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AMENDED 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.” NOTICE: This Amended Maltreatment Investigation Memorandum supersedes a version dated June 6, 2025, which should be destroyed. As a result of an administrative reconsideration, the original determination of maltreatment determined as to physical abuse (physical injury inflicted by a person responsible for the child’s care other than by accidental means) of a an alleged victim was changed to physical abuse (any physical injury that cannot be reasonably explained by the child’s history of injuries). For additional information, see Administrative Reconsideration section of this document. 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 was issued by DHS, pursuant to Minnesota Statutes, section 15.039, subdivision 2, this Amended Investigation Memorandum is being issued by DCYF pursuant to that transfer.
Suspected Maltreatment Reported: It was reported that an alleged victim (AV) sustained bruising to his/her right hand, and right and left shoulders, including a bite mark. The AV also had a skull fracture and several other fractures. Date of Incident(s): Unknown date prior to February 13, 2025. Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a), and subdivision 23, paragraph (a): "Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury. Summary of Findings: Pertinent information was obtained during site visits conducted on February 24 and April 23, 2025; from documentation at the facility, law enforcement records, county child protection records, and medical records; and through 13 interviews conducted with the AV’s family members (FM1 and FM2), two supervisory staff persons (P3 and P5), and nine facility staff persons (P1, P2, P4, P5, P6, P7, SP1, SP2, and SP3). The facility had two infant classrooms including the “Duck” classroom and the “Chipmunk” classroom which were across a hallway from each other. The Infant Duck classroom was rectangular and when walking into the room from the hallway there was a table with built in seats for the children to sit. To the right of the door was a changing table and a counter with a sink and another rectangle table with small chairs around it. Left of the door was a sleeping area with cribs and beyond the crib area was an open play area with a rug, toy shelves with toys, and infant chairs. In the hallway were several six seat buggies that were used to take infants on a walk. Staff persons typically walked the infants from open until 8 a.m and again from 4 p.m. to close. The facility used a mobile application (app) platform to communicate with families and streamline administrative functions. The facility had a single camera in the hallway pointed at the front door to monitor persons going in and out of the facility. The facility did not have additional cameras that monitored children or staff persons in classrooms. Facility documentation showed the AV was four months old and enrolled in the Infant Duck classroom at the time of the incident. FM1 and FM2 provided the following consistent information: · On the morning of February 12, 2025, FM2 dressed the AV. At that time, FM2 did not notice any bruising on the AV’s shoulders or right hand. FM1 drove the AV to the facility and at approximately 7 a.m., left the AV with an unknown staff person in the hallway for buggy time. At approximately 4:45 p.m., when FM1 arrived to pick up the AV, the AV was in a buggy in the hallway with an unknown staff person. FM1 then took the AV home. · At approximately 6 p.m., FM2 undressed the AV and saw “bruises” and what FM2 “thought” looked like a bite mark on the AV’s right shoulder. FM2 called for FM1 and asked him/her to look at the AV. FM1 came and looked at the marks on the AV which looked “bad.” As FM2 continued to undress the AV, s/he saw additional bruises on the AV’s left shoulder, the AV’s “entire” right hand palm, and a “small, circle” bruise on the AV’s back. FM1 took pictures of the AV’s injuries and planned to talk with the facility in the morning. · The next morning, February 13, 2025, FM1 took the AV to the facility and dropped him/her off with P1. FM1 told P1 about the bruising and asked if s/he could talk with SP1 and let FM1 and FM2 know “what they thought.” · At approximately 11 a.m., SP2 called FM2 and suggested that the AV be seen by a doctor because staff persons did not know what caused the bruising and they thought it might be an “infection.” · That afternoon, FM1 picked up the AV from the facility and at approximately 5:30 p.m., FM1 took the AV to his/her doctor who completed blood work and “ruled out a blood disorder.” The AV was then referred to an emergency room for a “more thorough exam.” · Between 7:30 and 8 p.m., FM1, FM2, and the AV arrived at the emergency room where the AV had a computed tomography (CT) scan of the head and was diagnosed with a hairline fracture of the skull. The AV was admitted to the hospital and stayed overnight. The next day, February 14, 2025, the AV’s bruising and inflammation was more evident. A law enforcement officer told FM1 and FM2 that what they thought were bite marks looked like “fingers.” · Prior to the incident neither FM1 or FM2 had concerns with the facility. The AV’s medical records provided the following information: · On February 13, 2025, the AV was seen at his/her primary care provider for bruising and was referred to the emergency room. At 7:44 p.m., the AV was seen at the emergency room. The AV had a “circular yellow bruise” on his/her back, bilateral shoulder bruises with “small bruises” on his/her right shoulder in a “curved semi-circular shape, and “bruises” on the right hand that “diffused on the palm of the hand.” The AV was admitted to “trauma” services and had a head CT scan. The AV was diagnosed with a “non-displaced right parietal bone [skull] fracture” and given oral acetaminophen for pain. · The AV attended the facility February 11, 12, and 13, 2025, and during that time had no other caregivers other than the staff persons, FM1, and FM2. The AV did not have a history of bleeding or clotting disorders and was not diagnosed with them at this time. · On February 14, 2025, the AV was discharged home and a skeletal survey was ordered to be completed in two weeks. · On February 28, 2025, the AV had the skeletal survey and was diagnosed with additional healing fractures including a rib fracture and a “buckle fracture” of both of the bones in the AV’s right arm. It was determined that these additional