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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: 1000499-CCC (Child Care Center) Investigator(s): Van Mulheron Suspected Maltreatment Reported: It was reported that a staff person (SP) put and left an alleged victim (AV) in the bathroom for approximately 60 minutes. Date of Incident(s): February 9, 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 February 28, 2024; from documentation at the facility; and through seven interviews conducted with two supervisory staff persons (P1 and P2), three staff persons (P3, P4, and the SP), and the AV’s two family members (FM1 and FM2). The AV’s enrollment form stated that at the time of the incident, the AV was 21 months old and enrolled in a toddler classroom. The AV was approximately 34 inches tall. Given the AV’s age, the AV was not able to provide information for this report. The facility had two toddler classrooms and the toddler classroom the AV was enrolled was triangular. The entrance to the Toddler A classroom was located at a corner of two walls. To the left of the classroom door were the children’s personal lockers and in front of the lockers were two half-moon tables that were used for meals and activities. Past the lockers at the end of the wall was bathroom. To the right of the classroom door were cabinets that teachers stored cleaning supplies and personal items. The bathroom door was not a full door but was approximately 43 inches high. The door handle to the bathroom was located inside of the bathroom and in the bathroom was a diaper changing station that was attached to a wall, a broom, a child size toilet, sink, and waste basket. There was a video surveillance camera located directly above the bathroom door the faced into the classroom. The middle of the classroom had toy shelves, a large motor play structure, and a carpeted area that was used for placing cots on during rest time. The classroom’s schedule said that lunch time was 11:30 a.m. to 12:30 p.m. and rest time was 12:30 p.m. to 2:30 p.m.
FM1 and FM2 were aware of the incident and had no concerns. The staff persons were very respectful and took good care of the AV. FM1 and FM2 said that at the time the AV had not started toilet training. P1-P4 provided the following information: · On February 9, 2024, P3 worked with the SP in the classroom with the AV. P3 said that s/he and the SP gave lunch the children and as they ate, P3 put out cots rest time. After lunch, P3 and the SP cleaned the children’s hands and they lay down for rest time. The SP helped some children fall asleep while P3 began to clean up lunch. · After P3 cleaned up about half of lunch, between 12:30 and 12:45 p.m. s/he went on break. At this time, the AV was still awake. · About 1 p.m., P2 went into the classroom to get a pacifier and noticed that lunch had not been fully cleaned up. P2 also saw that the AV was awake on his/her cot and was laughing “quietly.” P2 then told the SP to clean up lunch and left the classroom. · At 2:15 p.m., P3 returned to the classroom and noticed there were two empty cots including the AV’s. The SP had his/her coat on and was ready to go on break. P3 said s/he knew that one child (C) left during naptime and asked the SP where the AV was. The SP replied, “I locked [him/her] in the bathroom.” P3 asked, “Why?” and the SP replied, “Because [s/he] was not listening and I could not get [him/her] to sleep.” The SP then left the classroom. P3 saw that the bathroom door was closed and walked over to look in the bathroom and saw the AV standing there with his/her hands over his/her eyes. The AV looked “a little scared” but was not crying. P3 took the AV out of the bathroom, had the AV lay on his/her cot and rubbed the AV’s back until s/he fell asleep. P3 said s/he did not know how long the AV was in the bathroom and that the AV was not toilet trained and wore diapers. · At approximately 2:40 p.m., P3 saw P2 and told P2 about the incident and then P2 called P1. P1 had P2 review video footage and saw that the AV was in the bathroom for “over an hour.” · When the SP returned to the classroom, P3 told the SP that it “was not OK” to put the AV in the bathroom. The SP replied, “Yeah, but [s/he] was not listening to me … [s/he] should have listened to me.” P3 replied back, “It’s not OK to not have eyes on [the AV].” The SP replied, “Yeah, you are right.” · On March 12, 2024, P1 spoke with the SP about the incident. The SP told P1 the following said, “Yeah, I did have [him/her] in there,” and that FM1 and FM2 previously “complained” that they did not want the AV eating off the floor. The SP said s/he was cleaning up lunch