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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: 1105691-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP1) took his/her fingers under an alleged victim’s (AV1) chin and forcefully pushed AV1’s head back. On another occasion, SP1 aggressively dragged AV1 causing an injury to AV1’s back. Allegation Two: A staff person (SP2) dragged an alleged victim (AV2) across the room by his/her wrist. Date of Incident(s): November 13, 2023, prior and ongoing Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a), and subdivision 23, paragraph (a): "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 December 8, 2023; from documentation at the facility; and through eight interviews conducted with seven facility staff persons (SP1, SP2, P1, P2, P3, P4, P5), and AV1 and AV2’s family member (FM). Due to their ages AV1 and AV2 were not able to provide any information about the incidents. The Behavior Guidance policy stated that at no time was a child subjected to physical corporal punishment (included but not limited to rough handling, shoving, hair pulling, ear pulling, slapping, shaking, kicking, hitting, biting, pinching, spanking) and/or emotional abuse (included but not limited to name calling, ostracism, shaming, making derogatory remarks about the child or the child’s family, and using language that threatens, humiliates, or frightens the child. All staff persons interviewed for this investigation received training on the facility’s policies including the Behavior Guidance policy and on the Reporting of Maltreatment of Minors Act prior to the incident. Allegation One: It was reported that SP1 took his/her fingers under AV1’s chin and forcefully pushed AV1’s head back. On another occasion, SP1 aggressively dragged AV1 causing an injury to AV1’s back. AV1 was 29 months old at the time of the incident and enrolled in the Get Set classroom. The classroom was a long narrow room. There were several u-shaped child sized tables with child sized chairs. P1 provided the following information: · SP1 was very rough with the children, grabbed them by their arms, slammed them down on the ground, and swung them around. · On one occasion, during lunch time, AV1 went under a table in the classroom. SP1 pulled AV1 by the legs out from under table. AV1’s back lifted off the ground and s/he hit his/her back on a metal part on the table. Then SP1 “slammed” AV1 down in a chair and AV1 fell off the chair. P5 walked in and asked what happened. SP1 said that AV1 fell off the chair. P1 said that was not what happened and told SP1 that s/he needed to tell the truth. P5 lifted AV1’s shirt and on AV1’s back there was a mark where some skin was torn off and it was bleeding. · On another occasion, P1 was leaving the classroom when AV1 started to follow P1. P1 told AV1 that s/he needed to stay in the classroom. SP1 went up to AV1 and SP1 put a finger under AV1’s chin and “jerked” AV1’s neck back hard and made him/her cry. P5 said that on the day of the incident, that caused AV1’s back to be scratched s/he came into the classroom. SP1 told P5 that AV1 was on his/her hands and knees under the table with his/her head facing out. SP1 picked up AV1 under the arms and AV1 scraped his/her back on the top of the table. P5 had no concerns with SP1. P2 said that SP1 could be calmer and talk instead of yell at the children. P2 had never seen SP1 be rough with any children. P4 said s/he did not have any concerns with SP1 related to interactions with the children. The FM said that on the date of the incident, s/he received a call from SP1. SP1 said that AV1 was under a table and did not want to come out. SP1 was “probably too aggressive” and when s/he pulled AV1 out, AV1 hit his/her head on the table and scratched his/her back. The FM had concerns in the past with SP1 being aggressive with another child and AV1 coming home in wet clothing. SP1 provided the following information: · On the date of the incident, AV1 was lying on his/her stomach under the table. SP1 asked AV1 to come out multiple times for lunch, but AV1 refused. SP1 pulled AV1’s legs to “reach” him/her then lifted SP1 under his/her elbows. · AV1 scratched his/her back on a sharp piece of metal by the leg of the table and made a whining noise. SP1 was unaware that AV1 had scratched his/her back and thought maybe s/he just bumped him/herself on something. SP1 looked at AV1’s back and saw a mark right above AV1’s diaper line but did not think it bled. · When asked by this investigator if SP1 roughly pulled AV1 out and slammed him/her down in the chair, SP1 said that s/he “meant” to put AV1 in the chair softy but his/her “anger got to me.” SP1 said that s/he should not have done that and next time s/he should think before s/he acts. SP1 said s/he was “annoyed” about how many times s/he had to ask AV1 to come out from under the table and was angry and/or frustrated when s/he pulled AV1 out from under the table. · SP1 said on another occasion, AV1 was running in the classroom and SP1 gently put a finger under AV1’s chin and told him/her that s/he could not run in the classroom because it was not safe. SP1 said that it was a light touch and AV1 would have “barely” felt SP1’s finger on AV1’s chin. A review of Incident Reports for AV1 showed that on October 12, 2023, AV1 was crawling under the table and SP1 tried to push AV1 back in his/her chair and the leg of the table “got” his/her back. There was a red mark on AV1’s back. A photo provided by the FM showed a half dollar sized abrasion on the middle of AV1’s lower back near his/her waistline. During the course of the investigation, three other family members (CP1, CP2, CP3) of other children came forward with concerns from the past. CP1 had concerns about his/her child’s chronic diaper rash while working with SP1. CP2 had concerns about a thumb print shaped bruise his/her child had on his/her arm in spring 2023. SP1 told CP2 it was from being pinched in a drying rack but after allegations surfaced for this report, CP2 was concerned that SP1 caused the bruise. CP3 was told by P1 that SP1 had pushed CP3’s child’s head down into the ground sometime in summer 2023 or before. The child had a period where s/he had multiple bruises on his/her head and the facility was reporting that s/he was always falling. Given that at the time of these incidents there was no maltreatment suspected or alleged and that the injuries had reasonable explanations, these concerns were not investigated, and the focus of the investigation was the aforementioned allegations. Relevant Minnesota Statutes and Rules: Minnesota Rules, part 9503.0055, subpart 1, item A, states that facilities must ensure that each child is provided with a positive model of acceptable behavior. 