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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: 1044125-CCC (Child Care Center) Investigator(s): Kim Anderson/Van Mulheron Suspected Maltreatment Reported: It was reported that a staff person (SP) restrained an alleged victim (AV) by holding his/her hands and feet causing bruising on the AV’s hands and wrists. Date of Incident(s): September 27, 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 Friday, October 13, 2023; from documentation at the facility; and through three interviews conducted with the facility supervisory person (P1), and two staff persons (P2 and the SP). Attempts to contact the AV’s family members (FM1 and FM2) via telephone and mail were unsuccessful. The facility was a stand-alone two-story building. The AV’s classroom was located on the second floor and had a group rug near the wall and to the left of the rug was a library area. The library area had a child size chair. The facility had two video cameras in the classroom. The AV was four years old at the time of the incident and was enrolled in a preschool class. The AV had a speech delay and had a limited vocabulary, so was not able to provide information for this investigation. The facility’s Incident Report stated that on September 27, 2023, the SP held the AV down on a chair. On September 28, 2023, P1 watched video surveillance of the incident. The facility’s video surveillance of the AV’s classroom was not timestamped but lasted 15 minutes. The video provided the following information: · At the beginning of the video, the SP was across the room from five children, including the AV, who were on the group rug. The AV had a string around his/her neck. · At 29 seconds, the SP looked up and saw the AV taking off the string from his/her neck and walked toward the AV. The AV ran away from the SP and the SP ran after. · At 34 seconds, the SP grabbed the AV’s left arm above his/her elbow and roughly sat him/her onto a library chair. · At 51 seconds, the SP walked away with the string and the AV ran away. The SP returned the AV to the chair and sat down in front of the AV. At that time, P2 entered the classroom with another child. · For the next 10 minutes, the AV tried to get away from the SP, but the SP repeatedly held the AV’s hands, wrists, arms, and feet. During this time, the AV was crying and repeatedly tried to leave the chair. · Between 11 and 13 minutes, the SP was seen talking to the AV as the AV continued trying to leave the chair, but the SP continued to keep the AV sitting in the chair. When the AV attempted to leave the chair, the SP grabbed the AV’s arms and hand and placed the AV back into a sitting position. The SP held the AV’s hands until the AV sat still and then the SP removed his/her hands. This processed was repeated several times. · At 15 minutes, the SP allowed the AV to leave the chair and play. At no time during the video, was the AV seen throwing toys, running around the classroom, or appear as a danger to him/herself or others. P1, P2, and facility documentation provided the following information: · On September 27, 2023, P2 entered the classroom and saw the AV and the SP sitting in chairs by the group rug and library area. The SP sat facing the AV, holding the AV’s hands down, and preventing. · P2 saw that when the AV tried to get up, the SP said, “Say sorry. Tell me you are sorry.” The AV then said, “Sorry,” and the SP said, “Look me in the eye when you say it.” · P2 stated that the AV had difficulty with saying and understanding words and required one on one guidance to understand and follow directions. P2 “did not feel right” about the SP’s interaction and spoke with P1 the next day. · P2 said that the next day that the AV had bruises on his/her left arm above the wrist, one large bruise which resembled a thumb print and some smaller dots next to it. The bruises matched where P2 saw the SP hold the AV’s hands and arms down. · On September 28, 2023, P1 watched video footage of the incident and saw that at 4 p.m. the SP held the AV’s hands and feet for 15 minutes. The AV’s hands and wrists were held more often than the AV’s feet and for longer periods, and the feet were held down twice. The SP held the AV’s feet down by placing his/her feet on top of the AV’s feet. P1 then spoke with the SP about the incident. The SP told P1 that s/he was “just playing with [the AV].” · Later that day, P1 spoke with FM1 and FM2, told them about the incident and asked if they had seen any bruises on the AV the prior morning. FM2 replied that they had not seen any bruises on the AV’s arms or wrists. P1 stated that although FM1 and FM2 were “incredibly gracious” “considering the news,” FM1 was visibly upset about the incident. · Prior to this incident P1 had no concerns about the SP’s interactions with the children. The SP provided the following information: · The AV was “nonverbal and at times did not understand most words or directions.” The SP used facial expressions, exaggerated movements, and sound effects to communicate with the AV. · The SP stated