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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: 830403-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that a staff person (SP) flipped an alleged victim (AV) off a cot and the AV hit his/her head. Date of Incident(s): August 22, 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 September 6, 2023; from documentation at the facility; and through five interviews conducted with a supervisory staff person (P1), the SP, the AV, and the AV’s family members (FM1 and FM2). The facility consisted of five classrooms, including a preschool classroom. During naptime, the preschool children lay on cots that were placed on the floor in various locations throughout the room. The cots were approximately 54 inches long, 22 inches wide, and one to two inches from the floor, and had hard plastic ends. Facility documentation showed the AV was four years old and at the time of the incident was enrolled in one of the facility’s preschool classrooms. The AV stated that the SP “dumped” him/her off the cot because the AV did not read a book when the SP asked him/her to read. The AV hit his/her head “hard” on the wall, cried “a little bit,” and the “gum” inside his/her mouth hurt. The SP told the AV that s/he was “okay” even though the AV was not okay. The facility provided video footage of the incident that was two minutes and three seconds long. The video was not time stamped and did not have audio. The video provided the following information:
o As the video started the AV jumped on his/her cot. Other children in the classroom sat or lay on their cots. o At eight seconds, the AV sat down at the end of the cot on the long edge. Then the AV reached out and touched a stuffed animal that was being held by a child on a cot near the AV’s cot and put his/her hands back in his/her lap. o At twenty-two seconds, the SP entered the video and walked toward the AV’s cot. When the SP arrived at the AV’s cot, s/he quickly reached down and took the short end of the AV’s cot in both hands and began lifting the cot. The AV swung his/her legs onto the cot and lay back with his/her feet nearest the SP. The SP lifted up the short end of AV’s cot making it almost perpendicular with the floor. The AV held onto the long edge of his/her cot with his/her left arm, rotated almost 180 degrees backwards, fell off the cot and landed on his/her head. The AV hit his/her head on the floor and the hard plastic frame of the cot, as s/he lay partially against the cot that was still being held up by the SP and partially on the floor. The AV immediately began to cry and reached for the back of his/her head with both of his/her hands. o At twenty-nine seconds, the SP picked up the AV’s cot entirely off the floor and laid it next to the AV. The AV la on the floor with his/her hands on the back of his/her head, kicking his/her legs, and crying. The SP then sat on the floor by the AV and picked up the AV and cradled him/her in his/her arms for four seconds. The SP then lay the AV on the cot. During this entire time, the AV’s hands remained behind his/her head and the AV cried. o At forty-two seconds, the SP used the AV’s clothing and covered the AV’s face. The AV pulled the clothing off and the SP again covered the AV’s face. The AV kicked his/her feet and rolled onto his/her side away from the SP. The SP moved the AV’s clothing down from the AV’s face to his/her body. The AV continued to cry. o At fifty-two seconds, the SP turned and bent over the AV and picked up something off camera. o At one minute and twelve seconds, the SP crawled over to a nearby child and covered that child with a blanket as the AV still had his/her hands on the back of his/her head and continued crying. o At one minute and twenty-seven seconds, the SP stood and walked to another child and the AV continued to cry and the video ended. FM1 and FM2 provided the following consistent information: · FM1 stated that on August 22, 2023, s/he picked up the AV early to attend an appointment. While FM1 and the AV were in their car, the AV told FM1 that s/he had been “naughty” and the SP “dumped” him/her off his/her cot and onto his/her head. FM1 then called FM2 and asked that when s/he went to the facility later to go into the AV’s classroom and ask the SP if there was an accident report because the AV said s/he had an “ouchie” on his/her head. · FM2 stated that on August 22, 2023, s/he asked the SP if the AV bumped his/her head. The SP told FM2 that earlier in the day the AV was jumping, fell and hit his/her head and that the SP went to him/her and offered him/her comfort. FM2 asked if any other staff person saw anything, and the SP told FM2, “No.” The SP made it seem like s/he had no part in the AV falling off his/her cot other than to provide comfort after the AV fell. · Later in the day, FM2 told FM1 that the SP had stated s/he was across the classroom when the AV fell off his/her cot and the SP gave the AV hugs. The AV repeated the same story to FM1 so FM1 called the P. FM1 told the P what the AV said and that it was not consistent with what the SP had told FM2. The P told FM1 that s/he would review camera footage from the classroom. · That evening FM1 did not feel a bump on the AV’s head and the AV seemed fine. The next morning the AV told FM2 that the SP had dumped him/her off the cot and s/he hit his/her head on the “blower” thing and that it was an “accident.” · On August 23, 2023, FM1 dropped the AV off at the facility. At about 9:30 a.m., FM1 called the P. The P told FM2 that she would review the camera footage later that morning. After lunch, the P called FM1 and told him/her that s/he had seen an “unsafe practice” when s/he reviewed the video footage. Later, FM1 reviewed the camera footage and could not “wrap” his/her