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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: 1121542-CCC (Child Care Center) Investigator(s): Lindsay Arth/Heidi Murphy Lindsay.arth@state.mn.us 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) fell off playground equipment and/or had self-injurious behaviors (SIBs) which caused the AV to require medical attention. There were concerns that the facility provided conflicting information regarding the incident; that following the incident, the AV was drooling, crawling, and not able to talk; and that there was a delay in seeking medical attention. Date of Incident(s): June 18, 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 11, 2024; from documentation at the facility and medical records; and through six interviews conducted with a facility supervisory staff person (P1), four staff persons (P2, P3, P4, and P5), and the AV’s family member (FM). The AV was 27 months old and enrolled in the toddler classroom at the time of the incident. The facility had a playground area that contained several pieces of toddler and preschool play equipment. The surface of the playground was pea gravel. There was a white resin table near the building, with four concrete stepping stones nearby on the ground. The FM provided the following information: · At some point on the morning of June 18, 2024, the FM received a phone call from an unknown staff person stating that the AV had fallen off playground equipment and hit his/her head on a concrete slab. The staff person told the FM that the AV was having difficulty focusing his/her eyes. The FM told the staff person that s/he would have his/her significant other (SO) pick up the AV but that the SO could not be there for approximately one hour and 45 minutes. The FM asked the staff person to call an ambulance if they felt it was an emergency. · After approximately one hour and 45 minutes, the SO arrived to pick up the AV and brought the AV to the emergency department at the hospital to be evaluated. The FM met the SO and the AV at the hospital and noted the AV could not walk and was crawling, which the AV did not typically do. The AV was also drooling and could not focus his/her eyes, which the AV did not typically do. The AV was evaluated and diagnosed with a “severe” concussion. The AV returned to the facility the following day. · The FM requested a copy of the facility incident report which was completed by P4. According to the incident report, the AV engaged in SIBs when s/he hit his/her head on a wooden/metal plate. The incident report did not mention the AV falling off playground equipment and differed from what the FM was told by the unknown staff person on the phone at the time of the incident. · The FM said that the AV had a history of SIBs including banging his/her head. The AV was diagnosed with microcephaly (smaller than normal head) and at times, wore a helmet to prevent injury. Staff persons were instructed to have the AV wear the helmet when s/he had “difficult days,” was frustrated, was tired, or displayed SIBs (Note: There was no documentation in the AV’s plans regarding when the helmet was to be worn). The facility’s Incident Report written by P4 provided the following information: · On June 18, 2024, at 10:40 a.m., the AV was on the playground and wanted more crackers so a staff person got up to get the AV more crackers. The AV then “threw [his/her] body to the ground, causing [the AV] to hit the back of [his/her] head on a metal/wooden plate on the playground.” · After the AV fell to the ground and hit his/her head, the AV “banged” his/her head one more time as a staff person, who was not identified, immediately picked the AV up and told the AV to calm his/her body. The staff person felt the back of the AV’s head and noticed a “decent size bump.” An ice pack was applied and the AV was checked over by two additional staff persons. · The FM was called “immediately” and notified of the incident. Medical records provided the following information: · On June 18, 2024, at 12:58 p.m., the AV was seen in the emergency department at a hospital. The FM said that the AV was at the facility when s/he “fell backward or banged [his/her] head on the ground with a good amount of force with the resulting bump on the back of [his/her] head.” The AV “did not clearly lose consciousness but since this time, has had trouble focusing and balance seems off.” The AV “was crawling on arrival” to the hospital which the FM said was “quite unusual.” · The AV’s physical exam noted that the AV was not in “acute distress.” The AV had “normal mental status and tracking in the room, normal strength, and sensation to light and touch in all extremities.” There were no “focal neurologic deficits.” The AV had a “subtle” hematoma (closed wound with pooled blood within the tissue) on the back of his/her head. There was some “very mild” ataxia (clumsy movement) while attempting to walk a straight line where the AV appeared “somewhat unbalanced.” (Note: there was no mention that the AV drooled in the hospital records.) · The AV had a CT head scan which showed there was no bleeding in the brain and no fracture. · The AV was diagnosed with a closed head injury with mild concussion without loss of consciousness. The AV was to follow up with a concussion specialist. The AV was discharged the same day, at 1:59 p.m., in stable condition. P5 provided the following information: · On the date of the incident, P5 worked in the toddler room with P4. On that date, P5 was outside in the play area with his/her classroom, including P4 and the AV. The AV had his/her helmet on earlier in the day but it was removed at some point prior to going outside. · While outside, the AV was running around the play area with his/her friends when “out of nowhere,” the AV began screaming. P5 walked towards the AV who then “flung” him/herself backward, which the AV had a history of doing during SIBs. The AV then began banging his/her