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 person: 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 for Allegation One: A. Maltreatment: Regarding pushing AV1’s head back: Although P1 said SP1 put a finger under AV1’s chin and “jerked” AV1’s neck back hard and made him/her cry, given SP1 said s/he gently put a finger under AV1’s chin, and that AV1 did not sustain an injury there was not preponderance of the evidence that SP1’s actions inflicted an injury or a substantial risk of injury to AV1. It was not determined that abuse occurred (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 the scrape on AV1’s back: Information was consistent that on October 12, 2023, AV1 was under a table in the classroom when SP1 pulled AV1 out by his/her legs. AV1 sustained an abrasion on his/her back likely from something sharp on the table. P1 said SP1 pulled AV1 by the legs lifting him/her in the air and causing him/her to hit his/her back on the table. SP1 then “slammed” AV1 down on a chair. When AV1’s shirt was lifted there was a mark on AV1’s back where some skin was torn off and it was bleeding. The FM said s/he received a phone call on the date of the incident from SP1 who said that s/he was “probably too aggressive” when s/he pulled AV1 out from under the table. SP1 said s/he asked AV1 to come out from under the table multiple times and was “annoyed.” SP1 said, his/her “anger got to me” and s/he pulled AV1’s legs, then lifted AV1 under the arms causing him/her to scrape his/her back on a piece of metal on the table, and then put AV1 roughly in a chair. AV1 was not a danger to him/herself or others at the time of the incident and the conduct of pulling a child by their feet, picking them up roughly, and putting them roughly down on a chair was not accidental; was inconsistent with the facility’s Behavior Guidance policy; and a violation of Minnesota Rules part 9503.0055, subpart 3, item A. Therefore, there was a preponderance of the evidence that there was a failure to supply AV1 with reasonable and necessary care and a failure to protect AV1 from conditions or actions that seriously endangered AV1’s physical health when reasonably able to do so. In addition, given the appearance of AV1’s injury which was consistent with and described as being caused by a sharp area on the underside of the table; and that there was no information that AV1’s injury was sustained by other means, there was a preponderance of the evidence that SP1’s conduct inflicted a physical injury to AV1. 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. SP1 was responsible for AV1’s care and supervision at the time of the incident. SP1 received training on the facility’s Behavior Guidance policy and the Reporting of Maltreatment of Minors Act. SP1 was responsible for maltreatment of AV1. 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 SP1 was responsible was not “recurring” but was “serious” maltreatment. SP1 was responsible for a single incident for which AV1 sustained tissue damage which met the definition of serious maltreatment for physical abuse. Allegation Two: SP2 dragged AV2 across the room by his/her wrist. AV2 was 9 months old at the time of the incident and enrolled in the infant classroom. The FM was told by a former staff person that SP2 pulled AV2 by the wrist. When the FM asked SP2, SP2 started crying and was “mortified” and “apologetic.” The FM had no other concerns with SP2. P3 had no concerns with SP2’s or any other staff persons interactions with any children. P3 had never seen any staff person picking up or carrying a child inappropriately. P5 had no concerns with SP2. AV2 liked to crawl over the top of other children and often staff persons had to pick up AV2 and move him/her off the other child. P5 felt the former employee was upset or “disgruntled” with the facility.
SP2 said s/he never dragged AV2 by the wrist. The day after a former employee had visited the classroom, FM2 asked SP2 about dragging AV2 by the wrist. SP2 said this never happened and did not know why someone would say that. A review of Incident Reports for AV2 showed that on October 2, 2023, AV2 crawled and lost his/her balance falling forward on the hard floor. AV2 sustained a bruise on the left side of his/her forehead. On October 26, 2023, AV2 crawled on a mat and fell forward bumping his/her lip on the floor. No injury was noted. Conclusion for Allegation Two: Although it was reported that SP2 dragged AV2 by the wrist across the floor, given SP2 denied dragging AV2 across the floor, that P3 and P5 each had no concerns regarding SP2’s interactions with children, and that AV2 did not appear to have any injury that would indicate that s/he had been dragged across the floor, there was not a preponderance of the evidence that SP2’s actions caused an injury other than by accidental means or represented a risk of substantial injury. It was not determined that abuse occurred (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. 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 when P1 did not report the incident to a supervisory staff person. Action Taken by Department of Human Services, Office of Inspector General: SP1 was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that SP1 was responsible for maltreatment is subject to appeal. On January 26, 2024, 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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