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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: 802580-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was alone in bathroom for approximately ten minutes. Date of Incident(s): November 28, 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 December 19, 2023; from documentation at the facility; and through four interviews conducted with two supervisory staff persons (P1 and P2), a facility staff person (the SP), and the AV’s family member (FM). Attempts were made via telephone and mail to contact and interview a staff person (P3), but P3 did not respond to the requests. According to the AV’s enrollment information, the AV was 29 months old and enrolled in a toddler room at the time of the incident. Consistent information was provided that the AV was potty trained. The AV’s classroom was next to a toddler bathroom and each had a doorway to the hall. The doorway to the toddler bathroom did not have a door on it. On the other side of the toddler bathroom was a hallway that had an open play area referred to as the bike area. Consistent information was provided that the SP, P2, and another staff person (P4) were assigned to the AV’s classroom. According to the facility’s attendance app, there were 20 toddlers including the AV in that room at the time of the incident. Consistent information was provided that P4 was on break during nap time. P2 provided the following information: · On a previous occasion, at approximately 1:45 or 1:50 p.m., P2 and the SP were in the toddler room toward the end of nap time. Four children, including the AV, woke up so P2 changed the other children’s diapers and told the SP to take the four children including the AV out to the bike area. Right before the SP left the room, P2 told the SP that after they used the bike area, the AV would need to use the bathroom. P2 counted the four children including the AV and said the number out loud before the SP left with the four children including the AV. · P4 came back from his/her break and P2 went to the facility office for administrative duties. P2 walked past the toddler bathroom but did not look inside. At approximately 2 p.m., P2 saw P3, who worked in a different classroom, bring the AV to the bike area and ask the SP why the AV was alone in the bathroom. The AV was “unfazed” and did not have any injuries. It was approximately ten minutes from when the AV left the toddler room three until P3 brought the AV to the SP. P1 spoke to P3 who said that at approximately 3 p.m., s/he was stocking the bathroom with supplies when s/he saw the AV in the bathroom sitting on a toilet. The AV was not upset. P3 looked around but did not see staff persons so s/he assisted the AV with finishing in the bathroom. P3 then brought the AV to the SP in the bike area. The SP provided the following information: · On the day of the incident, after the children ate lunch, the SP assisted with getting the children down for nap before going on his/her lunch break. At approximately 2 p.m., the SP returned to the classroom and P2 met the SP at the door with six children, not including the AV, and told the SP to get them out of the classroom because they were “too loud” with the other children sleeping. · The AV lay awake on his/her cot and P2 told the SP that the AV needed to use the bathroom while at the bike area. The SP told the AV to “come on” but the AV continued to lay on his/her cot, so the SP thought the AV was going back to sleep. The SP counted six children not including the AV and stood talking to P2. · Another child (C) who was with the group had used the toilet while the SP was on break. The SP was talking to P2 and the C and during that time, the AV must have “joined the group.” The SP then took the children into the hall and P2 shut the door to the classroom. The SP did not remember if P2 told the SP the number of children that were transitioning into the hall. · When the SP got to the bike area, s/he counted six children. Within two minutes, another staff person (the SP did not remember who) came over with the AV. The other staff person gave the AV to the SP and went back to his/her classroom. The AV came and sat on the SP’s lap and did not have any injuries. · The SP said that the AV must have heard P2 tell the SP about the AV needing to use the bathroom, so s/he went inside the bathroom instead of to the bike area. The AV was alone for approximately two minutes in the bathroom. The SP denied that it was possibly ten minutes that the AV was alone in the bathroom. According to the internal review, when P1 interviewed the SP shortly after the incident, the SP said that although s/he called the AV to the door before leaving the classroom, the SP “forgot” that the AV was part of the group by the time they arrived at the bike area. The SP did not count the children after leaving the classroom and did not count once s/he arrived at the bike area. The FM was aware of the incident and did not have concerns with the facility. According to the facility’s Active Supervision Policy and active supervision training: · All staff persons in each group were accountable for the children in their care. · It was “vitally important” that all staff persons “constantly” know the number of children in their care and are able to provide this number “immediately” when asked. · Staff persons counted children with them upon leaving any area, during the transition, and again upon arriving to a new area. Staff persons used an app and kept a written list of names of the children in his/her care. · Staff persons provided “continuous, direct supervision at all times.” Children were in sight and sound of staff persons “at all times.” · Staff persons received monthly supervision training; counted children “continuously;” when transitioning from one area to another, staff persons did not close doors or leave areas unattended without a “proper count” of the children in his/her care; staff persons communicated with each other; staff persons counted out loud when counting children and “tripled checked” that they had the correct number of children; and all transitions were verbally acknowledged if a child was brought from an area and the staff person waited for verbal confirmation from the other staff person. According to the facility’s Risk Reduction Plan, staff persons were responsible for maintaining visual contact with all children at all times. Children were not allowed to leave their assigned area without supervision. Staff persons continually maintained an accurate head count of the children in his/her care, along with a “current” list of the names of the children present and was done on an app. Facility documentation showed that the SP and other staff persons interviewed in this investigation received training on the facility’s Active Supervision Policy, active supervision training, Risk Reduction Plan, and the Maltreatment of Minor’s Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A stated that a child must have supervision at all times and that supervision was 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.
Conclusion: A. Maltreatment: Although P2 and the SP had inconsistencies with the amount of children that the SP brought into the hall and how long it had been from when the SP left the classroom until the AV was brought out to the bike area; consistent information was provided that on November 28, 2023, the AV was alone in the toddler bathroom without the knowledge or supervision of a staff person which was inconsistent with the facility’s Active Supervision Policy, active supervision training, and Risk Reduction Plan; and was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Given that no staff persons were aware that the AV, who was a toddler, was in the toddler bathroom for between two and ten minutes, they would not have been able to intervene in the event of an emergency or to protect the AV. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health when reasonable able to do so. 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. The SP was trained on the Active Supervision Policy, active supervision training, Risk Reduction Plan, and The Maltreatment of Minor’s Act. Although the SP told this investigator s/he did not realize that the AV joined the group, shortly after the incident, the SP told P1 that s/he “forgot” that the AV was part of the group by the time they arrived at the bike area. The SP also told P1 that s/he did not count the children after leaving the classroom and did not count once s/he arrived at the bike area. The SP was responsible for the care and supervision of the AV at the time of the incident. 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 for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the AV did not sustain an 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. All children were to have been counted and recounted during transitions. All staff persons continued monthly supervision trainings and 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 February 28, 2024, the facility was issued a Correction Order for the violation outlined in this report and for violating behavior guidance policy. 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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