head on the ground, hitting it once on one of the stepping stones. P5 picked the AV up and had P4 evaluate the AV. P5 also observed a small bump on the back of the AV’s head. The AV cried for a short time following the incident but had also been crying prior to the incident. Staff persons remained with the AV after the incident to ensure the AV was “okay.” The AV appeared his/her normal self including that the AV was walking, focusing on objects, moving around as normal, and talking. The AV did not drool but seemed more tired than usual. · P5 did not recall who notified the FM of the incident but said that one of the staff persons immediately notified the FM through an online application stating that s/he “might want to get [the AV] checked out” because the AV hit his/her head on a hard surface. At some point after that, the FM responded and told staff persons to keep the AV awake during nap, which staff persons did. During nap, the AV remained in the office with a staff person and during this time, the AV was picked up early and taken to the doctor. P5 was on break when the AV was picked up. · The following day, an unknown staff person told P5 that the AV was diagnosed with a mild concussion. · At no point during the incident did P5 think that 9-1-1 needed to be called, for reasons including that the AV remained conscious throughout the incident. However, P5 felt comfortable calling 9-1-1 if s/he needed to do so. P5 was not aware of the AV falling off playground equipment. P3 provided the following information: · P3 did not recall the date of the incident but on that date, at some point in the afternoon, P3 was on the playground with P4, P5, and children including the AV. While outside, P3 saw that the AV was upset and “threw [his/her] body” from a standing position to the ground and hit his/her head “really hard” on one of the stepping stones. The AV was crying afterward, but P3 did not know if the AV began crying prior to hitting his/her head. P3 was unsure of what upset the AV. However, the AV had a history of getting upset and banging his/her head. The AV did not fall off of anything. · P5 immediately picked the AV up, felt the back of the AV’s head, and said that the AV had a bump forming. P5 brought the AV inside to be evaluated by staff persons, including P4, because P1 was not available. P5 also got an ice pack for the AV. The AV later rejoined the group outside, ate a snack, seemed “better,” and was running around and talking. At no point did the AV lose consciousness, have difficulty walking (including crawling), drool, have difficulty focusing, vomit, or have difficulty speaking. If P3 would have seen those things, s/he would have told the FM and not “dismissed” it. P3 also felt comfortable calling 9-1-1 if needed. · P3 did not recall who notified the FM of the incident but thought it was P4. The FM was notified of the incident because the AV hit his/her head and the FM later took the AV to the doctor. · The AV returned to facility the next day and acted like his/her normal self. The FM told staff persons that the AV had a “slight concussion.” Prior to the incident, the AV wore a helmet when s/he had “rough days.” At the time of the incident, the AV was not wearing his/her helmet. P4 provided the following information: · P4 did not recall the date of the incident but on that date, P4 worked in the AV’s classroom. Around 10 or 10:30 a.m., the classroom was outside but P4 was inside using the restroom. When P4 returned outside, P5 handed the AV to P4 and stated that the AV fell and P5 was unsure how to “take care of it.” · P4 then brought the AV inside so that P1 could assist, including to ensure the AV was “okay.” P4 observed a “lump” on the back of the AV’s head so staff persons applied an ice pack. P1 looked the AV over and told P4 to notify the FM immediately because the AV hit his/her head, which P4 did. · P4 told the FM that s/he did not witness the incident but was told that the AV fell outside, hit his/her head on cement, and had a “lump.” The FM said that s/he would “come pick [the AV] up immediately” and asked that the AV not take a nap. The AV then sat with P4 in the classroom for a while and then sat in the office with another staff person, but P4 did not recall which staff person that was. · P4 never saw the AV drooling, crawling, or unable to focus. After the incident, there were no issues with the AV’s balance, including with walking, and the AV remained responsive to staff persons. P4 never thought that staff persons needed to call 9-1-1 because the AV was able to respond to questions and ate lunch as normal. · When the AV returned to the facility the next day, the FM said that the AV had a slight concussion and told staff persons to keep the helmet on the AV all day. · The AV was known to bang his/her head and often wore a helmet. P4 stated the AV wore the helmet as needed, based on how his/her mood was. When the AV had “good days,” the helmet was not worn, and if the AV was having a “good period,” the helmet was taken off. When there was apparent risk to the AV, the helmet was put on. The AV was not wearing his/her helmet at the time of the incident. P2 provided the following information: · On the date of the incident, which P2 thought was around June 20, 2024, around 11 a.m., P2 was outside with children including the AV when either P3 or P4 “waved” P2 over. P3 or P4 told P2 that the AV was “having a tantrum” and hit his/her head. P2 did not see the incident because s/he was in a different area of the playground when it occurred. P3 or P4 asked P2 if s/he thought the AV had a concussion because the AV was acting “differently,” including that the AV was “tired and lethargic.” However, the AV was often tired or lethargic after displaying SIBs. P2 looked at the AV’s head but did not see a “goose egg.” P2 told P4 to notify P1 because it was “beyond our scope” to evaluate the severity of the AV’s injury. · P4 then notified the FM who was not able