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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: 1060501-CCC (Child Care Center) Investigator(s): Tessa Ripka/Danielle Morrison Minnesota Department of Children, Youth, and Families 651-539-8252 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) fell off a changing table when a staff person (SP) stepped away. Date of Incident(s): June 9, 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 June 25, 2025; from documentation at the facility, medical records; and through four interviews conducted with three facility staff persons (SP, P1, P2), and the AV’s family member (FM). The AV was not interviewed due to his/her age. The AV was two years old at the time of the incident and enrolled in a toddler classroom. P2 and the Internal Review provided the following information: · On June 9, 2025, at 11 a.m., the SP brought the AV to P2 and said that the AV had fallen off the changing table. P2 assessed the AV for any signs of concussion and injury. The AV was not crying at that time but looked like s/he had been crying. The SP said that s/he was almost done changing the AV’s diaper when another child began climbing to grab something off a counter. P1 had stepped out of the classroom to use the bathroom, leaving the SP as the only staff person in the room. The SP took his/her hand off the AV to intervene with the other child. The AV fell off the changing table and hit his/her head. · The AV had an approximately one-inch-wide circular red mark on the middle of his/her forehead. P2 iced the AV’s head and called the FM. The FM picked up the AV shortly after and at that time the AV was walking around, laughing and playing. The AV was seen by a medical professional and did not require any medical attention. · P2 had no prior concerns with the SP. P1 said that on the day of the incident, s/he was working in the classroom with the SP. At approximately 11:15 a.m., s/he went to use the restroom. P1 came back after approximately four minutes and as soon as s/he walked in a child tried to grab a plate off a counter. The SP, who was at the changing table, stepped toward the child and the AV rolled off the changing table. P1 was not able to see how the AV landed. The AV developed a golf ball sized area of swelling on his/her forehead The SP provided the following information: · On the day of the incident, the SP was working in the classroom with P1. Just before lunch time, the class’s lunches were set up on the counter and the SP was changing diapers, and P1 went to the restroom. · As the SP was changing the AV’s diaper, another child started to climb on the counter to try to reach the lunch plates. The SP took one step away from the changing table toward the child at the counter, taking the SP’s hand off the AV, and then reversed course, turning back around toward the changing table. Simultaneously, the AV rolled off the changing table onto the floor. · The AV immediately developed an approximately 1.5-inch-wide bruise on his/her forehead. The AV started crying and the SP picked him/her up. The SP took the AV to P2 and got some ice for the AV’s forehead. The AV cried for two to three minutes. The SP did not notice any other injuries. · The SP was trained that when staff persons changed diapers, they were to gather all supplies prior to starting and keep one hand on the child throughout the diaper change. During the incident, when the SP saw the child trying to get the food off the counter, s/he took a step toward that child as s/he did not want them to get the food or get hurt, but then the SP realized stepping away from the AV endangered the AV, and s/he turned back before intervening with the other child. The SP said that in retrospect, s/he could have just let the child get the food off the counter. The facility’s Accident Report stated that on June 9, 2025, the SP was changing the AV’s diaper and was “just about done” when another child was about to dump a plate of food on the floor. The SP took one step away from the AV and before the SP turned back around, the AV fell off the table. The SP brought the AV to the office and put ice on the AV’s head. Medical records showed that on June 9, 2025, at 1:34 p.m., the AV was seen in the emergency department (ED) after rolling off a changing table. The AV was observed in the ED for four hours post fall. The AV had bruising to his/her forehead but had no other signs of trauma. The AV remained stable without changes to his/her mental status and was discharged without treatment. Photos provided by the FM showed a golf ball sized red mark in the middle of the AV’s upper forehead. The facility’s Diapering Procedure stated that before diapering a child, staff persons were to gather all supplies and place them within reach, cover the diapering surface with single use paper and then put on disposable gloves. The child was then placed on the diapering surface, and the diaper was removed. Staff persons cleaned soiled skin and removed soiled gloves. A new diaper was placed on the child and hands were washed. Staff persons were to “always” keep one hand on the child during this entire process. The facility’s Risk Reduction Plan for Licensed Child Care Centers stated that children were placed on a changing table on their backs and strapped into place for diaper changes. The staff person that changed the child was never to the child unattended. Facility documentation showed that all staff persons interviewed were trained on the facility’s policies including the Risk Reduction Plan for Licensed Child Care Centers and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute: Minnesota Rule 9503.0140, subpart 12, states that the diaper changing procedures were: developed in consultation with a heath consultant, posted in diaper changing area, and followed by staff persons.
Conclusion: Information was consistent that on June 9, 2025, the SP was changing the AV’s diaper on the changing table. When another child tried to grab a plate of food off the counter, the SP stepped away from the changing table briefly toward the other child, taking the SP’s hand off the AV which was not in accordance with the facility’s Diapering Procedure and was a violation of Minnesota Rule 9503.0140, subpart 12. The SP then reversed course, turning back toward the table and simultaneously the AV rolled off the changing table landing on the ground and sustaining a bruise on his/her forehead. In retrospect, the SP acknowledged that s/he did not need to intervene with the other child. By removing his/her hand from the AV, the SP failed to protect the AV from conditions that seriously endangered the AV’s physical health. However, Minnesota Statutes, section 260E. 30, subdivision 3, states that rather than making a determination of substantiated maltreatment by an individual, the commissioner of children, youth, and families shall determine that the individual made a nonmaltreatment mistake. A nonmaltreatment mistake occurs when: 1) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; 2) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; 3) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; 4) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing and certification requirements relevant to the incident; and 5) at the time of the incident, the individual was performing duties identified in the licensed center's child care program plan required under Minnesota Rules, part 9503.0045. This clause applies only to child care centers licensed under Minnesota Rules, chapter 9503. Consistent information was provided that the SP was following policies and procedures prior to the incident but when a child tried to climb onto the counter, the SP for a second moved toward the child until realizing that s/he needed to remain with the AV and turned back. The SP’s actions or conduct was determined to be a nonmaltreatment mistake for the following reasons: 1) The SP had not been determined responsible for any previous incident that resulted in a finding of maltreatment; 2) the SP had not been previously determined to have committed a nonmaltreatment mistake under this paragraph; 3) the AV’s injury did not require medical treatment; 4) except for the period when the incident occurred, the facility and the SP were in compliance with all licensing requirements relevant to the incident; and 5) at the time of the incident, the SP was performing job related duties, as required by the facility’s policies. The nonmaltreatment mistake to the AV by the SP was not maltreatment. It was determined that neglect did not occur (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 (b), the investigative data in this report will be maintained by the Department of Children, Youth, and Families for a period of five years. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. Staff persons received retraining on the facility’s diaper changing procedure, and the SP received additional corrective action and training. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: The SP was not determined as a perpetrator of maltreatment of the AV because the Department of Children, Youth, and Families found that the incident for which the SP was responsible met the criteria to be determined a nonmaltreatment mistake. The SP was notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which the SP is responsible might not be considered a nonmaltreatment mistake. On March 11, 2026, 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 Children, Youth, and Families.
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