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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: 1077423-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was in a facility bathroom for approximately 25 minutes without staff persons’ (SP1 and SP2) supervision or knowledge. Date of Incident(s): March 19, 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 28, 2024; from documentation at the facility; and through five interviews conducted with the AV’s family member (FM), two facility supervisory staff persons (P1 and P2), and facility staff persons (SP1 and SP2). Facility documentation showed the AV was sixteen months old and enrolled in the Grape toddler classroom at the time of the incident. At the time of the incident the children were in the Banana toddler classroom. The facility was located in the lower level of a small, rectangular strip mall. In the middle of the facility was a long hallway and off the hallway were five classrooms, a muscle room, and three bathrooms. The Grape and Banana classrooms were at the end of the hallway and located within the Grape classroom was a bathroom the toddler children used. The toddler bathroom had a half door approximately three and a half feet tall and at the top of the half door was a slide lock. Inside the bathroom was a counter where children were placed to have their diaper changed. There was a hand sink built into the counter and on the counter was hand soap and Dawn dish soap. There was a set of movable wooden stairs next to the counter for children to climb up onto the counter themselves or to wash their hands. There was a single toilet in the bathroom and a stool next to the toilet for children to stand on. Also in the bathroom was a stacked washer and dryer, a foot operated trash can, and a bench that ran along a wall for children to sit on. The Banana classroom was on the opposite side of the hallway from the Grape classroom. In the hallway, there were cubbies where the children’s coats and personal items were stored. The facility had a video camera just outside the Grape classroom that provided recorded footage. The facility used a mobile application (app) platform to communicate with families and streamline administrative functions. The FM provided the following information: · The AV transitioned from infants into the toddler room earlier in the month and the FM was not “familiar” with the staff persons who cared for the AV. On March 19, 2024, at approximately 4:40 p.m., the FM arrived at the facility and prior to arriving the last update the FM had received on the app had been at 3:30 p.m. (Note: The app said that the AV had snack at 3:26 p.m.) When the FM arrived at the facility, “usually” the AV’s class was in the “muscle room.” The FM went there and looked for the AV at the doorway but did not see him/her. Then the FM went all the way into the room but still did not see the AV. The FM asked a staff person if s/he knew where the AV was, and that staff person did not respond. Then the FM left the muscle room and walked to the AV’s classroom at the other end of the hallway. · The door to the AV’s classroom was open, the lights were off, and a staff person was in the room cleaning. The FM asked the staff person where the AV was, and s/he told the FM that s/he did not know. The FM “started to panic” and began to look in other classrooms and on the playground. · A staff person suggested that maybe another family member picked up the AV and the FM called that family member and was told that s/he had not picked up the AV. The FM stayed on the phone with that family member and looked in “side rooms” with another staff person. That staff person found the AV in the Grape classroom bathroom with the lights off. The AV was sitting on the bathroom floor “silently crying.” The FM told the other family member that s/he had found the AV, ended the call, and picked up the AV. · The FM stated that s/he looked for the AV for approximately five minutes. P1 then came and told the FM that s/he would look into what had happened, and the FM and the AV left the facility. Once the AV was home, s/he was “happy” and “normal.” · Approximately 30 minutes later, P1 called the FM and told him/her that the “camera footage” showed that SP1 and SP2 brought “all” the children into the bathroom and when they were finished, took the children into the hallway to put on coats to go outside and that the AV had been left in the bathroom. After the group came back inside, they went to the muscle room and the AV was still not with them. P1 told the FM that it looked like SP1 and SP2 did a head count in the hallway before going outside but must have done it “incorrectly.” The FM did not know if other “head counts” were completed. · P1 told the FM that the AV was unsupervised for approximately 25 minutes. P1 provided the following information: · On March 19, 2024, at approximately 4:45 p.m., s/he was in