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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: 800435-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: Allegation One: It was reported that an alleged victim (AV) was left alone on the playground for an unknown amount of time. Allegation Two: It was reported that the AV fell off a changing table and sustained an injury that required stiches in his/her lip. Date of Incident(s): October 31, 2024, and another previous unknown date 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 November 21, 2024; from documentation at the facility and medical records; and through five interviews conducted with two supervisory staff persons (P1 and P2), two facility staff persons (P3 and SP1), and the AV’s family member (FM). Attempts were made via telephone and certified mail to contact and interview a staff person (SP2) but SP2 did not respond to the requests. According to the AV’s enrollment information, the AV was three years and nine months old at the time of the incident(s) and enrolled in the preschool room. Consistent information was provided that the AV was diagnosed with autism and did not often verbally communicate. According to the AV’s Individual Child Care Program Plan, the AV had developmental disabilities but did not require additional accommodations. The AV attended the facility for approximately two to three hours per day. The facility was located on the corner of a four-lane road with a speed limit of 45 miles per hour (mph) and a two-lane road with a speed limit of 30 mph and had a preschool playground that was enclosed by a chain link fence and visible to a passerby. There were apartment buildings, businesses, and parking lots around the playground and facility. There was a door from the playground that led inside to the prekindergarten room. According to the facility’s risk reduction plan, staff persons were trained on the child supervision record, which promoted keeping regular and accurate attendance, establishing accountability for children in attendance, and keeping children safe. Staff persons positioned themselves to ensure children were “never” out of sight and sound. According to the facility’s Diapering Guidelines, staff persons approached each child “slowly” and engaged with the child to get his/her attention. Staff persons informed the child that it was time for a diaper change and gave the child “a moment” to adjust to the information before removing him/her from his/her current activity. While transitioning, staff persons talked to the child about what was happening and continued interacting with the child while changing his/her diaper. Staff persons were “focus[ed]” on the child and had one hand on the child “at all times.” Children were not left unattended on the diapering table. Facility documentation showed that all staff persons received training on the facility’s risk reduction plan, the facility’s Diapering Guidelines, and the Maltreatment of Minors Act prior to the incident. Allegation One: It was reported that the AV was left alone on the playground for an unknown amount of time. Consistent information was provided that at the time of the incident, the preschool and prekindergarten rooms were combined and SP1 was the staff person working. The FM provided the following information: · On an unknown date, between 5:45 and 6 p.m., the FM arrived at the facility and went to the AV’s sibling’s (S) room first. The FM and the S walked into the prekindergarten room. The S called out the AV’s name, looked around the room, and then looked up at the FM and asked where the AV was. The FM looked around and saw SP1 and asked SP1 where the AV was. · SP1 told the FM that the AV was possibly left outside so the FM went to the door to the playground, opened the door, and said the AV’s name. The AV stuck his/her head out from under the slide and “laugh[ed].” The FM brought the AV inside and did not see any injuries. The FM asked SP1 how long the AV was outside alone and SP1 “could not tell” FM1 the amount of time. · P2 heard the conversation between the FM and SP1 and asked what happened. The FM told P2 that SP1 left the AV alone outside and did not know how long s/he was out there. The following week, P1 told the FM that s/he heard that the AV was alone outside and that P1 spoke to the corporate office and his/her supervisor and let them know about the incident. The FM was not provided an incident report or documentation about the incident.
P2 stated on an unknown date, the FM told P2 that s/he was “upset” because the AV was alone on the playground. P2 spoke to SP1 who said that s/he was at the prekindergarten door with some of the children coming inside when the AV ran back onto the playground. SP1 was at the door “calling” to the AV to come inside when the FM arrived. P2 and P1 discussed the incident but did not take any further action. P1 stated on an unknown date, SP1 worked in the prekindergarten room and was combined with the preschool room at the end of the day. While coming inside from the playground, the AV ran back out onto the playground while the other children were going inside. SP1 stood at the door with the door open with “one foot inside and one foot outside” talking to the AV when the FM arrived at the facility. P2 was working but SP1 did not want to leave the door to get P2 for help. P1 then spoke to P2 who said “the same thing” as SP1. An incident report was not completed for the incident. SP1 provided the following information: · On a previous occasion, SP1 was on the playground with the children when s/he had all the children, including the AV, line up on the playground near the door to go inside. SP1 used the attendance sheet and transitioned all the children inside the prekindergarten room. The FM arrived while SP1 stood at the door with the attendance sheet when SP1 realized the AV was not with them. SP1 got the AV inside “right away.” · When asked about a time s/he was not aware the AV was alone outside, SP1 then provided conflicting information about the incident and said that during the incident, the FM arrived and asked where the AV was. SP1 said s/he was inside the room, had just set down the attendance sheet, and closed the door. SP1 thought the AV was next to SP1 and then SP1 realized that the AV was not inside. SP1 said that the AV must have gone back outside. SP1 went back out to the playground and called for the AV to come inside. The last time SP1 remembered seeing the AV was when they were outside on the playground and the AV was near a bench. · SP1 discussed the incident with P2. SP1 told P2 that the FM came in and asked where the AV was and SP1 realized that the AV was not in the room. The AV was “always hiding or running away” when it was time to come inside from the playground. SP1 was trained to do a head count outside and check off the children’s names on the attendance sheet and then once again when back inside. SP1 “usually” did a final sweep of the playground before coming inside but did not do so the day of the incident. SP1 did not write an incident report for the incident. Relevant Rules and Statutes: 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 was defined as occurring when a program staff person was 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 Allegation One: A. Maltreatment: The FM stated that on an unknown date when s/he arrived to pick up the AV, the FM and the S walked into the prekindergarten room and when the S called