to go to the facility immediately but said that the SO would pick the AV up. However, the SO would not be able to get there for approximately one hour. While waiting for the SO, the AV remained in the classroom and was acting normal, including walking, eating, and talking. The AV was tired, but P2 thought that was because the AV had been kept awake during nap time. P2 was present when the SO picked the AV up, which was approximately two hours after the incident. P2 did not think the incident was a medical emergency, for reasons including that the AV was not “dazed or out of it.” The AV was not drooling and did not have difficulty focusing. The AV may have been “play crawling but nothing concerning,” but the AV remained able to walk following the incident and was walking around the classroom including when the SO picked the AV up. P2 felt comfortable calling 9-1-1 if needed. · Staff persons were told that the AV’s helmet should be worn when the AV displayed SIBs or could not calm his/her body. However, the AV was able to take his/her helmet off on his/her own and used it to hit him/herself or other children so at times, it became a distraction. At the time of the incident, the AV was not wearing his/her helmet. P1 was unaware of any incidents involving the AV, including the AV being diagnosed with a concussion. The FM and staff persons never notified P1 of that and P1 said that s/he spoke to the FM “frequently.” P1 was not aware of any times that the AV was not able to walk, talk, or was drooling. P1 said that on June 18, 2024, the AV left the facility at 12:33 p.m. However, P1 thought that on that date, the AV was picked up due to biting behavior and not due to an injury. The AV had a history of banging his/her head and the facility used mats in the classroom to keep the AV safe. The AV also wore a helmet at times. There was a period of time that the FM did not want the AV to wear the helmet, but staff persons asked the FM to send it to use when the AV banged his/her head. The facility’s Accidents policy said that staff persons were to be in “constant observation of any and all potential hazards” and remove them “immediately.” The facility’s Risk Reduction Plan said that children were to have “constant supervision” at all times. The playground had age-appropriate equipment. The facility’s First Aid policy stated in the case of an emergency resulting from a fall, burns, poisoning, aspiration or choking, convulsions, serious injuries or illness staff persons were to proceed as instructed, call an emergency vehicle, contact the parents, and accompany the child in the emergency vehicle to the hospital of the parents’ choice. However, the policy did not specify how to evaluate a head injury, nor how to determine whether a head injury was considered an emergency. Facility documentation showed that P1, P2, P3, P4, and P5 were each trained on pediatric first aid/CPR/AED, abusive head trauma, handling emergencies and accidents, the Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act, prior to the incident. Conclusion: Regarding the concern with the discrepancy in how the incident occurred: Although the FM had concerns that there was a discrepancy in what a staff person told him/her happened, compared to the incident report, including that s/he was told that the AV fell off playground equipment when the incident report said that the AV displayed SIBs and hit his/her head, information was consistent from staff persons that the AV hit his/her head on a stepping stone while displaying SIBs and there was no information that the AV fell off playground equipment. Regarding the concern that there was a delay in seeking medical attention, including because the AV was drooling, crawling, and not able to talk: Although the FM said the AV was unable to walk and was crawling, drooling, and could not focus his/her eyes after the incident, information from staff persons showed that the AV acted normal, with the exception of being tired, which was believed to be because the AV missed naptime. Staff persons did not observe any of the concerns the FM described. P4 stated the AV was his/her “normal self”, responded to questions, and ate lunch while waiting for the SO to pick him/her up from the facility after the incident. There were no written guidelines or documentation regarding when the AV should wear his/her helmet. Information from the FM, P4, P2, and P1 was consistent that the FM asked staff persons to consider the AV’s mood and behavior when determining when the AV should wear the helmet, and information from P5 and P3 was consistent that when the incident occurred, the AV abruptly began displaying SIBs when s/he was not wearing the helmet. After the AV was injured, staff persons immediately tended to the AV and assessed him/her for a head injury. Staff persons promptly notified the FM and recommended the AV be picked up. During the wait for the AV to be picked up, the AV was kept under constant supervision by staff. Staff persons did not observe any concerning behaviors that warranted an emergency response or intervention. Given the aforementioned, there was not a preponderance of evidence that there was a failure to supply the AV with necessary medical care or to protect the AV from conditions or actions that seriously endangered his/her physical health when reasonably able to do so. It was not 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). 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 determined that policies and procedures were adequate and followed. Following the incident, the facility removed the stepping stones. Action Taken by Department of Human Services, Office of Inspector General: On December 26, 2024, the facility was issued a Correction Order for failing to document separations and for failing to have an individual child care program plan for the AV. 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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