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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: 1057572-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 large motor room without staff person knowledge or supervision for approximately three minutes. Date of Incident(s): August 26, 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 September 5, 2024; from documentation at the facility; and through six interviews conducted with two supervisory staff persons (P1 and P2), three facility staff persons (the SP, P3, and P4), and the AV’s family member (FM1). The AV was 25 months old at the time of the incident and enrolled in the Busy Bees (toddler) classroom. Due to his/her age the AV was not interviewed for this investigation. The facility was a stand alone building with ten classrooms for infants through school-aged children. There was a large motor room (referred to as “the Village”) at one end of a hallway that had classrooms on each side of it. The Village was constructed to look like several shops. There was a blue toddler play structure in the center of the room. FM1 was aware of the incident. FM1 stated that on an unspecified date, the SP called another family member (FM2) crying and told FM2 that the AV was “okay,” but the AV was “forgotten” in the playroom for about three minutes. FM1 had no prior concerns with the SP. Facility documentation and video footage showed the incident occurred on August 26, 2024, at approximately 11 a.m. P3 stated on an unspecified date, a little before 11 a.m., s/he saw the SP walk by his/her classroom with his/her toddler class. P3 then lined up the children in P3’s class and walked them to the Village, where P3 saw the AV. P3 notified P2 who came to the Village and took the AV with him/her. P3 thought it was “about a minute” from when s/he saw the SP’s class walk by to when P3 entered the Village. P2 provided the following information: · On an unspecified date, P2 was cleaning when P3 used the walkie talkie to have either P1 or P2 come to the Village. P3 told P2 that s/he found the AV sitting on the blue play structure when P3’s class entered the Village. P2 said the AV was not crying so P2 took the AV from P3 and went to the front desk. · P2 then walked down the hallway toward the AV’s Busy Bee classroom and was still in the hallway when s/he saw P1 come out of the Busy Bees classroom. P2 told P1 what happened and then handed the AV to P1, who brought the AV into the classroom. P2 thought at that time, that the SP was aware the AV was not with him/her. · The SP told P2 that s/he thought s/he had everyone from his/her class when s/he left the Village and once the SP entered the classroom the SP realized s/he did not have everyone. P2 was unsure of how long the AV was without supervision. P1 provided the following information: · On August 26, 2024, P1 walked down the hallway, and the SP poked his/her head out of the Busy Bees classroom stating that s/he could not find the AV. P1 went into the classroom to look around, and then walked out to check the Village. P1 saw the AV with P2 at that point. P2 told P1 that P3 found the AV in the Village and P2 was holding on to the AV to see if the SP called to the office stating that the AV was lost. P1 said the AV looked “fine.” · P1 knew the SP and his/her class had not just entered the classroom when the SP poked his/her head out because P1 had not passed them in the hallway when s/he walked down the hallway earlier. P1 stated the SP was “panicked” when s/he told P1 that the AV was not with him/her. · P1 had P2 bring the AV back to his/her class and P1 reviewed video footage. In the video, P1 saw the SP and his/her class cleaned up the Village, the SP grabbed his/her things, turned off the lights, and three children (including the AV) were still in the Village. One child ran out and then the second child ran out after putting away a toy. The AV was on the blue play structure. Based on the angle, P1 was not able to see the SP, but from the video footage in the hallway, the SP was at the door when two of the three remaining children ran out. The SP then walked down the hallway with five children and then the video footage ended. The video footage in the Village showed the AV stayed on the blue play structure with a ball in his/her hands until P3 arrived with his/her class. P4 stated that on an unspecified date, P4 was working in a different classroom than the SP but when the classes combined for nap time, the SP told P4 that s/he left the Village and “miscounted” his/her children and the AV was left in the Village for approximately one minute. P1-P4 each provided information that they were trained to perform a name to face procedure and count the children when transitioning from one area to another. The SP provided the following information: · On August 26, 2024, around 11 a.m., the SP was in the Village with his/her class, including the AV. The SP stated that one child was running around, so the SP had the children clean up, and then the SP had the children line up. The SP turned off the lights, and the SP believed s/he had the whole group, so they left and walked down the hallway. The SP did not count the children with him/her before leaving the Village. The SP stated that as they made their way to the Busy Bee classroom, one child was running down the hallway and P1 was in the hallway speaking with a family member. · Once inside the classroom, it was time for the SP to change the children’s diapers. Without counting the children first, the SP gathered the diapers, and had placed a child on the changing table when s/he realized “within 30 seconds” s/he was missing the AV. The SP then counted the children in the room and did a name to face and then the SP placed the child back on the floor and went and asked the other toddler classroom staff persons if they had seen the AV. The SP stated that P4 “popped” his/her head in and then tried to help look for the AV. · The SP looked around his/her classroom again to make sure the AV was not hiding in there, and that was when P1 walked down the hallway with the AV. The SP said the AV was completely calm when s/he came back