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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: 1107419-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 a staff person (SP) was carrying a pitcher of hot water when s/he bumped into an alleged victim (AV), causing the water to spill on the AV’s arm. The AV sustained a burn. Date of Incident(s): March 14, 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 March 25, 2025; from documentation at the facility and medical records; and through six interviews conducted with two supervisory staff persons (P1 and P2), three facility staff persons (the SP, P3, and P4), and the AV’s family member (FM1). The AV was 16 months old and enrolled in an infant classroom at the time of the incident. The facility had six classrooms. The infant classrooms were in one large room that was divided into two sides by a half wall with a gate. The Infant One (younger) side had an area for preparing bottles that was out of reach of children. In the bottle prep area, staff persons used a hot water dispenser to fill plastic measuring containers to warm children’s bottles in. The Infant One side only had a portable sink without a drain, so in order to empty the hot water dispenser of any unused water, staff persons put the water in a pitcher and brought the pitcher to the Infant Two (older) side on the other side of the gate. Once on the Infant Two side, staff persons dumped water down two sinks at a low counter next to a changing table. The low counter with the sinks was accessible to children and had a changing table on one end and a bathroom/storage closet on the other end. The facility’s Ouch Report showed that on March 14, 2025, a staff person was dumping the water from the bottle warmer into the sink and the AV went under the staff person’s legs from behind and grabbed the bottom of the water pitcher causing it to spill on the counter, the floor, and the AV. Staff persons immediately took off the AV’s clothes, ran cold water over his/her left arm, applied a cold towel and ice pack. On March 14, 2025, FM1 and another family member (FM2) walked to the facility to pick up the AV. FM1 stated that s/he and FM2 walked into the facility within minutes of the incident happening. FM1 saw the AV sitting with P4. The AV was crying, had no clothes on, and had a cold washcloth on his/her arm. FM1 and FM2 grabbed the AV and his/her belongings, walked home, and then went straight to urgent care. A health care professional administered fentanyl to the AV and wrapped the AV’s burn, and then FM1 and FM2 drove the AV to a specialty burn hospital. The AV was sedated, the area was washed, and an antibiotic cream was applied. The AV was diagnosed with first and second degree burns on his/her left forearm. The AV was sent home the next day with instructions to take pain medications every six hours. P3 provided the following information to this investigator and during the facility’s internal investigation: · On March 14, 2025, around 5 p.m., P3 was working in the Infant Two classroom with the AV. P3 was speaking with another child’s family member when s/he saw the SP bring the pitcher of water over from the Infant One classroom to dump it out. The AV took a toy from another child who started to cry, so P3 picked up that child while still engaged with the other child’s family member. As they walked toward the gate, P3 saw out of the corner of his/her eye the pitcher of water on the low sink and the SP with his/her head in the closet. The SP did not have his/her hand on the pitcher, and P3 could not tell whether there was water in the pitcher. · P3 heard the pitcher fall on the floor, turned around, and saw the AV hitting him/herself on the left arm and screaming. P3 noticed steaming water on the floor near the AV. The SP backed out of the closet, picked up the AV, and placed the AV on the changing table. · As the SP took the AV’s clothes off, P3 heard the SP asking the AV, “Why are you touching things?” At that point P4 came over from the Infant One side and helped take the AV’s clothes off. P4 noticed the AV’s skin was peeling on his/her left arm. P4 went to get P1 and the SP remained with the AV, so P3 started getting the other children to a table with built in highchairs to keep them away from the hot water on the floor. · When P1 came in s/he asked why the AV’s arm was not under water. P1 took the AV to place his/her arm under water. A staff person tried to call FM1, but s/he did not answer. P4 took the AV over to the Infant One side and sat with the AV until FM1 picked the AV up. FM1 stated that s/he forgot his/her cell phone. · P3 said the bottom part of the AV’s left arm was “reddish pinkish” and had started to peel. P3 heard the AV had second degree burns. · P3 was trained to dump the water at the end of the day when there were no children present because the water was boiling hot. P3 did not know why the SP was dumping the water so early as there were still children on both sides. P4 provided the following information to this investigator and during the facility’s internal investigation: · On March 14, 2025, around 4:45 p.m., P4 was getting ready to