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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.” 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:
1111450-CCC (Child Care Center) Investigator(s): Judie Schwanke Minnesota Department of Children, Youth, and Families Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was strapped into an infant chair and placed on a counter. The AV fell off the counter and landed on his/her head. Date of Incident(s): April 4, 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 April 16, 2025; from documentation at the facility and medical records; and through four interviews conducted with the AV’s family member (FM), a facility supervisory staff person (P) and two facility staff persons (SP1 and SP2). Facility documentation showed the AV was seven months old and enrolled in the infant classroom at the time of the incident. The infant classroom was square with upper and lower cabinets along one wall. There was a counter on top of the lower cabinets that was approximately three feet and one inch from the floor. In the counter top was a small sink and approximately 18 inches beyond the cabinets was another sink. Approximately four feet beyond that sink was a changing table. On a high shelf in the classroom was a Bumbo brand infant chair. The floor under the counter was not carpeted. Bumbo.com stated, “Refer to instruction manual before use,” and provided a link to the manual. The manual and the back of the chair in the infant classroom each had a warning label that read “FOR INFANT FLOOR SEAT USE: FALL HAZARD: Infants have suffered skull fractures falling while in and from floor seats. Use ONLY on the floor. NEVER use on an elevated surface…ALWAYS keep children in view while in product.” The facility used Brightwheel which was a mobile application (app) platform used to communicate with families. Initially the P stated that video of the incident was not captured because the camera “gliched.” Later, a facility administrative staff person stated that there was video of the incident and s/he viewed the video and saw the AV on the counter in the chair, then there was a “glich” and then the AV was on the floor. The video footage was not saved, so the DCYF investigator was unable to review video footage of the incident. The FM provided the following information: · On April 4, 2025, the FM received a picture of the AV in Brightwheel that showed the AV on the counter in the Bumbo chair, and the FM thought that the AV should not “be up there.” At approximately 11:45 a.m., the FM received a phone call from the P who told him/her that staff persons were “next” to the AV but s/he “leaned forward” and fell from the counter to the floor while buckled into the chair. · The FM picked up the AV and took him/her to a local medical facility, which referred the AV to an emergency room. The emergency room observed the AV, determined the AV was “fine,” and sent the AV home with the FM. That evening the FM messaged the facility and wrote that the AV was “okay.” The AV had a “red bump” on his/her chin that improved in three days. · On the following Monday, the FM met with the P and discussed his/her concerns about why the AV was allowed to be on the counter. The P did not give the FM a “clear” answer on this and agreed the AV should not have been placed on the counter. · Prior to this incident, the FM did not have concerns with the facility. The P provided the following information: · On April 4, 2025, at approximately 11:45 a.m., the P returned from a break when SP1 and SP2 asked him/her to come into the infant classroom. SP1 “snuggled” the AV and the P asked SP1 and SP2 what happened. SP1 and SP2 each told the P that the AV “fell off” the counter. The P checked on the AV and saw that the AV had a “little mark” on his/her chin that was “smaller than a penny,” and his/her nose had “stopped bleeding.” The P told SP1 and SP2 that they should not leave children “unattended” on the counter or “have” children on the counter. · The P called the FM and told him/her that the AV had fallen off the counter. Approximately 15 minutes later, the FM arrived at the facility. The FM asked the P why the AV had been on the counter and the P told the FM that SP1 and SP2 were feeding the AV lunch. The FM told the P that s/he was taking the AV to the hospital and the FM and the AV left the facility. · At 7:49 p.m., the FM sent a message to the facility in the app that said the AV was home and “okay,” and that s/he wanted to meet with the P the following week. · On April 7, 2025, the P and the FM met and discussed what happened. The FM told the P that the AV was observed in the emergency room for four hours for signs of concussion. The AV was given a “clean bill of health” and sent home. The P stated that the mark on the AV’s chin was gone on April 7, 2025. · During the summer of 2024, the P saw staff persons bring children in from outside and place them on counters to clean their “skinned knees.” After that, during a summer staff meeting, the P told staff persons that they should not put children