that at the time of the incident the AV was “freaking out, running around and throwing toys.” The SP was not able to remember why the AV was upset. The SP put the AV in a chair for approximately 15 minutes to calm him/her down. · The SP stated that the AV hit and kicked the SP, so s/he held the AV’s hands and feet for a “moment” until the AV calmed down and then the AV got up and played. · The SP stated 15 minutes was a normal amount of time to sit with the AV because it was hard to get the AV to calm because the teachers could not understand what the AV was saying. · The SP stated s/he did not see any bruises on the AV the next day. The facility’s Behavior Guidance Policy stated that the following actions by a staff person is prohibited: “A subjection of a child to corporal punishment. Corporal punishment includes, but not limited to, rough handling, shoving, hair pulling, ear pulling, shaking, slapping, kicking, biting, punching, hitting, and spanking.” The Behavior Guidance Policy also prohibited the use of physical restraint other than to physically hold a child when containment is necessary to protect a child or others from harm. The facility’s records showed prior to the incident P1, P2, and the SP were trained on the facility’s Behavior Guidance Plan and the Reporting pf Maltreatment of Minors Act. Relevant Rules and Statutes: Minnesota Rules, part 9503.0055, subpart 4, states in part that no child may be separated from a group unless the license holder has tried less intrusive methods of guiding the child’s behavior which have been ineffective and the child's behavior threatens the well-being of the child or other children in the center Minnesota Rules, part 9503.0055, subpart 3, item A, states that the license holder must have and enforce a policy that prohibits the following actions by or at the direction of a staff persons: Subjection of a child to corporal punishment, which 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 from P1 and video was consistent that on September 27, 2023, for approximately 15 minutes, the SP held the AV’s hands and feet down, and preventing the AV from getting off the chair, which was a violation of Minnesota Rules, part 9503.0055, subpart 4. Video surveillance also showed the SP grabbing the AV’s arm and placing the AV in the chair. The AV struggled and repeatedly tried to get out of the chair. P1, P2 and pictures provided were consistent that the next day the AV had bruises on his/her arms that were consistent with where the SP held him/her. The SP provided conflicting information regarding his/her actions. The SP told P1 that s/he was “just playing with” the AV. The SP told this investigator that the AV was “freaking out, running around and throwing toys” and that s/he held the AV to help the AV calm. However, video footage showed that the AV was not throwing toys, running around, and/or was not a danger to his/herself and others at the time. Once the SP had removed the string from the AV’s neck there was no further need to physically intervene with the AV. The SP’s actions of grabbing and holding the AV’s arms and wrists down for 15 minutes was inconsistent with the standards of a professional caregiver licensed by the Department of Human Services and a violation of Minnesota Rules, part 9503.0055, subdivision 3, item A. Given that there was no information provided that the AV was a danger to him/herself or others and therefore did not require physical intervention; that grabbing, pulling, and moving a child by their arm was not accidental; and that the AV sustained bruises as a result of the SP’s actions, there was a preponderance of the evidence that the SP’s actions caused injury to the AV, were a failure to supply the AV with necessary care, and a failure to protect the AV from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. 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 of the AV at the time of the incident and was trained on the facility’s Behavior Guidance Policy and the Reporting of Maltreatment of Minors Act prior to the incident. The SP was 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 and physical abuse for which the SP was responsible was not “recurring” because this was a single incident that met two definitions of maltreatment but was “serious” because the AV sustained bruises on his/her arms. The SP was disqualified from providing direct contact services. 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 and internal review and determined that their policies and procedures were adequate but were not followed at the time of the incident. The facility added a new policy to their staff orientation training and employee handbook to include a more in-depth discussion regarding their guidance policy. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. On January 10, 2024, the facility was issued a Correction Order for the violations outlined in this report and for failing to note separations on a daily log. 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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