and the AV went to the table and tried to eat food. The SP redirected the AV back on his/her cot, but the AV went to the table again and ate food off the floor. The SP then took the AV into the bathroom, changed the AV’s diaper, gave the AV a ball to play with, and closed the bathroom door with the AV in the bathroom while the SP cleaned up lunch. The SP said that s/he checked on the AV while s/he was cleaning. The SP said that while cleaning s/he got tired and needed to take some breaks, so it took him/her approximately 20 minutes to clean up lunch. P1 asked the SP if s/he could had done “something different.” The SP replied, “Yeah, I could have sat with [the AV].” · P1 – P4 provided consistent information that when a child was in the bathroom, there must be a staff person in the bathroom with them the entire time. P1-P4 also stated that although the bathroom door was a not a full door, when the door was closed, staff persons could not see a child on the other side unless a staff person was next to the door and looked over. · P3 and P4 provided consistent information that if a child did not want to sleep after 30 minutes of being on his/her cot, staff persons would let the child lay quietly or give him/her a book to read either on the cot or at the tables. P3 and P4 said that all the children in the toddler slept during nap time. · P1-P4 said that the toilet was a possible hazard in the bathroom and that the toilet was unsanitary and there was a risk of the AV falling into the toilet. · P1 said that s/he had some prior concerns regarding the SP’s performance and placed written documentation of his/her concerns in the SP’s file. P1 concerns included not properly supervising infants, leaving an infant unattended on the changing table, and on two different occasions left two preschool classrooms out of ratio. There were two videos of the classroom. The first video began at 1 p.m. and was 60 minutes long and the second video began at 2 p.m. and ended at 2:30 p.m. Due to the placement of the camera, there was no view of the bathroom or the bathroom door. The videos showed the following: · At 1 p.m., the SP was sitting on the carpet next to the AV who was awake and lying on his/her stomach partially off his/her cot and a cell phone was located near the AV’s head. There were plates of food on the tables and food was on the floor. The AV was the only child in the classroom awake. · From 1:05:52 to 1:09:52 p.m., the C’s parent arrived, spoke with the SP, woke up the C and took him/her into the bathroom. The AV lay on his/her cot. · From 1:10 to 1:11:44 p.m., P2 entered the classroom, went to a locker and retrieved a pacifier, appeared to speak with the SP, and then left the classroom. The SP walked towards the teacher’s cabinets with his/her back towards the AV. · From 1:11:45 to 1:13:50 p.m., the AV got off his/her cot, walked to the lunch table, and ate food off a plate. The parent and the C left the bathroom and then the classroom. The SP saw the AV at the table, walked towards the AV, picked up the AV and placed him/her back on his/her cot with his/her blankets. The SP then picked up plates off the tables, threw the plates away, and then walked back towards the teacher’s cabinets. The AV again got up from the cot, walked to the table and ate the food on the table. The SP again walked over to the AV, picked the AV up, and walked holding the AV into the bathroom and out of sight of the camera. (Note: The SP said that at this time the AV was waving” his/her hands and “jumping around.” However, in the video the AV’s arms were down and not waiving, and the AV was not jumping around.) · At 1:18:46 p.m., the SP walked from the bathroom and returned into view of the camera. · From 1:18:46 to- 1:45:56, the following occurred: o The SP initially retrieved cleaning supplies from the teacher’s cabinet and started to clean off the tables. o At 1:19:32 and 1:22:30, the SP walked to the bathroom. o From 1:24:16 to 1:27:25, the SP sat on a table near the door and looked at his/her cell phone. o At 1:27:37, the SP walked to the bathroom. o From 1:28:27 to 1:32:25, the SP sat on a table near the door looking at an I-pad. o At 1:32:36, and 1:37:13, the SP walked to the bathroom. o From 1:40:30 to 1:42:11, the SP sat on a table near the door and looked at his/her cell phone. o At 1:42:22, the SP walked to the bathroom and reappeared with a broom and dustpan) and then at 1:45:13 walked to the bathroom. · At 1:45:56, the AV appeared on screen, stopped and picked something off the floor and put it into his/her mouth. At 1:46:04 p.m., the AV walked back into bathroom as the SP walked towards the AV. The SP followed the AV to the bathroom and out of view and reappeared at 1:46:22. · From 1:46:22 to 2:11:06 p.m., the following occurred: o The SP continued to clean the tables and sweep the floor. o At 1:46:41 and 1:48:07, the SP walked to the bathroom. o From 1:53:44 to 1:55:50, the SP stood by a large muscle toy facing classroom door while s/he spoke on his/her cell phone. o At 1:59:07 and 2:00:09, the SP walked back to the bathroom.
