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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: 1113648-CCC (Child Care Center) Investigator(s): Judith Schwanke Suspected Maltreatment Reported: It was reported that a staff person (SP) grabbed an alleged victim’s (AV) arm aggressively and caused the AV to fall and hit his/her head on a plastic block. Date of Incident(s): June 19, 2024 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a); and subdivision 23, paragraph (a): "Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 1, 2024; from documentation at the facility and law enforcement records; and through four interviews conducted with the AV’s family member (FM) who was also a staff person at the facility, a supervisory staff person (P1), and staff persons (P2 and P3). Several attempts were made via telephone and US mail to contact and interview the SP, but the SP did not respond to those requests. The SP provided information to law enforcement and that information is included below. The AV was 17 months old and enrolled in a toddler classroom at the time of the incident. The facility had two toddler classrooms that were separated by a shared bathroom with half walls to each classroom. The AV’s classroom had several tables, chairs, and short bookshelves placed around the classroom. In the center of the classroom was a carpet area. The FM provided the following information: · On June 18, 2024, the AV had “multiple scratches” on his/her face and the FM had not received information or an accident/incident report regarding the scratches. · On June 19, 2024, when the FM dropped off the AV in his/her classroom, s/he asked the SP about the scratches on the AV’s face. The SP answered, “with a snotty attitude,” that s/he did not know how the AV got the scratches on his/her face. The FM then left the classroom. · Approximately thirty minutes later, P1 called the FM into an office. P1 told the FM that s/he talked with P2 and learned about an incident with the AV and the SP that happened just prior. The FM watched a video, which showed that the SP grabbed the AV by the arm, pulled the AV one way and then turned and let go of the AV causing the AV to fall to the floor hitting his/her head on a block and crying. The next morning, the FM was bathing the AV and saw a “raised, red mark” in the “middle” of the AV’s forehead. The FM took pictures of the mark on the AV, but the mark did “not come out.” The mark lasted for approximately two days. (Note: In the photo provided by the FM, there was not a visible raised area or red mark.) · The FM stated that for the “first couple of days” after the incident, the AV “seemed upset,” had “more tantrums,” and then “seemed” to return to “normal.” The video that was reviewed by law enforcement and this investigator was time stamped with no audio and provided the following information: · At 8:14:25 a.m., the SP and P2 were in the younger toddler classroom with nine children, including the AV. Three children were seated at one table, and five children were seated at another table. The AV stood near the tables, behind a chair. The SP wiped the hands and face of another child who appeared to be crying. The SP picked up that child and carried him/her to the carpet area and sat him/her down in a seated position. The AV pushed the chair across the floor. P2 stood near the table with the five children and approximately two feet from the SP. · At 8:14:51 a.m., the SP walked to a counter in the classroom and picked up a cell phone and looked at it as the AV pushed the chair towards the child on the carpet. The AV lifted the chair when s/he got to the carpet and moved it toward the child seated on the carpet. The SP walked toward the AV while looking down at his/her phone. · At 8:14:56 a.m., the AV tipped the chair forward into the child and the SP approached the AV on his/her right side. The SP grabbed the AV’s right arm above the wrist with his/her left hand. · At 8:14:57 a.m., the SP pulled the AV away from the child on the floor and the AV fell backwards onto the floor on his/her back and pulled the chair with him/her. The SP still held the AV’s arm and the AV spun around so his/her head was in front of the SP’s legs. As the AV spun, s/he let go of the chair and it slid back toward the bathroom, hit the half wall, and bounced forward. P2 still stood near the table and faced the SP and the AV. · At 8:14:58 a.m., the SP pulled the AV upright by his/her right arm to an upright position and then put his/her left hand under the AV’s left arm and dropped his/her cell phone. The SP swung the AV to his/her right side and dropped the AV down on the carpet onto his/her knees in a forward motion. The AV fell face first and hit his/her head on a toy block that was on the floor. The impact caused the block to bounce forward approximately one foot. · At 8:15:01 a.m., the SP picked up the chair and walked toward the tables and dropped it down near the wall. S/he then dropped his/her phone on the counter, walked over to the carpet area and picked up some plastic blocks. The AV was still on the carpet on his/her knees with his/her head on the floor. · At 8:15:11 a.m., P3 walked to the bathroom wall