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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: 810015-CCC (Child Care Center) Investigator(s): Kimberly Anderson/Alice Percy 651-431-6553 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) climbed out of a crib and fell onto his/her head. Four staff persons (SP1, SP2, SP3, and SP4) failed to ensure that they were able to see all of the children who were in the crib room. After finding the AV on the floor, SP2 and SP3 did not immediately check the AV for injuries. Later that day, the AV was taken to the emergency room, where s/he was treated for a possible concussion. Date of Incident(s): April 17, 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 for this investigation was obtained remotely; from documentation at the facility and medical records; and through four interviews conducted with an administrative staff person (P1), SP1, SP2, SP3, and SP4. SP1 was also a family member of the AV. The AV was 15 months old and enrolled in the infant classroom at the time of the incident. The infant classroom was a large rectangular room with low shelves, tables, climbing toys, and infant chairs spread around the classroom. Counters ran along one side of the classroom and included a changing table. A half-wall separated the classroom from a crib room. The half-wall was clear so that a person could see through the wall into the cribs from the classroom. A door in the half-wall provided access to the crib room. There were 12 cribs in two rows in the crib room, one row along the clear half-wall and one row on the back wall. Information regarding the number of children in the classroom was different. Staff persons interviewed and the attendance sheet showed that there were 13 children in attendance, however, the video showed that 11 children were in the classroom. Therefore, it was not determined how many children were present at the time of the incident or if at any point, the classroom was out of ratio. P1, SP1, SP2, SP3, SP4, and the facility’s documentation provided the following information: · On April 17, 2024, there were 13 children in the infant classroom with SP1, SP3, and SP4. SP1 stated that at approximately 10:30 a.m., s/he placed the AV in his/her crib, which was located on the back wall of the crib room. SP1 then placed a mattress from a crib located at the front of the crib room in an upright position so that the AV could not see into the infant classroom. (Note: This also prevented staff persons from seeing portions of the crib room including the crib the AV was in.) SP1 stated that if the AV was able to see SP1, the AV stood and screamed. After SP1 placed the AV in his/her crib, P1 asked SP1 to go to another room to review training videos and SP3 entered the infant classroom. SP2 also entered the classroom to help serve lunch to the children when SP1 left the classroom. Prior to leaving the classroom, SP1 checked the crib room and saw the AV look at SP1 and cry. SP1 told SP2 that if the AV did not fall to sleep within 10 to 15 minutes, s/he should serve the AV lunch. SP1 then left the classroom. · SP2 stated that while s/he was preparing lunch in the classroom, SP3 entered the crib room and said that the AV was asleep on the floor. SP3 had not heard the AV fall from his/her crib and asked SP2 if s/he “heard anything.” SP4 stated that s/he did not see or hear the AV fall from his/her crib. SP2 did not know why SP3 did not pick up the AV when s/he first saw the AV on the floor before leaving the crib room, but believed SP3 was “shocked” that the AV was lying on the floor. SP2 stated that “no one knew what to do” so after SP2 finished changing a diaper, SP2 went to the crib room, picked up the AV, “looked [the AV] over,” and placed the AV back in his/her crib. The AV’s stomach “was going up and down” so SP2 “knew [the AV] was okay.” SP2 then returned to the classroom to serve lunch to the other children. SP3 stated that a short time later, s/he checked on the AV and saw a red bump in the center of the AV’s forehead but did not notify anyone or do anything for the AV. SP3 planned to complete an incident report about the incident, but SP1 later told him/her not to do so. · SP2 stated that when the AV woke up from his/her nap and was eating lunch, SP2 noticed a “bruise” on the AV’s forehead but did not put ice on the bruise. SP2 stated that s/he was trained to apply ice to bruises but that s/he made the “wrong” decision by not applying ice. · When SP1 returned to the classroom approximately two hours later, the AV was sitting at the table “with a glazed look” and was not eating. SP1 noticed a “huge red mark” on the AV’s head that had not been there prior to putting the AV down for his/her nap. SP1 placed ice on the AV’s head while SP2 continued serving lunch to the other children. SP3 told SP1 that s/he found the AV sleeping on the floor of the crib room. SP1 stated that SP3 told him/her that s/he thought SP1 took the AV to the crib room and let the AV “roam around.” SP1 then went to the staff office and told P1 that the AV had a red bump on his/her forehead and that SP3 found the AV sleeping on the floor. SP1 then asked to watch the facility’s video recording and saw the AV crawl out of his/her crib and fall to the floor approximately ten minutes after s/he left the room. SP1 did not understand why the staff persons in the classroom did not hear the AV fall from the crib or hear the AV cry after s/he fell. · Later that day, SP1 took the AV to the hospital, where s/he was diagnosed with a “possible concussion.” The AV returned to the facility the following day. SP2 stated that the AV often “fought” going to sleep, but SP2 never saw the AV climb out of his/her crib prior to the incident. SP1 stated that the AV had not previously climbed out of his/her crib. · SP4 was in the classroom at the time of the incident, but because of a medical condition, SP4 typically sat in a rocking