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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: 1101595-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) fell off a changing table when a staff person (SP) turned around. Date of Incident(s): March 8, 2024 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 March 27, 2024; from documentation at the facility, medical records; and through four interviews conducted with three facility staff persons (SP, P1, P2), and the AV’s family member (FM). Due to the AV’s age s/he could not provide any information about the incident. The facility was located inside a larger building with multiple other businesses. Through the front entrance and down the hall were several classrooms including the Infants 2 classroom. The classroom was a large open room with cribs and a play area on one side. There were cabinets along with back wall with shelving on the walls above. The diaper changing area was located on top of one of the cabinets. There was a changing pad on the cabinet counter with the diapers, wipes, and other changing supplies located on the shelves above. The floor in that area was a linoleum type tile. The AV was 11 months old at the time of the incident and enrolled in the Infants 2 classroom. The FM provided the following information: · On March 8, 2024, the FM received a call from P2 stating that approximately 10-15 minutes earlier, the AV had fallen off a changing table and hit the ground. P2 said they put ice on the AV’s head, and s/he was “okay.” · Shortly after, the FM called the facility and asked for paramedics to be called. The FM drove to the facility and met the paramedics in the parking lot. The AV was sitting on P2’s lap when the FM went inside the facility. The AV looked “dazed” but was not crying. The AV had a red mark the size of a baseball on the left side of his/her head. · The paramedics checked the area and said the AV should get checked by a medical provider. The AV and the FM went in the ambulance to the hospital. On the way the AV started losing consciousness. The paramedics could not tell if the AV was dozing off to sleep or actually losing consciousness. The ambulance turned on the emergency lights and diverted to a different hospital. · At the hospital, the AV was given a computerized tomography (CT) scan which showed no bleeding. While at the hospital the AV drank a bottle and fell asleep. The AV seemed to be acting “normal” and returned to his/her home that evening. The AV was more irritable for the next couple days. The red mark on the AV’s head was gone by March 10, 2024. P1-P2 provided the following information: · On March 8, 2024, at approximately 12 p.m., P1 and the SP worked in the classroom and had just finished lunch. P1 changed the AV’s diaper and put him/her in a crib. P1 took another child and changed his/her diaper and was taking that child to a crib when the SP picked up the AV and took him/her to the changing pad area. · P1 told the SP that s/he had already changed the AV. The SP said that the AV had a bowel movement and needed to be changed again. P1 looked and saw the SP at the diaper changing area with the AV on the changing pad. The SP’s upper body turned to the side, and s/he looked like s/he was grabbing something off the shelf. The AV tried to stand up and fell off the changing table onto the floor. It appeared that the AV hit the left side of his/her head. The SP was not sure if the AV was able to break the fall with his/her hands. · The AV started “screaming” and the SP picked the AV up. P1 ran over and grabbed the AV and took him/her out of the classroom and to P2. P1 and P2 got the AV an ice pack and P2 remained with the AV in the staff person office where s/he calmed down and was trying to chew on the ice pack. The AV had a two-inch narrow red mark on the left side of his/her forehead. · P2 contacted the FM to tell him/her about the incident. The FM called back and said to call paramedics. P2 contacted the paramedics who arrived at the same time as the FM (approximately 12:30 p.m.). The AV was taken to the hospital. · The facility policy was to have a hand on the child at all times while changing a diaper. P2 had no prior concerns with the SP. The SP provided the following information: · On the date of the incident at “a little after noon,” the SP brought the AV to the changing area and put the AV on the pad. The SP grabbed the diapers and other supplies, then “fluffed” the diaper out with two hands. · Another child screamed and it caught the SP “off guard” so s/he turned to look. P1 made “warning noises” and the AV leaned forward and rolled off the side of the SP’s stomach onto the floor. The AV hit the floor and the SP’s foot. · The AV started crying and had a palm sized red mark on the left side of his/her forehead. P1 took the AV to the staff person office to get assistance. · The SP kept a hand on children when s/he changed them, but on this occasion, s/he did not have a hand on the AV because s/he was prepping the supplies and that was the SP’s “routine.” The Incident/Accident Report stated that on March 8, 2024, at 11:55 a.m., the AV rolled off the changing table to the floor. The AV was given an ice pack for a red mark and 9-1-1 was called for assessment at the FM’s request. The Risk Reduction Plan stated that staff persons had one hand on children at all times during a diaper change. The Diapering Procedure stated to keep one hand on the child the “entire time.” Facility documentation showed that all staff persons interviewed were trained on the facilities policies including the Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Conclusion: A. Maltreatment: Information was consistent that on March 8, 2024, at approximately 12 p.m., the SP was changing the AV’s diaper at the diaper changing area. The SP looked to the side towards the crib area and the AV rolled/fell off the changing pad onto the floor. The SP did not have his/her hands on the AV. The AV cried and had a large red mark on the left side of his/her forehead. The FM and paramedics were called, and the AV was taken to the hospital. A CT scan showed no bleeding or other injury and the AV returned to his/her home. Given that while changing the AV, who was 11 months old at the time, the SP did not have his/her hands on the AV while preparing the changing supplies, resulting in the AV falling off the counter and sustaining a red mark on his/her forehead, there was a preponderance of the evidence that the SP failed to protect the AV from conditions that seriously endangered the AV’s physical health. 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 and/or 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 worked with the AV in the classroom and while changing the AV was responsible for the supervision and safety of the AV. The SP was trained on the facilities policies including the Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. 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 for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident, and the AV did not sustain a serious injury which required the care of a physician. 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 the SP did not have a hand on the AV at all times. All staff persons were retrained on diapering procedures. The facility added the requirement to use safety straps while changing any child and foam anti fatigue mats were added around changing table areas. 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. 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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