in the adjoining toddler classroom and looked in the younger toddler classroom. The SP walked toward P2 and put his/her arms and hands in the air and then walked out of the classroom. P2 walked over to the AV and picked him/her up and P3 walked through the bathroom to the half door on the younger classroom side and the video ended. P2 provided the following information: · On the day of the incident, P2 and the SP were working in the toddler classroom that included the AV. P2 stated that the SP “was fine” at the beginning of the day but at some point, the SP’s “attitude shifted.” P2 was unsure if the SP saw “something” on his/her phone but the SP’s tone of voice changed and s/he said, “Today is a hard day for me.” P2 did not recall if s/he asked the SP for further details. · As P2 served breakfast, the AV pushed a plastic chair across the floor. P2 heard the SP say, “I can’t do this today.” P2 then turned and saw the AV land on the carpet next to him/her. The SP “looked visibly upset.” P2 told the SP to leave the classroom to calm and come back when s/he was ready. The AV “whined” and P2 picked him/her up and looked him/her over for physical injuries. P2 saw a “tiny little red mark” on the AV’s forehead. P2 did not see a bump on the AV’s forehead. · P1 then came in and told P2 that the SP was “going home.” P2 told P1 that s/he had “never seen” the SP “that way.” P2 also told P1 that s/he did not see what happened. · Shortly after the incident, the FM took the AV home for the day. · The following day, P2 did not see a mark on the AV’s forehead. · P2 did not work with the SP “that often,” but when s/he did work with the SP, P2 had “never” seen the SP “act that way.” Prior to this incident, P2 did not have concerns regarding the SP’s interactions with children. P1 provided the following information: · On June 19, 2024, at approximately 8:17 a.m., P1 was in a classroom at the facility when another staff person told him/her that s/he saw the SP “crying.” P1 then went into the toddler classroom and asked the SP to come talk with him/her in the office. When they got to the office, P1 asked the SP why s/he was upset, and the SP said s/he was “overwhelmed with school and life” and that s/he wanted to go home. P1 had another staff person go into the toddler classroom and the SP left the facility. When P1 went to the toddler classroom to tell P2 that the SP left, P2 told P1 that s/he was not sure what happened, but saw something out of the corner of his/her eye that looked like the SP “pushed” the AV. · P1 left the classroom, went to his/her office, and watched video footage of the classroom from before the SP left. P1 saw the AV push a chair across the room and then into another child. The SP “grabbed” the AV “hard” and picked up the chair and the AV. Then the SP threw the chair and let go of the AV causing the AV to fall and hit his/her head on a block. · P1 left the office and went to the toddler classroom to check on the AV. P1 saw a “pea sized red mark” on the middle of the AV’s forehead. The mark was no longer visible after about a half hour. P1 said s/he did not see a mark on the AV’s forehead the following day. · P1 then went to the office and called the SP. P1 told the SP that s/he could not work at the facility any longer and the SP told P1, “Okay.” · P1 then had the FM come into the office and told the FM about the incident. P1 asked the FM if s/he wanted to go home, and the FM and the AV left the facility. · P1 stated that the SP should have “walked away.” Staff persons were trained that if they needed a break they should ask, and someone would step into the classroom for them. · Prior to this incident, P1 did not have concerns regarding the SP’s interactions with children. A local law enforcement incident report provided the following information: · On June 24, 2024, a law enforcement officer (LEO) met with the FM. The FM told the LEO that on June 19, 2024, at approximately 8:15 a.m., the SP “grabbed” the AV by the arm and “threw” the AV to the floor causing the AV to “hit” his/her head on a block. · The AV had a red mark on the center of his/her forehead and some slight bruising that had “resolved” in a day or two but was not seen by a medical professional. The AV also had “emotional” damage from the incident. · The LEO spoke with the SP and the SP told the LEO that it had been a “stressful week,” and the SP was “over ratio” that morning. (Note: According to the video, at the time of the incident, the SP’s classroom was not over the staff to child ratio.) The SP had an argument with a friend and was “irritable,” and it was not a “good morning” for the SP. The SP told the LEO that the AV approached another child with a chair, and it was the SP’s “reaction” to get the AV away from the other child. The SP told the LEO that his/her reaction to the AV was not the “right reaction,” and s/he “wished” s/he had handled it “differently” or “left sooner before it happened.” The SP was “unaware” of the amount of force s/he used on the AV. · The SP was charged with malicious punishment of a child and at the time of this report, the trial was pending. P3 provided the following information: · On the day of the incident at