to the classroom. · The SP called FM2, told him/her what happened and apologized to FM2. FM2 told the SP that s/he knew the SP loved the AV and it sounded like the AV was safe. The SP thought the AV was without supervision for about three minutes. · The SP was trained to have the children line up during transitions and to make sure s/he had all of the children. The SP had used name to face procedure at a previous facility but stated that it was not what s/he was trained on at this facility. The SP stated that because s/he had fewer children at the time of the incident, there was “a level of confidence” that s/he had all of his/her children without actively counting them, but acknowledged, “I was wrong for that.” This investigator reviewed video footage from the incident and noted the following: · On August 26, 2024, at 10:56:52 a.m., the SP gathered his/her clipboard, walkie talkie, and backpack and then turned off the lights in the Village. The SP moved out of camera view while three children (including the AV) were still visible in the Village. · One child ran toward the doorway and was no longer in view of the camera, while another child picked up a ball and placed it in a tub. The AV was leaning on the blue play structure with a ball in his/her hand. At 10:57:15 a.m., the child who placed the ball in the tub ran toward the door and was no longer visible in the camera view. · Video footage from the hallway was lower quality and as a result the timestamp was illegible. The footage showed the SP at the doorway to the Village looking into the Village. As the SP walked backwards a few steps, s/he glanced behind him/her toward the front desk. The SP then looked back toward the doorway of the Village. The SP stopped and motioned the children to go down the long hallway while the SP followed them. There were five children with the SP. · At 11:00:28 a.m., a child from P3’s classroom entered into the Village. Other children entered the Village and walked over and surrounded the AV. At 11:01:00 a.m., P3 was visible on the camera view. P3 walked over to the AV and took his/her hand as P2 entered the Village. P2 picked up the AV and walked out of the Village and out of view of the camera. The facility’s Risk Reduction Plan stated that during transitions, “[Staff persons] count each child (face to name) and do a final sweep of the area they are leaving to ensure no child is left behind.” The facility’s Employee Handbook stated, “[Staff persons] shall never leave a child unsupervised.” The Rollcall Sheet for the Busy Bees classroom on August 26, 2024, showed six Busy Bees children were present at the time of the incident, including the AV. Facility records showed that P1, P2, P3, P4, and the SP were each trained on the facility’s Risk Reduction Plan and the Maltreatment of Minors Act. Relevant Rules and/or Statutes Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A, state that “supervision” means 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; and that children are required to be supervised at all times. Conclusion: A. Maltreatment: On August 26, 2024, around 11 a.m., the SP was in the Village with six children including the AV. When it was time to leave, the SP gathered his/her things, turned off the light and waited at the doorway. The SP was seen on video footage backing away from the doorway to the Village with five children, and then proceeded down the hallway with the same five children. P3 saw the SP walk his/her class down the hallway and then P3 proceeded to line his/her class up to go to the Village for their large motor time. When P3 entered the Village s/he saw the AV and used his/her walkie talkie to ask P1 or P2 come to the Village. P2 arrived at the Village and took the AV out with him/her. When the SP arrived at his/her classroom, without counting the children first, s/he started to gather items to change diapers and “within 30 seconds” realized the AV was not with the group. The SP then counted and performed a name to face and confirmed the AV was not in the classroom. The SP looked around his/her room and checked with the other toddler classroom staff person. The SP stated that P4 looked in the room and assisted the SP in looking for the AV. P1 stated that s/he was walking in the hallway when the SP poked his/her head out and stated that s/he was missing the AV. P1 went into the classroom to double check, and then left to check the Village when s/he saw the AV with P2. P2 told P1 that P3 found the AV in the Village and P2 was waiting to see if the SP called to the office that the AV was missing. The AV did not seem upset by the incident and returned to the classroom. Video footage showed the AV was without staff person supervision for approximately three minutes which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and also a violation of Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A. P1 stated that the SP notified him/her that the AV was missing, and the SP stated that P4 assisted in looking for the AV. However, P1 stated that s/he knew the SP had not just entered the classroom when the SP poked his/her head out of the classroom, P4 stated s/he was not aware of the incident until later that day, and the SP did not follow the facility’s Risk Reduction Plan by performing a name to face or sweeping the area when s/he left the Village. While the AV was unsupervised, staff persons were not with the AV to intervene in the event of unsafe activity, injury or 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 seriously endangered his/her 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. The SP was responsible for the supervision of the AV when the incident occurred. The SP was trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. 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 as it was a single incident, and the AV sustained no injuries. 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. The SP was retrained on the facility’s supervision 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 January 8, 2025, 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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