the kitchen and a staff person told him/her that the FM was at the facility and looked for the AV. P1 left the kitchen and saw SP1 in the hallway and asked if the AV had been outside with him/her. SP1 told P1 that the AV had not been outside with him/her. P1 then went to the playground but did not see the AV. When P1 came back inside, the FM had the AV. P1 did not recall if the AV was wearing his/her jacket when the FM found him/her. · P1 apologized to the FM and told him/her that s/he would follow up with him/her later that evening and the FM and the AV left the facility. P1 talked with SP1 who told him/her that when the group left the bathroom, s/he told SP2 that they had 10 children. SP2 told SP1 that a child had left so they had 9 children. P1 then talked with SP2 who was “distraught” and did not think that it was his/her fault that the AV had been unsupervised because s/he was not the lead teacher. Then P1 viewed the camera footage. · P1 watched the video and saw that at after the group used the bathroom in the Grape room, including the AV was in the Banana room eating snack. At 4:13 p.m., the group went into the hallway to put on coats. P1 did not see the AV at that time and stated that the AV may have “wandered” into the bathroom as the group transitioned from the Banana classroom to the hallway or when they were putting on coats in the hallway. Then the group left the hallway and the recording stopped because the camera was motion censored. The camera started to record again when the FM went down the hallway to the AV’s classroom. P1 estimated the time the AV was unsupervised was 35 minutes from the time the group left the hallway until the FM found the AV in the bathroom. P1 then called the FM and told him/her what s/he learned and saw on video. · Staff persons were trained to use the app on an iPad to complete name to face attendance when children transition from one place to another. SP1 and SP2 should have completed name to face counts using the app when the group moved from the classroom to the hallway to put on coats, at the door to the playground when going out and coming back inside, and at the door to the large muscle room. There were no transitions “documented” in the app. SP1 told P1 that the iPad was not working but when P1 checked the iPad and at that time, it was working. There was also a “back up” paper attendance sheet and an additional iPad that could have been used. · SP1 and SP2 “failed to follow supervision and name to face policies.” The video footage from the facility was one minute and ten seconds long. The video was time stamped and was one hour behind. The video did not have audio. The video started at 3:10:49 p.m. and showed an empty classroom. At 3:11:10 p.m., a staff person moved in the bottom left corner of the video. Then there was no motion, and the camera did not record. At 3:45:45 p.m., the FM is in the bottom left corner of the video holding the AV and the video ended. (Note: A request was made for the entire timeframe of the incident that included the classroom going to the bathroom. However, the facility only saved a portion of the incident and not the entirety of it.) SP1 provided the following information: · On March 19, 2024, after 3 p.m., SP1 and SP2 were working with the Grape classroom children in the Banana classroom when they took them back to the Grape classroom and into the bathroom and changed diapers. (Note: SP1 could not recall how many children were in attendance but the app showed that there were 13 children at this time.) When they were done, the group, including the AV, left the bathroom and went back to the Banana classroom and ate snack. SP1 shut the door to the bathroom but did not lock it. SP1 did not complete a count or name to face check but “remembered” the AV was in the Banana classroom for snack. · The group, including the AV, then went into the hallway to put on the children’s jackets. Some children ran to the front door and SP1 told SP2, “Stop them.” When “all” of the children had their jackets on, SP1 got the iPad but could not use it to do a “name to face” attendance because it was “locked up” on a message from either P1 or P2 that stated that their group was at “seven to one.” SP1 handed the iPad to SP2. Then SP1 went into the classroom to “double” check to make sure there were no children in the room. SP1 also “grabbed” a clipboard with the Roll Call Sheet which was not “any use” because it was not “filled out” and the AV’s name was not included so SP1 left it in the classroom. Then SP1 went back to the hallway and picked up the iPad. During this time, SP1 saw two Grape classroom children leave the facility with family members. · SP1 “thought” there were eight children present and told this to SP2 who said that there were seven children present. SP1 asked SP2, “Who was the third one that left?” and without waiting for a reply, SP1 said names out loud “from