changed the AV’s diaper and then the AV stood up. The AV’s feet got tangled in the paper liner. The SP said something like, “Wait let me get it.” Because the SP was concerned about the AV standing up and with the paper liner the SP worried that the AV might fall. The SP tried to grab the paper so the AV’s feet would not tangle in it when the AV backed up and fell over the back of the changing table. · The SP ran around the table and grabbed the AV who was crying. P3 took the AV to the office and the FM came to get the AV. · The SP said that the AV did not normally use the stairs, but on that day wanted to. After the AV’s diaper was changed, s/he “popped” up to go back down the stairs. The Diaper Changing Policy stated that staff persons carried the child to the changing table or allowed the child to walk up the steps if age appropriate. Staff persons always kept a hand on the child. The Risk Reduction Plan stated that one hand was kept on children at all times. A child was laid down on the changing table and was not left unattended. Facility documentation showed that all staff persons interviewed were trained on the facilities policies, the Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. Conclusion: Information was consistent that on September 22, 2023, the classroom was getting ready for naptime. P1 and P2 both were in the classroom assisting children to go to sleep. The SP changed the AV’s diaper and the AV stood up causing his/her feet to become tangled in the paper liner on the changing table. The SP asked the AV to wait and tried to pull the paper away from the AV’s legs but the AV backed up and fell over the back of the changing table. Both P1 and P2 did not see the fall but heard the AV cry. The AV was observed and taken to the emergency department where s/he was diagnosed with a possible mild concussion. 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 next to the AV assisting the AV to get untangled from the paper liner on the changing table during the time of the incident. The SP’s actions or conduct were 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 previously determined to have committed a nonmaltreatment mistake under this paragraph; (4) The AV bumped his/her head had was diagnosed with a possible mild concussion but did not require any medical treatment; and (5) 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 to the AV by the SP was not maltreatment. It was determined that neglect did not occur (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. All staff persons reviewed the protocols and guidelines related to diaper changing. 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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