chair and rocked children. According to the facility’s Internal Review, SP4 told an administrative staff person (P3) that SP2 and SP3 talked about the AV lying on the floor and were uncertain if the AV fell or if SP1 placed the AV on the floor. After the incident, SP4 saw a mark on the AV’s forehead. · SP1 stated that the staff person sometimes placed the mattresses of empty cribs in an upright position so that the children in adjoining cribs were unable to see the staff persons because some of the children, including the AV, cried when they saw the staff persons and then refused to sleep. Once the children fell asleep, the staff persons took the mattresses down. SP1 stated that the staff persons had done this “for years” and SP1 was never told not to use the mattresses to block the children from seeing the staff persons. SP2 stated that the AV and another child refused to sleep if they saw the staff persons, so the staff persons sometimes placed the mattresses in an upright position to block their view of the staff persons. SP2 stated that s/he recently began working at the facility and s/he “got accustomed” to placing the mattresses in that position because s/he saw the other staff persons do it. SP4 stated that s/he would not have seen the AV climb out of his/her crib even if the mattress was not placed to block the view of the AV because s/he was sitting in a chair facing away from the crib room. SP4 did not hear the AV fall or hear the AV crying. SP4 stated that SP1 frequently used a mattress to block the AV’s view of the classroom, but that SP4 never placed the mattresses in an upright position. · P1 stated that s/he was not aware that staff persons placed mattresses upright in the cribs in order to prevent children in the other cribs from seeing other children and staff persons and that it was against the facility’s crib policies. The upright mattresses also blocked the staff persons’ view of the children. P1 stated that after the incident, a timer was placed in the classroom to remind the staff persons to check on the children in the crib room every five minutes. A video camera was placed near the ceiling in one corner of the crib room and provided a view of the majority of the crib room and of the classroom. The facility provided camera footage of the infant classroom on April 17, 2024, from 10:31:00 to 10:46:59 a.m., and upon review, the following information was noted: · At 10:31:00 a.m., a staff person (P2) stood at the counter changing a child’s (C1’s) diaper, SP1 stood in a corner of the classroom, and SP4 sat in a rocking chair with his/her back to the crib room. SP3 sat on the floor with his/her back to the half-wall. One child (C2) was awake in a crib in the back row of cribs. A crib from the front row was pulled in front of C2’s crib and a mattress was placed upright in the crib blocking the view of C2 from the classroom. · At 10:31:22 a.m., P2 carried C1 from the changing table to the crib room and reached over the half-wall and placed C1 in a crib. · At 10:31:33 a.m., SP1 carried the AV into the crib room and placed him/her in a crib in the back row. SP1 then moved a crib from the front row in front of the AV’s crib parallel on the log sides and placed the mattress of that crib and the mattress of another crib in an upright position in the crib blocking the view of the AV from the classroom. During this time, the AV stood in the crib reaching for SP1. SP1 then left the crib room as the AV stood in his/her crib and cried as s/he hung onto the railing of the crib at 10:32:00 a.m. · From 10:32:00 to 10:37:03 a.m., the AV continued to stand in his/her crib and C1 and C2 moved around on their stomachs in their cribs. During this time, P2 left the classroom, SP1 changed children’s diapers, SP2 entered the classroom, and at 10:35:58 a.m., SP1 left the classroom. The AV stood in a corner of his/her crib, grabbed the railing, and attempted to pull him/herself on top of the railing. SP2 began to change children’s diapers while SP3 and SP4 continued to sit with their backs to the crib room. · At 10:37:03 a.m., the AV continued to try to climb out of the crib by holding onto the railing and lifting his/her feet off the mattress onto the railings and/or sides of the crib. · At 10:37:10 a.m., the AV raised his/her right leg up to the top of the crib railing and fell over the side of the railing headfirst onto the floor appearing to fall onto his/her head. The AV then stood and walked to the door of the crib room, where s/he was out of the camera’s sight. All three staff persons had their backs to the crib room and none appeared to react to the AV falling. · At 10:38:59 a.m., the AV walked back into view to the corner of C1’s crib and lay down on the floor. Between this time and 10:40:45 a.m., the AV moved around on the floor and/or rubbed his/her eyes while staff persons remained in the classroom. · At 10:39:22 a.m., SP3 stood and wiped the hands of a child held by P3. The AV rolled around on the floor in the crib room. · At 10:40:01 a.m., SP3 sat on the floor with his/her back to the half-wall. C1 and C2 moved around in their cribs and the AV moved around on the floor. · At 10:40:45 a.m., the AV was still as s/he lay on the floor. SP2 walked near the half-wall and picked up another child, took him/her to the changing table, and changed his/her diaper. · At 10:42:46 a.m., SP3 stood, walked to the crib room door, then turned around and walked to the half-wall near the AV, looked into the crib room and appeared to see the AV on the floor. SP3 and SP4 then appear to be talking to one another. · At 10:43:17 a.m., SP3 entered the crib room, walked to the AV, and stood looking around, but did not pick the AV up or bend down to look at the AV. · At 10:43:39 a.m., SP3 turned away from the AV and walked away out of the crib room and appeared to talk to SP4. · At 10:44:11 a.m., SP2 entered the crib room and went to the AV. SP2 stood next to the AV