on the counters. If any staff persons were not present during that meeting, other staff persons were responsible to relay that information to them. · In or around the autumn of 2024, a previous infant classroom staff person purchased the Bumbo chair for the classroom. Prior to the incident, the P had seen staff persons place children in the Bumbo chair on the counter “only to do art projects,” and staff persons stood “right there” and removed them “immediately.” The P did not recall if s/he said anything to staff persons at that time. The P stated s/he never saw other staff persons feeding a child on the counter in the Bumbo chair. The P “never” saw the AV on the counter in the Bumbo chair. SP1 and SP2 provided the following consistent information: · On April 4, 2025, at approximately 11:45 a.m., SP1, SP2 and six children, including the AV, were in the infant room. At lunch time, four children were placed in low chairs on the floor and SP2 placed the AV in the Bumbo chair on the counter. SP2 buckled the AV into the chair and put on the chair tray. SP1 and SP2 each stated the AV was placed on the counter for “convenience.” The four children in the low chairs were given table food to eat on their own and SP2 fed the AV “puree” food. · It was the after lunch “routine” that SP1 cleaned the bibs and the chairs while SP2 cleaned and diapered the children. Some children in the low chairs were done eating lunch so SP1 took over feeding the AV and SP2 cleaned the children. When the AV was done with lunch, SP1 removed the AV’s bib and stepped to the sink near the cupboard to clean the bib, leaving the AV in the Bumbo chair on the counter. Approximately 30 seconds after s/he stepped to the sink, out of the “corner” of his/her eye, SP1 saw that the AV “reached out” and “tipped” off the counter. · SP1 stated the AV first hit his/her chin and then his/her “upper forehead” on the floor. SP1 “ran” to the AV, unbuckled and “grabbed” him/her. The AV’s nose bled, and the AV had a “rug burn scrape” on his/her chin approximately the size of a “quarter.” · SP2 stated s/he was at the changing table and did not see the AV fall from the counter but turned when s/he heard a “loud crash.” SP2 saw the AV “face down” on the floor, the tray of the Bumbo chair had “snapped off.” SP2 stated the AV “cried right away,” for approximately five minutes. The AV had a mark on his/her forehead that was approximately “two finger widths” wide and one “finger width” long. The AV had a mark on his/her chin that looked like a “rug burn” that did not “bleed” and looked “bruised. That mark was approximately the size of the “top end” of SP2’s thumb. · SP1 or SP2 went to get the P and s/he came into the room. SP1 held an ice pack to the AV’s head and the P called the FM and told him/her what had happened. SP1 held and “rocked” the AV and s/he fell asleep, then the FM arrived at the facility. · When the FM arrived at the facility, s/he told the P that they were taking the AV to the hospital to be “checked out.” Then the FM and the AV left the facility. At approximately 7:30 p.m., the FM messaged the facility in the app that the AV was “okay.” · SP1 stated the mark on the AV’s chin lasted “a week.” SP2 stated that “two days” after the incident, the mark looked more “red and blue” and “went away” after a week. · SP1 was taught how to feed infants from a previous staff person who no longer worked at the facility. Prior to the incident, the AV and other children had been placed in the Bumbo chair on the counter to be fed and to do crafts. SP1 said s/he saw the warning label on the Bumbo chair but did not read it. Prior to the incident, SP1 was not “aware” that children should not be placed in the Bumbo chair on the counter. SP1 was never told not to place children on the counter. · SP2 was taught how to feed infants from a previous staff person who no longer worked at the facility and that staff person placed children in the Bumbo chair on the counter when s/he fed children purees. SP2 said the P saw the AV in the Bumbo chair on the counter while SP2 fed the AV, and also saw other children in the Bumbo chair on the counter while SP2 did art with the children. The P did not “say anything” to SP2 about placing children on the counter . · SP2 stated that before the incident s/he saw but “never thought” to read the warning label on the Bumbo chair. After the incident SP2 read the warning label and learned that the Bumbo chair should not be placed on “high surfaces” with children in it because they could fall. · Neither SP1 nor SP2 worked at the facility the summer of 2024, and neither received training that children should not be placed on the counter. The AV’s medical records provided the following information: · On April 4, 2025, the AV was seen at the emergency room for a fall from a counter. The AV seemed “more fussy” on arrival and had a “bloody nose.” · The AV had a “small abrasion” on his/her chin, was “alert,” and acted “appropriately.” · The AV was given acetaminophen orally and observed for three hours for “concerning signs and symptoms.” When