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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: 1002647-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 bathroom without staff person knowledge or supervision for approximately eight minutes. Date of Incident(s): July 1, 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 July 10, 2024; from documentation at the facility; and through seven interviews conducted with two supervisory staff persons (P1 and P2), four facility staff persons (SP, P3, P4, and P5), and the AV’s family member (FM). This investigator met with the AV, but s/he did not provide information pertaining to this investigation. The AV was four years old at the time of the incident and enrolled in the “Pre 2” preschool classroom. The facility was located inside of a church. There was an indoor gym that was used by the facility for combined morning drop off and meals. The gym had a door that led to a short hallway with two bathrooms (one on each side). The bathrooms were used by children at the facility as well as by community persons within the church. The other end of that short hallway connected with a long hallway that led to a common area inside the church and to a set of stairs that led to classrooms. The facility’s Incident Form documented that at 8:30 a.m. on July 1, 2024, a staff person left the AV in a bathroom during breakfast cleanup. The AV returned to the gym and told another staff person what happened. The FM said s/he was called and informed about the AV being left in a bathroom “accidentally.” The AV “never” mentioned anything to the FM. The FM “loved” the facility and “absolutely” had no prior complaints. P3, P4, P5, and the SP provided the below information: · P3 stated that on July 1, 2024, around 8:30 a.m., s/he finished cleaning tables after breakfast in the gym and was seated on the floor with some children when the AV approached P3 with a huge smile and stated s/he was in the bathroom all by him/herself. P3 asked the AV if s/he meant s/he was in a stall all by him/herself. The AV gave P3 “kind of a story” and then P3 brought the AV over to tell P4 what happened. P3 went on with his/her day. · P3 thought the AV was unsupervised for five to six minutes based on the amount of time it took the children to wash hands after breakfast. P3 was trained to check the bathrooms after everyone was out to make sure no children were hiding or left behind. P3 did not talk to the SP about what happened. · P4 stated that on July 1, 2024, around 8:30 a.m., s/he was cleaning tables after breakfast while the children were combined in the gym area playing. The SP brought a group of children over to the bathrooms and monitored handwashing. When the children were done, P4 saw the SP return to the combined group in the gym. · P4 was told by P3 that the AV was in the bathroom by him/herself. P4 asked the AV about what happened, and the AV stated s/he knocked on the door (from the hallway into the gym). The AV seemed “happy” and “proud.” P4 spoke with the SP who was not sure how the AV was left and seemed “embarrassed” by what happened. · P4 was not sure how it was discovered the AV was left in the bathrooms unsupervised. P4 thought the AV was unsupervised between five to ten minutes based on how long hand washing normally took. · P4 said there was a “semi” new process for combining for breakfast in the gym and staff persons determined who was going to monitor the bathrooms based on who was still at the tables having conversations with children. A staff person took a group of children who were done eating to wash hands in the bathroom, and then that group of children went and played in the gym while the staff person stayed by the bathrooms to supervise other children washing up and the remaining staff persons cleaned up. P4 stated that while this process was new, the children used the bathrooms before when utilizing the gym, there just were not as many children waiting in the hallway to wash hands or use the bathroom. P4 said s/he double and triple checked when s/he monitored the bathrooms to make sure no one was hiding or left behind. · P5 stated that on July 1, 2024, s/he started work at 8:30 a.m. (this was consistent with the staff schedule the facility provided). When P5 entered the gym, s/he saw the SP over by the door to the hallway with bathrooms with a group of children. Some of the children were playing, and P4 was cleaning off the tables. P5 did not see what happened but heard P4 talking about the incident later. P5 stated s/he was trained to “keep eyes” on the children for supervision. · The SP stated that on July 1, 2024, around 8:20 a.m., s/he was monitoring the bathrooms in the hallway. The AV went in and closed the door to the stall to use the bathroom while the door to the bathroom was still open and other children of the same gender washed their hands. · The SP stated s/he got distracted by worrying over what the children in the gym were doing, “lost track” of what was going on where s/he was, and thought the AV snuck past the SP. The SP stated that s/he did not double check the bathrooms before going back into the gym. · The SP did not think P5 had arrived at the time of the incident, and P4 was cleaning up after breakfast. The SP stated that s/he went to use the bathroom and when the SP opened the door to the short hallway, the AV was standing there, and the AV thought it was “silly” that the SP left the AV in there. The SP said the AV was not tearful but told the SP that s/he knocked on the door. The AV then went into the gym and found another staff person while the SP went to the bathroom. The SP heard it was eight minutes that the AV was unsupervised. · The SP stated that P4 asked him/her about the incident right after it happened and then sometime after nap P1 talked to the SP. The SP stated that s/he was trained to double check when the children were done in the bathrooms to make sure no children were left behind. P1 and P2 provided the below information: · P1 stated that on July 1, 2024, around 12:30 p.m., P3 asked P1 if s/he was aware that around 8:30 a.m. the AV ran back into the gym stating s/he had been left in the bathroom. P3 told P1 that the AV was laughing and “happy” about what happened. · P1 then asked P4 what s/he observed that morning. P4 stated that the AV was ‘happy” and not bothered by what happened. P1 saw the AV at lunch time and stated that s/he seemed “fine.” · P1 stated the classrooms were together in the gym at the time and that the SP brought a group of children to the bathroom including the AV when the incident occurred. When P1 spoke with the SP, the SP stated that s/he was not aware that the AV had been left and thought all of the children had come back into the gym after using the bathrooms. The SP told P1 that it was “busy” since the classrooms were in the gym and there had been a steady flow of children, and that the SP did not check