rote memory.” When s/he called out the AV’s name, SP1 “thought” SP2 said that the AV “went.” SP2 stated that they had seven children and told SP1 that they because there were seven which was ratio, s/he was going to another classroom. SP1 asked SP2 to help get the children down the hallway and SP2 did so. · SP1 turned and walked backwards watching the children as they walked down the hallway. SP2 was at the end of the group. When they reached the exit door, SP1 went out to the playground with seven children and SP2 stayed inside. On the playground, the iPad was still “frozen.” As children left the facility with family members and five children remained on the playground, SP1 and the group transitioned into the facility to the large muscle room. SP1 then left the children with other staff persons and walked down the hallway, got a vacuum cleaner, and went into the Banana classroom to vacuum. As SP1 vacuumed, s/he heard someone ask where the AV was and state the AV “was missing.” · SP1 said s/he did not have the AV outside but ran outside to look for him/her. SP1 did not see the AV on the playground, so s/he ran to the infant room to look for the AV because s/he thought that when SP2 said the AV “went” that maybe s/he had said “sent,” which meant the AV had gotten moved to the infant room. · SP1 did not find the AV in the infant room so s/he left and went back down the hallway and “heard” the AV “crying.” SP1 found the AV in the bathroom, sitting on the floor, crying. SP1 picked up the AV and held him and the FM came into the bathroom. The AV did not have a coat on when SP1 found him/her in the bathroom. · SP1 thought the AV “wandered” into the “vacant” Grape classroom while the group was in the hallway and got “startled” when s/he turned on the vacuum and then went to the bathroom. The bathroom door was shut but not locked. SP1 estimated the time the AV was unsupervised was approximately 30 minutes, because s/he was outside for 30 minutes. · SP1 stated there was not another iPad that s/he could have used when the iPad was frozen. Staff persons were to do “name to face” attendance/counts of children “all the time.” · SP1 stated s/he “should have gotten the class list,” even if it was not complete, and called off names and that s/he “was at fault,” but it was not “all” his/her fault that the AV was unsupervised. SP1 should have “double checked” when s/he thought there were eight children and SP1 said seven. SP1 took SP2’s “word for it” when SP2 stated they were at seven children. · SP1 said s/he did not have adequate training and was “given a handbook” and “read through it.” SP1 then worked with another staff person for a day and a half and then “learned as s/he went.” SP1 stated s/he told P1 that s/he “felt lost” and P1 told him/her to “ask for help.” SP2 provided the following information: · On March 19, 2024, SP2 and SP1 were in the classroom with 14 children. At approximately 3:05 p.m., SP1 and SP2 took the children, including the AV, to the bathroom. SP1 was at the front of the group and SP2 “checked” the classroom to ensure they had all the children. · At approximately 3:15 p.m., the group went back to the classroom. SP2 could “not remember” who was at the front of the line and who was at the end. Neither SP1 nor SP2 counted the children when they left the bathroom. The bathroom door was shut. SP2 could not recall if the door was locked. The group then ate snack and played “in stations” until it was time to go outside. By that time, “a lot of kids” had left for the day. · Between 4:30 and 4:45 p.m., SP2 went out to the hallway to get coats for the children and four or five students ran out after him/her. SP2 sat down with them and helped them put on their jackets. SP1 was still in the classroom during this time. Then SP2 went back into the classroom with the remainder of the jackets and got the rest of the children ready to go outside. SP2 did not recall putting a jacket on the AV. · SP2 “remembered” that one child left the facility with a family member and “thought” that there were now seven children in attendance and counted seven children in “front” of him/her. SP2 told SP1 they had seven children and SP1 told SP2 that s/he had a “different number” but did not tell SP2 what that number was. SP1 “brushed it off” and said, “Oh whatever,” and “continued to do what [s/he] was doing.” SP2 did not know what SP1 was doing because s/he was not looking at him/her. SP2 did not “think” to use the iPad to check the count because SP1 said the iPad “was frozen” and it “did not click into [his/her] head” to get the Roll Call Sheet. · Then the group left the classroom and walked down the hallway toward the playground door. A name to face count had not been done. SP2 was at the end of the line and when they got to the playground door, SP2 left the group and walked to the infant classroom and asked P1 where s/he should go next. P1 told SP2 