and looked around as SP3 also entered the crib room. At 10:44:28 a.m., SP2 picked up the AV and placed him/her in a crib. · At 10:44:43 a.m., SP3 left the crib room as SP2 picked up C2 and they also left the crib room. SP2 worked at the counter and SP3 sat on the floor in front of the half-wall. SP4 remained sitting in the rocking chair. The video ends at 10:46:59 a.m. prior to the AV waking up. According to the AV’s After Visit Summary, on April 17, 2024, the AV was seen by a physician because s/he fell while at the facility. The VA was diagnosed with a head injury but received no treatment for the injury. According to the facility’s Unqualified Substitute Report, on April 17, 2024, from 10:30 a.m. to 12:30 p.m., SP4 was used as an unqualified substitute in the infant classroom. According to the facility’s Welcome to Day One policy, all children were to be within sight and sound at all times. Infants and toddlers who were sleeping were to be supervised by sight and sound at all times. The staff persons were to position themselves so that they could hear and see any sleeping children for whom they were responsible. According to the facility’s Nap and Rest Policy, during naptime, the staff persons must be able to visibly see each child in case they needed immediate care. The staff persons were to enter the crib room no less than every 30 minutes to check on the sleeping infants. Facility documentation showed that SP1, SP2, SP3, SP4, P1, and P2 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 Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, state 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 April 17, 2024, SP1, SP2, SP3, SP4, and P2 each worked at some point in the infant classroom with either 11 or 13 children. Video showed that SP1 carried the AV into the crib room and placed the AV in a crib in the back row and then placed the mattresses of two cribs in an upright position in one of the cribs in order to block the AV from seeing the staff persons. In addition, C1 was in a crib next to an upright mattress which also blocked the view of C1. Using mattresses to block the views of children who were in the crib room was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Without staff persons knowledge, the AV climbed out of his/her crib and fell on the floor onto his/her head. SP2, SP3, and SP4 were each in the infant classroom at the time and did not see or hear the AV fall. The AV walked around the crib room and then lay near a crib. Approximately six minutes after the AV fell from his/her crib, SP3 entered the crib room and saw the AV lying on the floor but did not pick the AV up or check the AV for injuries. SP3 left the crib room and talked to SP2 and SP4. SP2 then entered the crib room and picked the AV up and placed him/her in his/her crib. SP2 did not check the AV for injuries prior to placing the AV back in the crib to sleep approximately seven minutes after the AV fell or provide care for the AV after the AV woke up from his/her nap when SP2 noticed a “bruise” on the AV’s forehead. When SP1 returned to the classroom approximately two hours later, the AV was sitting at the table and SP1 saw a “huge red mark” on the AV’s head that was not there prior to the AV lying down for his/her nap and placed ice on the AV’s head. SP3 told SP1 that s/he found the AV sleeping on the floor of the crib room. SP1 then went to the staff office and told P1 about the incident. Later that day, SP1 took the AV to the hospital, where s/he was diagnosed with a possible concussion. Given that that it was common practice among infant staff persons to put the mattresses up to block the view of the children; that the AV fell out of his/her crib and sustained a red mark on his/her head without staff persons knowing; that staff persons did not check the AV for injuries when they found the AV on the floor and instead put the AV back in the crib to sleep; and that after nap when the AV had an injury on his/her head, no care was provided to the AV until SP1 returned to the classroom, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care required for his/her physical or mental health and a failure to protect the AV from conditions that seriously endangered his/her physical or mental health. 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 and/or 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. SP1, SP2, SP3, and SP4 were trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including those regarding the supervision of children, prior to the incident. SP2, SP3, and SP4 were each responsible for the supervision and care of the AV at the time of the incident and did not supervise the AV and did not obtain immediate care for the AV when it was clear the AV had fallen from the crib. Although SP1 was not in the classroom when the AV climbed out of his/her crib and fell to the floor, SP1 contributed to the incident by placing mattresses in another crib in such a way that it blocked the other staff persons’ view of the AV in his/her crib. Therefore, SP1, SP2, SP3, and SP4 were 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 SP1, SP2, SP3, and SP4 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and although the AV was seen by a doctor and diagnosed with a head injury, the AV did not required treatment or the care of a physician. 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 the facility’s policies were adequate, but were not followed by the staff persons. P2, SP1, SP2, and SP3 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, SP3, and SP4 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1, SP2, SP3, and SP4 were each 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 disqualification. The determination that SP1, SP2, SP3, and SP4 were each responsible for maltreatment is subject to appeal. On January 10, 2025, 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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