leave as s/he was no longer needed to be in ratio. The SP went over to the bottle prep area on the Infant One side and filled a pitcher “too full” of hot water from the dispenser. P4 told the SP that s/he should wait or empty part of it as it was too full. The SP stated, “It is fine,” and then carried the pitcher over to the Infant Two side to dump the water. · P4 was by the door on the Infant One side of the room with his/her back turned toward the Infant Two side so s/he did not see what happened. P4 turned around when s/he heard the AV scream. · P4 went over to the Infant Two side to help provide first aid to the AV. P4 saw that the AV’s left hand was bright red and the sleeve of the AV’s shirt was all wet. The SP was removing the AV’s pants, so P4 assisted in removing the AV’s shirt and noticed that the skin on the AV’s arm was “bubbling and peeling.” P4 told the SP to get the AV’s arm under cold water. The SP picked up the AV to get the AV’s arm in cold water and P4 went out to find a supervisor. · P1 was the first person P4 found, so P1 went into the infant classrooms and put the AV’s arm back under cold water and told P4 to find P2. P4 found P2 and they both went back to the infant classrooms. The SP tried calling the AV’s family members from the facility telephone and P4 tried calling FM1 from a cell phone. FM1 did not answer, so P4 left a voicemail. · P1 gave the AV to P4 to try to console, so P4 sat down with the AV and held a cold wet towel on the AV’s arm until FM1 arrived. · P4 said s/he personally waited until there were no children present to dump hot water and s/he did not know why the SP was dumping water when there were still children present. The SP provided the following information to this investigator and during the facility’s internal investigation: · The incident happened around 4:30 p.m. on March 7 or 14, 2025, whenthe SP was emptying the hot water dispenser at the end of the day because no more children needed bottles. The SP emptied the dispenser into a pitcher and carried it over to the edge of the sink on the Infant Two side of the room. · The SP provided inconsistent information about what happened next. The SP documented and told facility management that s/he was going to dump the pitcher when the AV reached between the SP’s legs, grabbed the pitcher, and it spilled on the AV. However, the SP told this investigator that s/he was not sure why s/he set the pitcher down that day as s/he “normally” just walked over and dumped it; and that s/he was not sure if s/he was going to turn on the water or grab a paper towel, but when s/he turned back to grab the pitcher, the AV had it. The SP said the AV was on a carpeted area when the SP brought the pitcher over, and the SP did not see the AV come closer to the SP until the AV was in contact with the pitcher. · After the pitcher spilled, the SP picked up the AV, took off the AV’s clothes, and noticed his/her left arm was burnt. The SP ran cold water over the AV’s arm and an unidentified staff person went to get a cold rag and to get P1. The AV’s arm was red and had started to bubble and peel. · A call was placed to FM1, but s/he did not answer, then someone got ahold of FM2. The SP had someone get towels to clean up the water on the floor and put the other children in highchairs. P4 went to sit with the AV and rocked the AV until FM1 arrived about 20 to 25 minutes after the incident. FM1 said s/he had walked to the building and forgot his/her cell phone. · The SP was trained to empty the pitcher of hot water on the Infant Two side. The SP stated that was the only hot water in the classroom as staff persons were not allowed to have hot coffee or drinks in the classroom. The SP stated s/he could have dumped the pitcher later once the children were gone and that was what had happened since the incident. P1 provided the following information: · On March 14, 2025, P1 was in the hallway speaking to another child’s family member when P4 found P1 and stated s/he was needed in the infant classrooms. P1 walked into the infant classrooms and saw the AV’s left arm was swollen to the size of a golf ball, red, and peeling. · P1 took the AV from the SP, ran his/her arm under water, and put a cold compress on it. P1 did not want the compress on too long, so then P1 switched to a washcloth that had cold water on it. P1 tried calling FM1 and FM2. When P1 got ahold of them, they were two minutes away. FM1 and FM2 arrived and then left with the AV. · The SP told P1 that s/he was dumping water in the low sink when the AV went between the SP’s legs and grabbed the pitcher full of water, causing it to spill on the AV. P4 told P1 that s/he saw the pitcher on the sink counter when s/he was speaking with another child’s family member, and the SP was leaning into the closet. No one saw the AV pull the pitcher down on him/herself. P1 followed up with FM1 later and learned the AV went to a specialty burn hospital and was diagnosed with second degree burns. · P1 was trained to empty the hot water canister on Fridays only, and only after all of the children left the classroom because hot water or hot liquids should not be available to