to go to the muscle room for another staff person. Then SP2 took off his/her coat and went into the muscle room. · “Usually” when taking children outside, staff persons stopped in the hallway near the playground door and counted children and then looked at the iPad to see if the numbers “matched up.” SP2 did not go to the playground door with the group and did not complete a count of the children. · SP2 stated s/he failed to supervise the AV and s/he “should have done better.” SP2 said s/he “should have grabbed” the iPad and “made sure everybody was there.” · P1 told SP2 the AV was unsupervised for 35 minutes. · SP2 could not “remember” the training s/he received at the facility but felt that his/her training was adequate. P2 stated that on the app, there was attendance and staff persons had the “numbers” of children in attendance. P2 “only” monitored the facility’s app when P1 was not there and did not monitor the app on March 19, 2024. P2 stated that s/he had not heard that there was a problem with the iPads “freezing,” and if they did, the Roll Call Sheet was used. App communication between the Grape classroom, other facility classrooms, and P1 showed that at 3:54 p.m., P1 wrote that the Grape classroom had 13 children and the Grape classroom responded that they had 13 children. At 3:58 p.m., the Grape classroom wrote that they were “cleaning up” to go outside. At 4:06 p.m., P1 posted a “room check” that showed the Grape classroom had 10 children and 2 staff persons. At 4:13 p.m., the Grape classroom wrote that they were “heading outside with 9.” At 4:14 p.m., the Grape classroom wrote, “Ok now we have 7.” At 4:32 p.m., P1 posted a “room check” that showed the Grape classroom had 7 children and 1 staff person. The facility’s Roll Call Sheet showed that on March 19, 2024, there were eleven children present in the Grape classroom. At 4:12 p.m., there were eight children present. The AV’s name was preprinted on the Roll Call Sheet. On March 19, 2024, for the AV, there was a handwritten time in at 8:09 a.m. and out at 4:48 p.m. The facility’s Risk Reduction Plan stated that when transitioning from one area to another and when in the hallway, children would be in a line with one staff person at the front and one staff person at the end and staff persons would count the number of children to “ensure” all were present. The facility’s Staff Handbook stated that children were supervised by sight and sound of a staff person. Supervision consisted of “Name to Face Procedure” at each transition to “ensure accurate attendance and supervision” for all children. Facility documentation showed that prior to the incident, P1, P2, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act, and the facility’s Risk Reduction Plan and Staff Handbook. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, state 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 March 19, 2024, the AV was found in the facility bathroom without the knowledge or supervision of a staff person. The AV was unsupervised for approximately 25 to 35 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 and SP2 were in the hallway getting children ready to go outside. SP1 stated there was “miscommunication” between him/her and SP2 regarding the number of children present and neither SP1 nor SP2 completed a name to face count using the app or the Roll Call Sheet when they went into the hallway or when they transitioned outside to the playground. Although the AV was found in the Grape bathroom and was not injured during this time, given that the AV was sixteen months old and unsupervised in the bathroom without staff knowledge, it was unlikely that the AV would be able to provide for him/herself in an emergency and staff persons were not aware that the AV was in the bathroom 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 could seriously endanger 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; 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. SP1 and SP2 were each trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies including the Risk Reduction Plan and Staff Handbook. At the time of the incident, SP1 and SP2 were working in the Grape classroom and each responsible for the care and supervision of all the children in the classroom, including the AV. SP1 and SP2 were each 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 SP1 and SP2 were 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 determined that their policies and procedures were adequate but not followed by SP1 and SP2. All staff persons were retrained on the facility’s supervision and name to face process. SP1 and SP2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each 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 disqualification. The determination that SP1 and SP2 were each 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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