· At 2:11:06 p.m., the SP finished cleaning and sat on a shelf near the AV’s cot and looked at his/her cell phone while the AV remained in the bathroom. · At 2:15:26, P3 returned to the classroom and engaged in a conversation with the SP. · At 2:16, P3 walked into the bathroom and retrieved the AV and lay the AV on his/her cot. · At 2:28, the SP left the classroom. Based on a review of the camera footage, the AV was in the bathroom for approximately 59 minutes. During the time the SP brought the AV into the bathroom 1:18:46 until P3 took him/her out of the bathroom at 2:16, the SP checked on the AV approximately 11 times with each check lasting between 10 to 48 seconds. The SP last checked on the AV at 2:00:09, 15 minutes prior to when P3 took the AV out of the bathroom at 2:16. The SP provided the following information: · On February 15, 2024, (actual date was February 9, 2024) the SP was working in the toddler classroom with P3. The SP said that the class had spaghetti that day and it was “pretty messy.” Normally after lunch, one staff person helped the children fall asleep and the other staff person cleaned up lunch. On that day, the SP was helping the children to sleep and P3 was to clean up lunch but P3 also helped the children to sleep and did not clean up any of the lunch mess. P3 then went on break at 12 p.m. and at that time the AV was awake and on his/her cot. · At an unknow time later, P2 came into the classroom and told the SP to clean up lunch and then left the classroom. · The SP began to clean, and the AV got off his/her cot and started to eat food that was on the floor. The SP went to the AV and took the food out of the AV’s mouth. The SP said that previously FM1 and FM2 had voiced concerns that the AV ate off the floor at home and they did not want him/her to eat off the floor at school. · The SP said that the AV was toilet training and that when the AV was eating the food, the AV made “cues” including “waving” his/her hands and “jumping around” indicating that s/he wanted to go to the bathroom. The SP provided two different accounts of what happened next: o First, the SP said that the AV was toilet training, so s/he took the AV into the bathroom, let the AV use the toilet by him/herself, the SP left the AV in the bathroom with the door “cracked” open, and began to clean up lunch. The SP checked on the AV as s/he cleaned. o Later, the SP said that when s/he took the AV into the bathroom, s/he took off the AV’s diaper, sat the AV on the toilet, and waited with the AV for 10-15 minutes as the AV sat on the toilet. After the AV completed toileting, the SP gave the AV a bucket of toys, that was kept in the bathroom, to occupy the AV while s/he cleaned the classroom. The SP kept the AV in the bathroom to not “wake up” the other children leaving the door “half-way” open. · The SP left the AV in the bathroom and started to cleanup. The SP said that as s/he cleaned, s/he checked on the AV “20-30 times” and walked to the bathroom to check on the AV “multiple times.” Once or twice the AV tried to leave the bathroom, but the SP redirected the AV back into the bathroom. · The SP said it took him/her about “30 minutes” to clean up lunch because s/he had to sit down several times, but s/he was always able to see the AV. The SP said that the bathroom door was a half door, and the AV was about “the same size” or a “little bit” smaller than the door. The bathroom door was “really small,” and the SP saw the AV “over the door.” The SP also said the bathroom door was open. · At 2:45 p.m., P3 returned to the classroom and the SP told P3 that “[the AV] was in the bathroom … I left him/her there so I could clean up” and that the AV was “not in trouble.” The SP then left the classroom. · The SP said that the AV did not cry or yell while s/he was in the bathroom. The SP felt that it was “reasonable” for a toddler to be in the bathroom for 30 minutes because the AV was “content,” and the SP did not want the AV eating off the floor or waking up the other children. · The SP said that when s/he was trained on supervision, that a child was considered “unattended” if a staff person “left the classroom” and s/he did not leave the classroom. The facility’s