|
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.” On June 18, 2025, most of the children and family work, including investigations of maltreatment at childcare centers, at the MN Department of Human Services (DHS) Office of Inspector General transferred to the new Minnesota Department of Children, Youth, and Families (DCYF), as directed by state law. While this investigation began under DHS, pursuant to Minnesota Statutes, section 15.039, subdivision 2, this Investigation Memorandum is being issued by DCYF pursuant to that transfer.
License Number and Program Type: 808906-CCC (Child Care Center) Investigator(s): Danielle Morrison Minnesota Department of Children, Youth, and Families 651-539-8252 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was in a bathroom alone, walked into an empty adjoining classroom, proceeded out of that classroom into a hallway, and out the front door without staff person knowledge or supervision. The AV was without staff person supervision for approximately three minutes. Date of Incident(s): February 3, 2025 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 February 10, 2025; from documentation at the facility; and through five interviews conducted with two facility supervisors (P1 and P2), two facility staff persons (the SP and P3), and the AV’s family member (FM1). The AV was three years old and enrolled in the Early Preschool classroom at the time of the incident. The facility had seven classrooms serving infants through school aged children. Upon entering the facility there were two hallways which formed a horseshoe shape with classrooms along each hallway. The Early Preschool Classroom was at the back of the facility near the end of the horseshoe shaped hallways, and there were two entrances into the Early Preschool classroom, one from each hallway. The Early Preschool classroom had a “Jack and Jill” bathroom (a bathroom that connected to the Early Preschool on one end and to an adjacent Toddler classroom on the other end). FM1, P1, P2, the SP, and video footage provided consistent information that on February 3, 2025, around 7:40 a.m., the SP was in the Early Preschool classroom with the AV. The AV went in to use the bathroom. The SP went to check on the other children in the classroom and greet a child who was arriving to the Early Preschool classroom with his/her family member. During this time the AV left the bathroom and went into the adjoining Toddler classroom which was unoccupied at that time. The AV proceeded out that classroom’s main door, along a hallway, out the front door of the building, and walked along a sidewalk. The SP and P2 said the AV was “happy,” and P1 said the AV looked like s/he was “living [his/her] best life.” The AV was unsupervised for approximately three to four minutes. P1, P2, and FM1 had no prior concerns with the SP. P3 said that on February 3, 2025, s/he was working in an infant classroom with another staff person when P3 saw the AV outside on the front sidewalk. Another child’s family member was trying to get the AV inside. P3 knew the AV listened better to the SP and P3 was worried that if s/he went to bring the AV inside, the AV would run further away. P3 went and told the SP the AV was outside. P3 stayed in the SP’s classroom while the SP went to bring the AV back inside. Once the SP and the AV were back in the Early Preschool classroom, P3 went back to the infant classroom. P1 and P2 provided information consistent with P3 about how the AV was found. The SP stated children were seated at the tables doing activities and a child was being dropped off into the Early Preschool classroom by his/her family member when P3 entered the classroom and said the AV was out front. P3 stayed in the classroom while the SP went out the front door to bring the AV back inside. The AV was playing in a grassy area between the building and the sidewalk when the SP found the AV. P1, P2, P3, and the SP provided the following additional information: · P1 said that if a child was the only one using the bathroom a staff person should check on the child if they were in there “so long.” If multiple children using the bathroom simultaneously, a staff person was to be within sight of the bathroom and classroom to make sure children were using the bathroom and not “goofing” around. · P2 said staff persons were trained to open the bathroom door and let children go one by one into the bathroom. In a Jack and Jill bathroom staff persons were to check on the preschoolers “every minute or so” if they were alone in the bathroom. If there were multiple children using the bathroom simultaneously, a staff person stood by the doorway. · P3 said that prekindergarten children could go into the bathroom and staff persons “monitored” them. P3 said the bathroom had two toilets in it so they tried to have two girls, or two boys, go in together, or have children use the bathroom one at a time. · The SP said preschool children were allowed to use the bathroom as long as they were checked on. The SP said it was an everyday thing for months for the AV to go into the bathroom in the morning, take off his/her diaper, go to the bathroom,walk out with his/her pants down saying, “I’m done.” The SP would then help the AV pull up his/her pants and then the AV washed his/her hands. · P1 said the SP was distraught by what happened and in the video footage P1 could tell the SP was “shaken up” and when P2 spoke with the SP, the SP was crying. P2 said the SP was “scared” and trying not to cry after the incident happened and was worried s/he was not keeping the children