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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: 801568-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was in a nap room without staff person knowledge or supervision for approximately 13 minutes. Date of Incident(s): May 14, 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 22, 2024; from documentation at the facility; and through four interviews conducted with a supervisory staff person (P1), and three facility staff persons (the SP, P2, and P3). The AV’s family members (FM1 and FM2) were notified of the investigation. However, they did not provide information to this investigator. The AV was four years old and enrolled in the Children’s House Two (preschool) classroom at the time of the incident. This investigator observed the AV in his/her classroom during the site visit. However, FM1 and FM2 did not consent to the AV being interviewed. The facility was located in a lower level of a church building and had a separate primary entrance. There was a main hallway. On one side of the hallway were two classrooms for preschool through school aged children (Children’s House One and Children’s House Two) along with cubbies. On the other side of the hallway were bathrooms, benches, and an office used for the facility. Next to this office was an office used for the church, then a sick room, and then two rooms used for napping by the facility. There was video footage of the hallway showing the classroom doors, cubbies, office door, and the bench. The doors to the nap rooms were not visible in the video footage. The facility’s Incident Report stated that on May 14, 2024, shortly before 3 p.m., a staff person (later identified as P2) was serving snack and noticed the AV was not in his/her classroom, so P2 poked his/her head out into the hallway and asked another staff person (later identified as the SP) if the AV was still in the bathroom. The SP said, “No,” walked to the nap room, and returned with the AV. The SP told P1 that the AV must have fallen back asleep on his/her cot when the SP lined up other children to bring them from the nap room to the classrooms for afternoon snack and/or dismissal time. P1, P2, P3, the SP, and video footage of the incident provided the following information: · The SP and P2 worked in the nap room every day and their typical practice was as follows. When the children fell asleep, P2 left the nap room to take care of other tasks around the facility. Around 2:45 p.m., as the children woke up, P2 returned to the nap room and took a group of children from the nap room to use the bathroom and get ready for either dismissal or afternoon snack. P2 then stepped into the Children’s House Two classroom to allow P3 to take a break. At this time, the SP usually had two or three children left with him/her in the nap room and s/he and those children were the last to leave the nap room. The SP took the remaining children into the hallway to wait their turn to use the bathroom and helped in the hallway to assist with children who were waiting to use the bathroom. · On May 14, 2024, P2 left the nap room with a group of children (not the AV) and was seen on the video footage at 2:45 p.m. waiting in the hallway as the children were seated on benches waiting to use the bathroom. The SP stated that s/he tried to wake the AV up three times. The AV sat up on his/her cot, but the SP did not remember if the AV stood up. When the SP left the room with the two other children, s/he looked around the nap room and did not see the AV and thought the AV went out with P2. P1 was in the hallway and saw the SP walk out of the nap room with two children (not the AV). The SP documented in a written statement that s/he and the two children left the nap room at 3 p.m.; however, this time conflicted with the video footage, which showed the SP in the hallway outside the office doorway with P1 at 2:46 p.m. P1 took the children from the SP to have them sit on the benches. The SP walked into the office. · At 2:47 p.m., video footage showed the SP left the office, and s/he walked down the hallway. The SP stated that s/he assisted some children in “bigger” bathrooms further down the hallway. At this time P1 and P2 were still in the hallway with the other children who were seated waiting to use the bathroom. At 2:52 p.m., the SP brought the children s/he had with him/her to the door of the Children’s House Two classroom, the children entered, and were followed inside by P2 who shut the door. The SP then went and sat down on the hallway bench with the remaining children and P1 went into the office. · At 2:55 p.m., the video footage showed an unknown staff person came out of the Children’s House One classroom with a group of children who gathered their belongings from the cubbies in the hallway. The unknown staff person and P1 went up the stairs with the children for pick up. · At 2:58 p.m., video footage showed P3 left the Children’s House Two classroom. P2 remained in the classroom getting snack out and realized s/he only had eight children instead of nine. P3 was still in the hallway when P2 poked his/her head out of the classroom door at 2:59 p.m. asking if the AV was still in the bathroom, as the AV was normally one of the last children back in the classroom after using the bathroom. The SP was in the hallway at that time and went to the nap room and found the AV still asleep on his/her cot. The AV had his/her blanket over his/her head and was curled up into a ball. · The SP was seen on the video footage at 3 p.m. walking with the AV past the door to Children’s House Two classroom. The SP brought the AV to the bathroom and then brought him/her to the Children’s House Two classroom for snack. · P3 said the AV seemed “unfazed” when the SP brought him/her down the hallway. P3 thought the AV was alone in the nap room for five to ten minutes. The SP said the AV did not even realize s/he was alone because s/he was still sound asleep. P2 and the SP each stated the AV was hard to wake up from nap. · P1, P2, and P3 said the process was to count the children when transitioning from one space to another. The SP stated the process was to make sure all of the children made it out of the nap room to use the bathroom and back to the classrooms. The facility’s Staff Handbook stated, “Children are not left unattended at any times. Staff [persons] will maintain attendance and count the children frequently. After transitions, staff [persons] will take attendance and ensure all children are accounted for.” The facility’s Risk Reduction Plan stated, “Children are always within sight and hearing of a staff [person], due to the fact that we are located in a public space.” Facility documentation showed that the SP, P1, P2, and P3 were each trained on the facility’s Risk Reduction Plan, Staff Handbook, and the Reporting of Maltreatment of Minors. 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: Consistent information was provided that on May 14, 2024, at 2:45 p.m., P2 was seen on video footage from the hallway after exiting the nap room with a group of children, which left the SP in the nap room with the AV and two other children. The SP stated that s/he tried to wake the AV up three times, and at one point the AV sat up on his/her cot, so when s/he looked for the AV again and did not find him/her in the nap room, the SP thought the AV had left the nap room already with P2. The SP left the nap room with two children (not the AV) and at 2:46 p.m., the SP was seen on video footage talking with P1 outside the office doorway. At 2:52 p.m., P2 went into the Children’s House Two classroom so P3 could take a break and at that time the SP was still in the hallway with children needing to use the bathroom. At 2:58 p.m., P3 left the Children’s House Two classroom and P2 noticed the AV was not in the classroom. At 2:59 p.m., P2 poked his/her head out of the classroom to see if the AV was still in the bathroom. At that time the SP went to the nap room and found the AV curled up in a ball on his/her cot with a blanket covering all of him/her. The AV seemed “unfazed” by what happened, as s/he was asleep when the SP came back into the nap room. Video footage showed the AV was in the nap room unsupervised for approximately 13 minutes. Although the AV was asleep and unaware that s/he was alone, given that s/he was unsupervised for approximately 13 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A; and that the classroom is located in a public space; there was a preponderance of the evidence that there was 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. 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. P2 took his/her group of children out of the nap room as was normal procedure, leaving the SP as the last staff person to exit the nap room with the remaining children, therefore P2 was mitigated from his/her responsibility. The SP was the staff person responsible for the AV at the time of the incident and had received training on the facility’s plans and the Reporting of Maltreatment of Minors. Therefore, 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 maltreatment because 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 found their policies and procedures adequate, but not followed by the SP as the AV was left alone. All staff persons were retrained on supervision of children including during transition times. 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 August 28, 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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