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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: 801244-CCC (Child Care Center) Investigator(s): Kimberly Anderson/Alice Percy Minnesota Department of Human Services 651-431-6553 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) left an alleged victim (AV) unsupervised in a classroom for approximately two minutes. The AV was found in the classroom by his/her family member (FM). Date of Incident(s): August 8, 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 August 27, 2024; from documentation at the facility; and through four interviews conducted with two facility administrative staff persons (P1 and P2), SP1, and SP2. Attempts were made via telephone and mail to contact the FM, but the FM did not respond to the request for an interview. The AV was 31 months old and enrolled in the toddler classroom at the time of the incident. The toddler classroom was a large square room that had carpeting on one half of the classroom and tile on the other half. Low bookcases were placed along the walls and a large table was on the tile floor. Three large windows were located along the right side of the classroom. Two three-foot-high half doors were located along two walls in the tiled area of the classroom. One door opened to a hallway that led to two large entry doors at the front of the facility. The children’s family members typically entered the toddler classroom through that door. The second door opened to an adjoining preschool classroom. When the staff persons took the toddler children to the playground, they walked through the preschool classroom to the playground door. SP1 and SP2 provided the following information: · On August 8, 2024, SP1 and SP2 worked in the toddler classroom with thirteen children, including the AV. Each day, the staff persons posted a list of the children present in the classroom on the wall. The staff persons also used a cell phone app to track how many children were in the classroom. At approximately 4 p.m., after three of the children had left the facility for the day, SP1 and SP2 told the children they were going outside and had the children pick up their toys while SP1 and SP2 applied sunscreen to the children and ensured that they put their shoes on. · SP1 and SP2 lined the remaining children up near the classroom door prior to taking the children to the playground. SP2 stated that as the children lined up, s/he “counted them in [his/her] head” and counted nine children, which is the number of children SP2 believed were in the classroom at the time. SP1 then led the group of children to the playground door while SP2 followed the group. SP1 stated that s/he “forgot” to count the children while they were in the toddler classroom but counted them as they went out the playground door. SP1 stated that s/he counted nine children, but after learning that the AV was left in the classroom, s/he believed there were “supposed to be ten.” After the incident, SP1 believed s/he miscounted the children because it was a “hectic day” and s/he was “in a rush.” SP1 told SP2 that s/he counted nine children, but s/he was uncertain if SP2 also counted the children. SP2 believed they “forgot” the AV because s/he was “quiet” during the “chaotic” time when they took the children out of the classroom. SP2 stated that s/he typically looked around the classroom prior to leaving the room to ensure that no children remained in the classroom, but on the day of the incident s/he did not check the classroom prior to leaving. Neither of the staff persons counted the children once they arrived at the playground. P1 and P2 provided the following information: · P1 stated that on the day of the incident, as s/he walked the school-age children from a school bus into the facility, the FM entered the facility behind P1 to pick up the AV. P1 took the school-age children to their classroom and then walked back to the front of the building where s/he saw the FM and the AV. The FM told P1 that s/he found the AV unsupervised in the toddler classroom. P1 told the FM that s/he would retrain the staff persons on the facility’s supervision policies and FM1 and the AV left the facility. At an unknown time later, 2hen SP2 entered the facility, P1 told SP2 that the FM found the AV unsupervised in the classroom. SP2 told P1 that s/he believed the AV came to the playground with the rest of the children and s/he did not realize the AV was left unsupervised in the toddler classroom. Neither P1 nor P2 talked to SP1 about the incident. · P2 stated that s/he was not at the facility at the time of the incident and learned about it the following day from P1. P2 checked the facility’s video camera recording for the time of the incident and saw that the AV was left unsupervised in the classroom for approximately two minutes before the FM entered the classroom and found the AV. The video recording did not have sound so P2 was uncertain if the staff persons communicated the number of children with each other. P2 did not see SP1 count the children and the group left the classroom as the AV stood by a window. · P1 stated that the staff persons were trained to “group” the toddler children near the door and then look at the children’s faces as they counted them prior to leaving the classroom. The lead staff person then told the other staff person how many children were counted as s/he led the children out of the classroom and the second staff person would follow the children out of the classroom. The staff persons then counted the children again when they transitioned into the new area. · P1 stated that the roster each classroom had on the wall listed the children enrolled in that classroom. Most of the staff persons checked off which children arrived at the facility each day. The staff persons also had a cell phone app that allowed them to see which children were clocked in and out by their family members throughout the day. However, P1 stated that s/he would not “bank on” the phone app because it “does not synch right” so the staff persons had to ensure that all of the children in their classroom were clocked in and showed up on the phone app. According to the facility’s Risk Reduction Plan, the staff persons were to be within sight and sound of the children at all times. A door chime was installed on the toddler classroom doors that alerted the staff persons when the doors were opened. The staff persons were to provide supervision of the children during outdoor play and community outings. Facility documentation showed that SP1, SP2, 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: Information from all sources was consistent that on August 8, 2024, the AV was unsupervised in the toddler classroom for approximately two minutes after SP1 and SP2 took the children to the playground, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. When the FM arrived at the facility to pick up the AV, the FM found the AV unsupervised in the classroom and told P1. When SP2 entered the facility, P1 told him/her that the AV was found unsupervised in the classroom by the AV. Until told by P1, SP2 was unaware that the AV was left unsupervised in the classroom. SP1 and SP2 each stated they counted the children prior to leaving the classroom and each counted nine when they in fact had ten children, including the AV. SP2 stated that s/he typically looked around the classroom prior to leaving the room to ensure that no children remained in the classroom, but on the day of the incident s/he did not do so prior to leaving and neither SP1 nor SP2 counted the children once they arrived at the playground and were not aware they left the AV inside until an unknown time later when SP2 went inside and was told by P1 that the FM found the AV unsupervised in the classroom. Although the AV was not injured, given that the AV was 31 months old, 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 in the classroom in the event of an 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 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 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 and SP2 were each responsible for the care and supervision of the AV at the time of the incident and 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. SP1 and SP2 were 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 and SP2 were responsible was not recurring or serious because it was a single incident and the AV did not sustain any injury that required 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 person. After the incident, the staff persons were retrained on the facility’s supervision policies and trained to use name-to-face counting during transitions. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 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 and SP2 were each responsible for maltreatment is subject to appeal. On March 12, 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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