approximately 8 a.m., P3 dropped off his/her child with the SP and the SP seemed “fine.” The SP told P3 “good morning” and was “pretty normal.” At approximately 8:30 a.m., P3 was in the adjoining toddler classroom and heard “very loud yelling.” P3 did not recall what the SP yelled but knew it was not “normal.” P3 “ran” across the bathroom and by the time she got to the other classroom, the SP was walking out the door and P2 had picked up the AV. · P3 worked with the SP in the past and did not have concerns regarding his/her interactions with children. · P3 was trained to never put hands on a child and if staff persons felt “overwhelmed,” they should “step back” and ask someone to step into the classroom for them. The facility Incident/Injury Report Form showed that on June 19, 2024, at 8:15 a.m., the AV pushed a chair toward another child and the SP grabbed the AV by the arm and pulled the AV away, “yanking” his/her arm. The SP then “yanked” the AV “around to the other side” of the SP and let the AV “go” and the AV hit his/her head on a block. The AV was given “TLC [tender loving care], snuggles and hugs.” The facilities Behavior Guidance policy showed that staff persons ensured each child was provided with a positive role model of acceptable behavior and protect the safety of children. Prohibited actions included rough handling, shoving, hair pulling, ear pulling, shaking, slapping, kicking, biting, pinching, hitting, and spanking. The facilities Staff Handbook showed that staff persons were trained on Abusive Head Trauma and acceptable and unacceptable guidance/discipline techniques. Staff persons could request “temporary relief” when they were unable to perform their duties. Facility documentation showed that P1, P2, P3, and the SP each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. Relevant Rules and/or Statutes Minnesota Rules, part 9503.0055, subdivision 3, item A, states that the license holder must have and enforce a policy that prohibits the subjection of a child to corporal punishment. Corporal punishment includes, but is not limited to rough handling, shoving, hair pulling, ear pulling, shaking, slapping, kicking, biting, pinching, hitting and spanking. Minnesota Rules, part 9503.0040, subdivision 1, states that the staff to child ratio for the toddler age group is one staff person to seven toddlers. Conclusion: A. Maltreatment: Information provided from P1, P2, P3, the FM, video footage, and the LEO, showed that on June 19, 2024, the SP and P2 were working in the classroom with the AV when the AV pushed a chair to a carpet area in the toddler classroom. As the AV approached another child on the carpet, the SP grabbed the AV by his/her forearm and swung the AV backwards causing the AV to fall onto the floor on his/her back. The SP still held the AV’s arm as the AV spun so his/her head was in front of the SP’s legs. The SP pulled the AV upright by his/her right arm and then put his/her left hand under the AV’s left arm dropping a cell phone s/he was holding. The SP swung the AV to his/her right side and dropped the AV down on the carpet onto his/her knees in a forward motion. The AV fell face first and hit his/her head on a toy block that was on the floor. The impact caused the block to bounce forward approximately one foot. The AV sustained a small, red mark on his/her forehead. The FM stated the mark lasted two days; however, the mark did not appear visible in photos taken the next morning and P1 said the mark was gone within a half hour. The SP’s actions as seen on video were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; were a violation of the facility’s Behavior Guidance policy; and a violation of Minnesota Rules, part 9503.0055, subpart 3, item A. Although the AV was pushing a chair towards and into a child and required some intervention, the AV was 17 months old and not likely a serious danger to him/herself or the other child at the time. Therefore, there was a preponderance of the evidence that the SP’s physical interactions with the AV were not accidental, caused injury to the AV, and represented a substantial risk of injury to the AV. It was determined that physical abuse occurred (“Physical abuse” means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child’s care on a child other than by accidental means. “Threatened injury” means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury.) 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 Behavior Guidance policy, and the Reporting of Maltreatment of Minor’s Act. 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 physical abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious. It was a single incident and although the FM stated the AV’s red mark last two days, the mark did not appear visible in photos taken the next day and P1 said the mark was gone within a half hour. Therefore, it was not determined whether the AV sustained a serious injury or a mark that was transitory in nature. 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 the SP. 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 November 22, 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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