Positive Behavior Guidance Plan and Separation Report Guidelines stated that no child can be separated from the group unless the staff persons had tried less intrusive methods of guiding a child’s behavior which have been ineffective, and the child was demonstrating imminent physical danger to self or others with behaviors that was significantly or persistently unsafe. A child who requires separation from a group must remain in an unenclosed part of the classroom where a child can be continuously seen and heard by a staff person. In addition: separations must be noted on a Separation Log. The facility’s Supervision Policy and Risk Assessment and Reduction Plan stated that all children must be within sight and sound at all times. The facility’s Rest Time policy stated that children who have not fallen asleep must be allowed to get up and do quiet activities. Facility records showed that P1-P4 and the SP were trained on the facility’s Positive Behavior Guidance Plan and Separation Report Guidelines, Supervision Policy, Rest Time Policy, Risk Assessment and Reduction Plan, and the Reporting of Maltreatment of Minors Act. Relevant Rules or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states that a child must have supervision at all times and that supervision is 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. Minnesota Rules, part 9503.0055, subpart 4, states in part that no child may be separated from the group unless the child’s behavior threatens the well being of the child or other children in the center. A child who is separated must remain within an unenclosed part of the classroom where the child can be continuously seen and heard by a program staff person. Conclusion: A. Maltreatment: On February 9, 2024, the SP was supervising a toddler classroom, including the AV, during nap time. At 1:10 p.m. P2 came into the classroom and told the SP to clean up lunch. The AV walked to the table twice and ate food from the table. The SP then picked up the AV and took him/her to the bathroom where the SP left the AV by him/herself for approximately 59 minutes. This was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were violations of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A; and Minnesota Rules, part 9503.0055, subpart 4. From approximately 1:18 to 2:16 p.m. the SP cleaned up lunch and sat in the classroom at locations that based on the height of the AV and the height of the door the SP would not have been able to see the AV and looked at an I-pad and/or his/her phone. The SP walked to the bathroom 11 times with each time lasting between 10 to 48 seconds. According to the video, the SP last checked on the AV at 2:00:09, 15 minutes prior to when P3 returned to the classroom and took the AV out of the bathroom at 2:16. The SP said that the bathroom door was open, however, P3 said that when s/he came into the classroom, the bathroom door was closed and P1-P4 provided consistent information that the AV would not have been visible over the door unless a person was standing next to the door looking over. When P3 asked the SP where the AV was, the SP replied, “I locked [him/her] in the bathroom.” P3 asked, “Why?” and the SP replied, “Because [s/he] was not listening and I could not get [him/her] to sleep.” The SP said s/he told P3 that “[the AV] was in the bathroom … I left [him/her] there so I could clean up” and that the AV was “not in trouble.” Later after the SP returned from break, P3 told the SP that it “was not OK” to put the AV in the bathroom. The SP replied, “Yeah, but s/he was not listening to me … s/he should have listened to me.” P3 replied, “It’s not OK to not have eyes on [the AV],” and the SP said, “Yeah, you are right.” The SP left the AV, who was 21 months old, in the bathroom unsupervised for 59 minutes exposing the AV to dangers in the bathroom and did not allow for staff person’s intervention in the event the AV needed assistance or if there was an emergency. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered his/her physical or mental health when reasonably 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 responsible for the care and supervision of the AV at the time of the incident and was trained on the facility’s Supervision Policy, Separation Report Guidelines, 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 an injury that 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 found that their policies and procedures were adequate but not followed. 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 May 9, 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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