the bathrooms before closing the door from the hallway to the gym and returning to the gym. · P1 notified the FM who stated the AV liked to play with water in the bathroom. The FM asked if the AV was upset, and P1 told the FM that the AV was laughing. · P1 stated staff persons thought the AV was unsupervised from two to five minutes, but then P1 heard from P2 who watched the video that it was eight minutes. · P2 said s/he was not at the facility on July 1, 2024, but P2 received a text message from P1 letting him/her know what happened and P1 asked P2 to pull video footage. When P2 reviewed the video footage from around 8:30 a.m., s/he saw the SP standing between the doorway from the gym to the hallway and several children going through the door into the gym, then the SP shut the door. During that time P2 saw P3 playing with children on the floor, P4 cleaning up after breakfast, and P5 playing with children. After the SP shut the door, s/he was also engaged with the children until a child approached him/her and they walked toward the door that led to the bathrooms. When the door opened, the AV came out. The AV ran to P3 and talked to him/her. The AV appeared playful. P3 then walked to P4 and spoke with him/her and after that P4 spoke with the SP. · P2 spoke with the SP the following day and the SP was “somber and sorrowful.” P2 and the SP talked about ways to prevent this from happening again, such as counting the children and double checking the bathrooms. · P2 stated the morning combination was a new process that had been in place since June 10, 2024. The classrooms were combined and had breakfast as one big group from 8 to 8:30 a.m. · P1 and P2 stated staff persons were trained to have the door from the gym to the hallway open and monitor the bathrooms from there. P1 said staff persons should count how many children were coming in and going back out and check the stalls before coming back into the gym. P1 also stated that staff persons should count once back in the gym. This investigator reviewed video footage and noted the following: · On July 1, 2024, at 8:34 a.m., a child (not the AV) walked through the door from the bathrooms followed by the SP. The door then shut. P5 was walking on the other side of the gym in the open area. P3 and P4 were standing by the tables talking with a family member who was dropping off his/her child. · P3 went to a table to look over something and then went and played with a group of children on the floor. P4 wiped off a table and got the child who was just dropped off set up with breakfast. P5 and the SP were at the open end of the gym mingling between groups of children. · At 8:42 p.m., the SP opened and walked through the door toward the bathrooms. The AV came out through the door and the SP followed the AV out back into the gym. The AV then ran over to P3 who was sitting with a group of children and pointed toward the door leading to the bathrooms. While the AV talked to P3, the SP went through the door to the bathrooms. · P3 got up and walked over to P4 who had just finished sweeping by the tables. The AV ran over by them as well and the SP returned to the gym through the door leading to the bathrooms. The SP and P4 then walked toward each other in the middle of the play area along with the AV. They stepped away from each other as the video footage ended. Facility records showed that the SP, P4, and P5 were scheduled to work with the Pre 2 class on July 1, 2024. The facility’s Risk Reduction Plan stated, “Classes are required to count their students through out the day. Classes are required to do a name to face roll call for every transition they make.” The facility’s Supervision Policy stated, “Supervision occurs when a staff person is accountable for the children’s care and is within sight and hearing of the child at all times.” Facility records showed that the SP, P1, P2, P3, P4, and P5 were each trained on the facility’s 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, stated 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: On July 1, 2024, around 8:30 a.m., the SP was with P3 and P4 in the gym with their respective classrooms. The SP took a group of children to the bathrooms to wash hands and/or use the bathrooms. P3 helped clean up tables and then sat on the floor with a group of children. P4 cleaned up the remaining tables while P5 arrived for the start of his/her shift. Video footage showed that at 8:34 a.m., the SP walked from the bathroom area into the gym and shut the door that led from the gym to the hallway with bathrooms. The SP said s/he was distracted by what the children in the gym were doing and “lost track” of what was happening and as a result s/he did not double check the bathrooms to make sure no one was hiding or left behind before s/he returned to the gym. Video footage showed that approximately eight minutes later, the SP went back to the door leading to the hallway with bathrooms and the AV re-entered the gym from the hallway. P3 said the AV seemed “happy” when the AV told P3 s/he was in the bathroom all by him/herself, and P4 said the AV seemed “proud.” Although the AV did not seem upset by what had happened, given that s/he was unsupervised for approximately eight 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 hallway connected to another hallway that led to a common area within the church and a stairwell, and was accessible to community persons in the church, there was a preponderance of the evidence that there was a failure to project 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. P3, P4, and P5 were in the gym when the incident occurred, and P4 and P5 were scheduled in the AV’s classroom along with the SP. However, given that P3 was engaged with children on the floor, P4 was cleaning tables off after breakfast, P5 started his/her shift at 8:30 a.m. and was just arriving at the gym when the incident occurred and none were directly supervising the AV; P3, P4, and P5 were each mitigated from their responsibility. The SP was the staff person responsible for monitoring children using the bathrooms, including the AV, at the time of the incident. In addition, the SP had received training on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Therefore, the SP was responsible for the 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 was not injured. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures not followed by the SP. The facility also did not find their policies and procedures adequate to address supervision when the children used the bathrooms. All staff persons will be retrained on supervision and updated policies. 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 November 6, 2024, the facility was issued a Correction Order for the violations outlined in this report and for a background study violation. 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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