no concerning symptoms were observed the AV was sent home with the FM with no further treatment ordered. The facility’s Risk Reduction Plan stated that children must be under staff person’s supervision at all times. The facility’s Identified Hazards to Children policy stated that staff persons “must identify any potential hazards such as falling objects,” must “safely secure objects such as furniture,” and, “Infants and toddlers will not be left alone on changing tables or other furniture.” Facility documentation showed that the P, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s Risk Reduction Plan and Identified Hazards to Children policy before the incident. Relevant Rules and Statutes: 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 145B.54, subdivision 2, and Minnestoa Rules, part 9503.0155, subpart 15, state child care centers must develop a risk reduction plan that identifies general risks to children served by the child care center and must establish procedures to minimize identified risks and train staff persons on the procedure and prohibit the accessibility of hazardous items to children except during periods of supervised use. Conclusion: A. Maltreatment: Consistent information from the FM, the P, SP1 and SP2 showed that on April 4, 2025, SP2 placed the AV into a Bumbo chair on a counter to feed the AV. SP1 took over feeding the AV and then stepped away from the AV. The AV, still buckled in the chair, fell off the counter and landed on the floor, causing a bloody nose and an abrasion to the AV’s chin. Leaving the AV alone on top of furniture was inconsistent with the facility’s Risk Reduction Plan and Identified Hazards to Children policy; and was also a violation of Minnesota Statutes, section 142B.01, subdivision 27, and Minnesota Rules, part 9503.0045, subpart 1, item A; and Minnesota Statutes, section 145B.54, subdivision 2, and Minnestoa Rules, part 9503.0155, subpart 15. The AV’s injuries were preventable with the exercise of due care, and were the result of SP1’s actions of placing the AV in the chair on the counter and SP2’s actions of stepping away from the AV and allowing him/her to fall three feet to the floor. Therefore, there was a preponderance of the evidence that SP1’s and SP2’s actions were not accidental and were a 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. It was determined that neglect occurred (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): 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 P, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s Risk Reduction Plan and Identified Hazards to Children policy before the incident. SP1 and SP2 each stated they saw the warning label on the Bumbo chair but failed to read it before the AV was placed in the Bumbo chair on the counter. SP1 placed the AV in the Bumbo chair on the counter and then swapped duties with SP2. SP2 stepped away from the AV and was not able to intervene when the AV fell off the counter. Therefore, SP1 and SP2 were each responsible for the maltreatment of the AV. SP1 and SP2 each said that prior to the AV falling off the counter, SP1 and SP2 were trained to place children in the Bumbo chair on the counter by a previous employee. The P, SP1, and SP2 each stated that the P saw children in the Bumbo chair on the counter prior to the incident, and SP1 and SP2 each stated that they were never told not to place children on the counter. The P did not recall if s/he ever told staff persons not to place children in the Bumbo chair on the counter. The P had significant administrative and supervisory authority over the operation of the facility and maintaining compliance with Minnesota Rules and/or Statutes. Given that the P failed to ensure that the facility’s Identified Hazards to Children policy was followed by SP1 and SP2, the facility was also 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 neglect for which the facility was responsible did not meet statutory criteria to be determined as serious because the AV did not require medical care other than an over the counter pain reliever and observation. 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 completed an internal review and determined that their policies and procedures were not followed. The facility created a new policy prohibiting placing children on counters. Infant staff persons, including SP1 and SP2, were retrained on the new policy. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: The Department of Children, Youth, and Families informed the Department of Human Services, Office of Inspector General, Background Studies Division that SP1 and SP2 were each determined responsible for maltreatment. The determination that SP1 and SP2 are each is responsible for maltreatment is subject to appeal. On August 21, 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. On August 21, 2025, the facility was issued a Correction Order for failing to report this incident within 24 hours as required. 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.
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