head around what the SP had done. FM1 was upset that the SP had not been truthful. The P and a facility document titled Internal Review provided the following consistent information: · On August 22, 2023, the SP worked in the preschool classroom with ten children, including the AV. · At approximately 6 p.m., the P received an email from FM1 requesting that they connect. The P called FM1 and FM1 told the P that the AV had told him/her that s/he had been “tipped or flipped” off of his/her cot during nap and that the AV had hit his/her head on the “thing that blows air.” The P told FM1 that s/he would review video footage and then reach out to him/her again. · The next morning the P asked the SP if there had been a time the previous day when the AV had “hit” his/her head on something. The SP told the P that the AV could have rolled off his/her cot and hit his/her head but that the SP had not seen it happen. Then the P watched the video footage for the classroom and saw information consistent with the video information provided above. · Then the P called FM1 and told him/her that the SP had moved the AV’s cot in a way that made the AV fall off his/her cot and bump his/her head. · Later that afternoon, the P rewatched the video footage with FM1 and they cried and hugged. The SP provided the following information: · On August 22, 2023, at approximately 1 p.m., the SP was “frustrated” because the AV was on his/her cot “fighting” to go to sleep. The AV was not “listening,” was not “going to sleep” and was not “laying down nicely.” The SP walked to the AV’s cot and picked it up on one end and lifted it about as high as the SP’s “stomach” because s/he was “upset” with the AV. The AV “rolled off” the other end of the cot and cried for a “little bit.” The SP “assumed” the AV hit his/her head on the wall because the AV held his/her head. · The SP looked for “bumps or bruises” on the AV’s head but did not find any. The AV told the SP that his/her mouth hurt. The SP looked for a sore inside the AV’s mouth and did not see one and then the SP gave the AV water to drink. · When the AV was picked up by FM1, the SP “briefly” told FM1 that the AV fell. Later that day, FM2 came to the classroom and talked with the SP. The SP told FM2 that the AV fell off his/her cot, hit his/her head, and complained about his/her mouth. The SP did not recall if she told FM1 or FM2 that s/he had lifted the cot and the AV fell off of it. · The SP said s/he was “frustrated” at the time of the incident because s/he worked “a lot” of overtime the past months and trained a new staff person and that had started to “wear” on the SP. The facility’s Positive Behavior Guidance policy stated that staff persons were never to use any type of physical or verbal punishment. The facility’s Behavior Guidance Policy stated that staff persons developed a trusting relationship with children by using a “nurturing touch,” and redirecting children to positive behaviors. The facility’s prohibited regulations included, but were not limited to, rough handling, shoving, shaking, excessive tickling, slapping, kicking, biting, pinching, hitting, spanking, and pulling arms, hair or ears. The SP and the P each received training on the reporting of Maltreatment of Minors Act, the facility’s Positive Behavior Guidance and Behavior Guidance policies and prohibited regulations. Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0055, subdivision 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: A. Maltreatment: Information provided via video showed that on August 22, 2023, the AV was seated on a cot when the SP picked it up at one end, lifted it almost perpendicular to the floor which caused the AV to fall off the cot and hit his/her head on the floor and/or hard plastic edge around the cot. The SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; and were a violation of the facility’s Positive Behavior Guidance and Behavior Guidance policies; and a violation of Minnesota Rules, part 9503.0055, subpart 3, item A. Although the AV did not sustain an injury, given that the AV was four years old and was “dumped” him/her the cot hitting his/her head, that the AV was not a danger to him/herself or others at the time and did not require physical intervention, and that the SP stated s/he lifted the AV’s cot because s/he was “upset” and “frustrated” that the AV fought to go to sleep, , there was a preponderance of the evidence that the SP’s actions were not accidental and were a failure to supply the AV with necessary care, a failure to protect the AV from conditions or actions that seriously endangered his/her physical health, and represented a substantial risk of injury to the AV. It was determined that neglect and physical abuse 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. “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.) 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. The SP was responsible for the care and supervision of the AV at the time of the incident and was trained on the facility’s Positive Behavior Guidance, Behavior Guidance policies, and the Reporting of Maltreatment of Minor’s Act. The SP was 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 and physical abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident that met two definitions of maltreatment but did not meet the definitions of serious maltreatment. 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 conducted an internal review and determined their policies were adequate but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was 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 the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On December 1, 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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