safe. P3 said the SP was kind of pale and P3 thought maybe P3 was “shocked.” The SP said s/he was terrified that the AV was in the parking lot and replayed the entire period of what s/he could have done better. This investigator reviewed video footage from February 3, 2025, and the video footage was consistent with the information provided by FM1, P1, P2, P3, and the SP. The AV left the bathroom at 7:42:52 a.m. and the SP was seen on the camera outside of the front of the building at 7:45:48 a.m. to bring the AV back inside, so the AV was unsupervised for approximately three minutes. The facility’s Risk Reduction Plan stated, “[The facility] provides direct supervision for toddlers and young preschoolers when using bathrooms. Preschoolers can use the bathroom independently and close the door when: only one preschooler is using the bathroom, the door can be shut for privacy. Staff [persons] will monitor while the student is in the bathroom. If the bathroom in the classroom is adjoined by another classroom, the door will remain open, and supervision is required.” The Risk Reduction Plan referenced the Safety and Supervision Policy. The facility’s Safety and Supervision Policy stated, “Preschool and school-age children may be out of direct sight only when using the restroom independently and they should be checked on frequently.” Facility documentation showed that P1, P2, P3, and the SP were each trained on the facility’s Risk Reduction Plan, the facility’s Safety and Supervision Policy, and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute: Minnesota Statutes, section 142B.01, subdivision 27, and Minnesota Rules, part 9503.0045, subpart 1, item A, states 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. Minnesota Statutes, section 142B.01, subdivision 27, paragraph (e), states when a single preschooler uses an individual, private restroom within the classroom with the door closed, supervision occurs when a program staff person has knowledge of the child’s activity and location, can hear the child, and checks on the child at least every five minutes. (Note: the Department determined that Minnesota Statutes, section 142B.01, subdivision 27, paragraph (e) does not apply to this incident because the Jack and Jill bathroom involved in the incident was not an individual, private restroom within the classroom.) Conclusion: A. Maltreatment: Consistent information was provided that on February 3, 2025, the SP was working alone in the Early Preschool classroom. The SP brought the AV into the Jack and Jill bathroom so the AV could use the bathroom. The SP then went to do other work-related tasks including greeting a child who arrived at the classroom and interacting with other children in the classroom. During this time the AV left the bathroom into the adjoining Toddler classroom, which was unoccupied, went out that classroom’s door, down the hall to the front door, exited the facility, and began to play on the facility grounds. P3 saw the AV outside and went to get the SP to bring the AV back inside because the AV was not as familiar with P3. When P3 told the SP the AV was outside, the SP ran out of the classroom and out the front door to bring the AV back inside. Video footage showed the AV was without staff person supervision after leaving the Jack and Jill bathroom for approximately three minutes, which was a violation of Minnesota Statutes, section 142B.01, subdivision 27, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV left the facility which exposed the AV to community dangers including the parking lot, unknown community persons, and vehicles. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with the necessary care and a failure to 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. The SP was responsible for the supervision of the AV at the time of the incident. However, at the time of the incident, the SP was the only staff person working in the AV’s classroom and the SP was engaged with other work related activities that required him/her to leave the immediate area of the Jack and Jill bathroom. In addition, the facility’s Safety and Supervision Policy stated that preschool children could be out of direct sight when using the restroom independently and should be checked on frequently; and the SP, P1, P2, and P3 provided consistent information that common practice at the facility was to allow a preschool child to use the bathroom alone (individually), and check on the child. This practice did not ensure preschool children were supervised according to Minnesota Statutes, section 142B.01, subdivision 27, and Minnesota Rules, part 9503.0045, subpart 1, item A. Therefore the SP’s individual responsibility was mitigated and the facility was determined responsible for the maltreatment of the AV. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious as the AV did not sustain injuries as a result of this incident of maltreatment. 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 Children, Youth, and Families for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility reviewed their policies and procedures and found they were adequate, and followed by the SP. There was no corrective action taken, but the facility used the incident as a “teachable moment” to heighten staff persons’ awareness of child elopement. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: On July 31, 2025 the license holder was ordered to forfeit a fine of $1,000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each 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 Children, Youth, and Families.
|
