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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: 830403-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left in a classroom unsupervised for 14 minutes. Date of Incident(s): April 17, 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 May 2, 2024; from documentation at the facility; and through four interviews conducted with two facility staff persons (SP, P), the AV’s family member (FM), and the AV. The facility was in a building with five classrooms located along the outside edges of the building. Through the main entrance was an office, a kitchen, and two bathrooms. The preschool classroom was to the left of the entrance down a short hallway. The classroom was a large open room with three large tables and multiple shelving units. The bathroom for the classroom was located outside of the classroom down a short hallway. The bathroom had three stalls with toilets. The AV was three years old and enrolled in the preschool classroom at the time of the incident.
The AV said s/he did not line up at the door and was “hiding” because s/he did not want to go to the bathroom. The SP came back and told the AV to come out and use the bathroom. The P provided the following information: · On the date of the incident, the P was in his/her office when the SP asked to talk about what had just happened. The SP said that the AV had been in the classroom alone for a period of time. The P reviewed the cameras and determined the AV had been alone in the classroom for 14 minutes while the class was out in the hallway using the bathroom. · When using the bathroom, the children went out into the hallway and sat down along the wall. Several children used the bathroom at a time while the SP watched from the hallway keeping all the children within sight and sound. · The SP said that the AV had not wanted to use the bathroom and when s/he was in line to leave the classroom, s/he went and snuck under a table. After using the bathroom, the SP lined up the children to go back inside the classroom and noticed that the AV was not in the hallway. · The P had no prior concerns with the SP. After this incident, the facility implemented a laminated sheet with children’s names on them so that the staff persons could check off as they counted. The SP provided the following information: · On the day of the incident, the SP worked in the classroom by him/herself. The SP lined the children up by the door to go to the bathroom. There were two children in front of the SP that were unhappy and started screaming and crying. The SP started counting the children as they exited the classroom, and the AV must have “somehow snuck out” of line. The SP counted all the children. · The SP exited the classroom and went into the hallway with the children. After a “good ten minutes,” the SP was going to tell the AV to use the bathroom, but the SP did not see the AV. The SP looked into the classroom and saw the AV under a table talking to him/herself. The SP brought the AV out into the hallway and told a supervisory staff person. · The SP said that s/he knew that the AV was in line because the SP counted the AV. The SP counted the children as they were walking out the door but did not know how the AV got back inside the classroom. · The AV had sensory issues when it was loud and did not like to go to the bathroom as the hallway was loud. The AV often cried or covered his/her ears when it was too loud. The FM said that the AV had some “issues” with noise and might try to hide if there was a lot of noise in the classroom. Video footage showed that on the date of the incident, the classroom was sitting down at the tables and eating. After about five and a half minutes, the children start lining up at the door. The AV went to a fabric gaming type chair and hid behind it. After approximately 45 seconds the children left the view of the camera (likely going out the door). After approximately 15 seconds the AV came out from behind the chair and did multiple things throughout the room including going over to the door out of the camera’s view, jumping on a cot, and going under tables. At some point a staff person came into the room and took the lunch cart out but did not seem to notice the AV. The AV went still and stood near the wall. After approximately fourteen minutes the AV ran to the door and out of camera view (likely going out to the hallway with the rest of the class). The School Employee Handbook stated that children were within sight and sound of a staff person at all times. The Risk Reduction Plan stated that during times of transition, children formed a line using a walking rope. Staff persons called the children by name to hold onto the rope. Staff persons used face to name every time the rope was used. If only one staff person was present, the staff person was at the front of the line facing the children. Staff persons counted the number of children transitioning to ensure that all children were present. Facility documentation showed that staff persons were trained on the facility’s policies including the School Employee Handbook and The Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute 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. Conclusion: A. Maltreatment: Information was consistent that on April 17, 2024, the AV was left in the classroom without the knowledge or supervision of a staff person for approximately 14 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The SP was not aware that the AV was still in the classroom when s/he took the other children out of the classroom to the hallway to use the bathroom, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Although the classroom was contained, the AV, who three years old, was unsupervised for 14 minutes with no staff person available to intervene if the AV attempted to do something dangerous, injured him/herself, or in the event of 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 the AV’s 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 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 in the AV’s classroom and was responsible for supervision of the classroom at the time of the incident. The SP was trained on the facility’s policies including the School Employee Handbook and The Risk Reduction Plan 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 for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV was not injured. 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 the supervision policy was not followed. Staff persons were retrained on following all policies on transitioning children within 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 June 12, 2024, the facility was issued a Correction Order for the violation 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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