children. P2 provided the following information: · On March 14, 2025, between 4 p.m. and 5 p.m., P2 was at the front of the facility when P4 found him/her and stated there was an emergency in the infant classrooms. P2 went to the infant classrooms and “instantly” saw the burn on the AV’s arm. The AV was crying and visibly upset. When the AV did calm down and staff tried to tend to his/her arm, the AV started crying again. · P2 reached out to his/her supervisor who gave some brief instructions. P4 was holding the AV, so they placed a towel with cool water on the AV’s arm, found a report for the SP to use to document what happened, and tried to call FM1 and FM2. P2 said staff persons did not get ahold of FM1 and FM2, but FM1 arrived shortly after the incident. P4 handed the AV to FM1 and briefed FM1 on what happened. · The SP told P2 that s/he went to dump the pitcher when the AV crawled between his/her legs and pulled the pitcher down, causing it to spill on him/herself. Later P3 told P1 that the SP set the pitcher down on the sink counter and stepped into the closet when the AV went over and spilled the pitcher. The AV sustained second degree burns. · P2 was not sure if there was a certain procedure staff were trained on for dumping the water, but stated hot water was to be kept out of reach of children. The AV’s emergency department medical records showed the AV was seen on March 14, 2025, at 5:19 p.m., with partial thickness burns to his/her left forearm. The AV was given fentanyl and ibuprofen for pain. The AV’s wound was wrapped and when s/he was stable, FM1 and FM2 transported the AV to a hospital burn unit. The AV’s medical records from the hospital burn unit showed the AV was admitted on March 14, 2025, with three percent partial thickness, second degree burns to his/her left arm, and superficial burn to his/her left wrist and hand. The AV underwent a sedated dressing change with Pediatric Intensive Care Unit (PICU) sedation. On March 15, 2025, the AV tolerated dressing changes with oral medications only. The AV was discharged that day with orders to return to the burn and would clinic after one week. The AV was prescribed oxycodone (as needed) and over-the-counter medications (as needed) for pain control. The facility’s Risk Reduction Plan stated, “Bottle warming cups will remain out of reach of children in the food prep area of the infant rooms.” Facility documentation showed the SP, P1, P2, P3, and P4 each received training on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rules and/or Statutes:
Minnesota Rules 9503.0140, subpart 17, states in part that hazardous objects must be stored out of reach of children. Conclusion: A. Maltreatment: Consistent information was provided that on March 14, 2025, the SP carried a pitcher of hot water from the Infant One side of the classroom to the Infant Two side of the classroom, in order to dump it out. The SP set the pitcher down on the counter between the low sinks and the AV was able to grab the pitcher and tip it over on him/herself. First aid was provided, and attempts were made to reach FM1 and FM2. FM1 and FM2 took the AV to urgent care and then to a hospital burn unit. The AV was diagnosed with first and second degree burns on his/her left arm that required prescription pain medication, sedated wound dressing, and hospitalization. The SP initially stated and documented that s/he was dumping the pitcher when the AV came between his/her legs and tipped the pitcher. However, the SP later stated that s/he set the pitcher down and was grabbing a towel or turning on the faucet when the AV spilled it, which was consistent with P1’s account that just before the incident, s/he saw the pitcher on the sink counter and the SP’s head was in the closet. Therefore, there was a preponderance of the evidence that the SP set down the pitcher of water in an area that was accessible to children, including the AV. This was a violation of Minnesota Rules 9503.0140, subpart 17, was inconsistent with the facility’s Risk Reduction Plan, and the AV spilled the hot water on him/herself causing a second degree burn. Therefore, it was determined that there was a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical health when reasonably able to do so. It was determined 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 SP received training on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. The SP was responsible for maltreatment of the AV. 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 found their policies and procedures were adequate, but were not followed by the SP. The SP received a written warning for violating the facility’s Risk Reduction Plan and received retraining on the plan. 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 the SP was determined responsible for maltreatment. The determination that the SP was responsible for maltreatment is subject to appeal. On August 13, 2025, the facility was issued a Correction Order for the violations outlined in this report and for failure to report suspected maltreatment 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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