out the AV’s name and they did not see the AV, the FM asked SP1 where the AV was. The FM said that SP1 told the FM that the AV was possibly left outside so the FM went to the door to the playground, opened the door, and said the AV’s name. The AV stuck his/her head out from under the slide and “laugh[ed].” The FM brought the AV inside and did not see any injuries. The FM asked SP1 how long the AV was outside alone and SP1 “could not tell” FM1 the amount of time. SP1 provided conflicting information regarding the incident. SP1 initially told P1, P2, and this investigator that s/he was still at the door having children come inside when s/he called the AV’s name to come in, however, SP1 then provided consistent information to that of the FM that SP1 was in the classroom with the door closed, when the FM arrived to get the AV and it was discovered the AV was still on the playground unsupervised, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Given that the AV who was three years and nine months old was diagnosed with autism and did not often verbally communicate, it was unlikely that the AV would be able to provide for him/herself in an emergency and staff persons were not aware that the AV was outside on the playground in the event of an emergency. In addition, being alone outside for an unknown amount of time exposed the AV to community dangers, including traffic and community persons. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure protect 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. SP1 was responsible for the care and supervision of the AV at the time of the incident and was trained on the facility’s risk reduction plan and the Reporting of Maltreatment of Minors Act. SP1 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 SP1 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the AV did not sustain an injury. Allegation Two: It was reported that the AV fell off a changing table and sustained an injury that required stiches in his/her lip. Inside the preschool room was a changing table that staff persons used to change children’s diapers. The table was wooden with a plastic top where the children lay and was approximately three feet high. There were removeable wooden stairs that attached onto the side of the changing table that had five steps. The changing table was against a wall and open on three sides. The FM provided the following information: · On October 31, 2024, at approximately 5:45 or 6 p.m., the FM walked into the facility and was met by SP2 holding the AV who had a bloody towel on his/her face. SP2 told the FM that the AV “fell off the changing table and busted [his/her] lip and nose.” · The FM took the AV and carried him/her back to the preschool room where s/he rinsed the AV’s mouth with water. The AV indicated s/he was hungry and when the FM gave the AV food, s/he refused to eat because his/her mouth was in “pain.” The FM told P2 about the incident and then s/he left the facility. · Later that evening, the FM brought the AV to the hospital where the AV received stiches in his/her lip. The FM then spoke to P1 about the incident and P1 said s/he was going to contact the corporate office and follow up. The FM did not receive any follow up from P1. As of November 13, 2024, there was still a mark on the AV’s lip from the injury. According to the AV’s medical records, on October 31, 2024, the AV was seen in the emergency room for a laceration on his/her lower lip and a contusion on his/her nose. The AV received four sutures in his/her lower lip. P3 stated on an unknown date, s/he finished working in another room and was leaving the facility when s/he saw SP2 carrying the AV and the AV’s mouth was bleeding. P3 asked SP2 what happened and SP2 said that the AV jumped off the diaper changing table and hit his/her mouth. At that time, the FM arrived. P3 then told P2 about the incident and the next day, P3 told P1. P2 provided the following information: · On a previous unknown date, at approximately 6 p.m., as P2 was driving home, s/he received a phone call from P3. P3 said that the AV fell off the diaper changing table when SP2 was in the preschool room, was bleeding from his/her mouth, and the FM was at the facility for pick up. P2 instructed P3 to have SP2 to write up an incident report and give it to the FM. Later on, SP2 texted P2 and said that the FM had signed the incident report and SP2 left it on P2’s desk in the office. · The following day, while at the facility, P2 asked SP2 what happened with the AV. SP2 told P2 that s/he was changing the AV’s diaper on the diaper table when the AV jumped off the table hitting his/her mouth. P2 then told P1 about the incident. P2 signed off on the incident report and gave it to the FM at pick up. At that time, P2 asked the FM how the AV was and the FM explained that the AV needed stitches in his/her mouth. Staff persons were trained to keep a hand on children while on the changing table. P1 stated on an unknown date, when s/he arrived at the facility, P2 told P1 that the previous afternoon, the AV walked up the steps to the diaper changing table and instead of the AV laying down, the AV “jumped” off the table and hit his/her mouth. P1 then told SP2 to write an incident report. P1 called and notified his/her supervisory person and corporate of the incident. P1 said it was “not uncommon” for the AV to jump off things and P1 was “not surprise[d]” about the incident. Staff persons were trained that they prepared ahead of time when changing diapers so they never had to leave children alone on the table. Staff persons were required to keep a hand on children at all times when changing them. According to the Incident Report written by SP2, SP2 “was getting ready” to change the AV’s diaper. The AV was on the diaper table and “jumped off which caused a busted lip and nose.” Conclusion Allegation Two: On October 31, 2024, at approximately 5:45 p.m., SP2 met the FM holding the AV with a bloody towel on the AV’s face. SP2 told the FM that the AV “fell off the changing table and busted [his/her] lip and nose.” Although SP2 did not provide information for this report, SP2 provided consistent information to P2 and P3 that the AV jumped off the table, possibly after climbing the stairs, and hit his/her mouth. Given that there was no other information to support or refute SP2’s information, there was not a preponderance of the evidence whether SP2 failed to supply the AV with necessary care or a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health. 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 (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 policies and procedures were adequate and followed. Additional transition training was provided to SP1 and ten staff persons received additional training on the safety of children while using the changing table. The stairs were removed from the preschool room. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. On March 6, 2025, the facility was issued a Correction Order for the violation outlined in this report, failing to complete an incident report, failing to document separation of a child, and failing to report suspected maltreatment as required (Allegation Two). In addition, it was determined that facility mandated reporters had knowledge of the alleged incident (Allegation One) and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal.
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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