fractures had “new bone formation” which indicated that they occurred at or around the same time as the previous bruises and skull fracture. · A medical doctor documented that the injuries in a child the AV’s age, who was not “independently ambulatory” were “highly concerning for child abuse.” The type of “patterned” bruises on the AV’s shoulder were seen with an “abusive squeeze by an adults hands.” The bruise on the AV’s right palm was seen in “abusive squeezing,” and “may have” caused the distal radial and ulnar fractures. The AV’s rib fracture was an injury “associated with trauma such as squeezing or compression mechanism.” · Fractures in non-ambulatory children were “highly concerning” for physical abuse in children under four years of age, “as well as any bruise occurring in an infant” under five months of age. It would not be expected that the AV’s injuries “occurred in a single accidental or non-accidental event.” The AV’s injuries were “clinically diagnostic of child physical abuse.” The local county child protection also investigated this report and determined that ongoing services for the AV, FM1, and FM2 were not needed. It was believed that the AV’s injuries were sustained at the facility by a staff person. [Note: Prior to going to the facility the morning of February 12, 2025, the AV had no bruising or injuries. On February 12, 2025, after the AV attended the facility, the AV had injuries. The AV’s medical records showed that the AV’s injuries diagnosed on February 13 and 28, 2025, were determined to have occurred at or around the same time. Therefore, it was most likely that the AV sustained the injuries on February 12, 2025, while at the facility.] Information obtained showed that on February 12, 2025, P6, P7, SP1, SP2, and SP3 worked in the AV’s classroom with the AV. SP1, SP2, SP3, P1, P2, P3, P4, P5, P6, and P7 provided the following information: Regarding February 12, 2025: · “Typically” P7, SP2, and SP3 were the staff persons who worked in the AV’s classroom but at times other staff persons also did so. “Sometimes” when staff persons stepped out of the classroom for various reasons, a staff person was then alone with the children. P1, P2, P3, and P4 did not work with the AV on February 12, 2025. · SP1 stated that on an unknown Wednesday morning (likely February 12, 2025 ), SP1 worked with the infants from 7 to 8 a.m. At 7 a.m., SP1 and P6 were with an unknown number of children in the buggies. Between 7:10 and 7:15 a.m., FM1 and the AV arrived and FM1 “handed” the AV to P6 who then handed the AV to SP1. The AV was “happy” at that time. [Note: P6 stated that when FM1 handed the AV to him/her, P6 put the AV into the buggy. Approximately 15 minutes later, the AV was hungry, so SP1 took the AV and two other children into the classroom to feed the AV and P6 did not have further contact with the AV that day.] SP1 then took the AV into the classroom and set the AV down on the floor and prepared a bottle for the AV. At this time, SP1 was the sole staff person in the classroom with the AV. Another person then brought his/her child into the classroom and SP1 put that child into a swing and then fed the AV a bottle. As SP1 fed the AV, FM1 returned, dropped off the AV’s belongings, and then left again. The AV finished drinking his/her bottle and was “fine.” SP1 lay the AV on the floor and went and rinsed the AV’s bottle and documented the feeding into the tablet. SP1 did not notice anything unusual with the AV. SP1 could not recall but may have changed the AV’s diaper during this time. · SP1 stated that at approximately 7:40 a.m., as SP1 sat on the floor with the AV and the other child, SP3 came into the classroom to drop some things off and then left the room. At approximately 7:45 a.m., P6 came to the classroom door and handed SP1 two more babies. P6 returned to the hallway and stayed in the hallway with the children who were in the buggy. At 8 a.m., SP3 returned to the classroom and SP1 left. [Note: SP1 was the sole staff person in the classroom from when the AV arrived until 8 a.m. when s/he left the classroom with the exception of when P6 and SP3 momentarily stepped into the classroom. SP1 did not work with the AV at any other time that day.] · SP3 stated that on February 12, 2025, SP3 worked in the AV’s classroom but s/he did not recall specific times, who s/he worked with, or what s/he specific interactions s/he had with the AV. [Note: Based on information from SP1, SP2, P5 and P7, SP3 was the sole staff person in the classroom from 9 to 10:26 a.m.] · P7 stated that on February 12, 2025, at 8 a.m. s/he arrived and worked in the classroom. At that time SP3 was the sole staff person in the classroom. The children, including the AV, were seated at the table with the built in seats. Then P7 was moved to a different classroom until 11 a.m. and then came back to the classroom and SP2 and SP3 were there. P7 was then in the classroom until 1 p.m. and did not recall his/her interactions with the AV when s/he was in the classroom. [Note: According to P5, P7 left the classroom at 9:30 and returned at 11 a.m.] · SP2 stated that on February 12, 2025, s/he began work at 10:26 a.m. and went into the classroom where SP3 was holding the AV. SP2 did not recall details of what the AV did or who interacted with the AV between 10:26 and 11:45 a.m. At 11:45 a.m., SP2 lay the AV in his/her crib and the AV slept until between 2 and 2:30 p.m. SP2 did not recall details of what the AV did or who interacted with the AV between 2-2:30 and 4 p.m. At 4 p.m., SP2 took the AV and other babies into the hallway to a buggy and walked with them. As they were walking, the AV was picked up while s/he was on the buggy. SP2 did not recall other details about the day. [Note: Based on information from SP2, SP2 was the sole staff person working with the AV from 4 p.m. to the time the AV was picked up.] Regarding February 13 and 14, 2025: · P1 and P5 stated that on the morning of February 13, 2025, P1 was pushing a buggy with children when FM1 arrived with the AV. FM1 handed the AV to P1, told P1 that the AV had “markings,” and showed P1 the AV’s hand and told P1 that the AV also had marks on his/her shoulder. At that time, P1 thought the AV had “paint” on his/her hand. P1 strapped the AV into the buggy and walked for a little bit. At some point, P1 took the AV into the classroom and fed him/her a bottle which the AV drank. Then P1 changed the AV’s diaper and looked at the marks on the AV. P1 thought that the bruises on the AV’s shoulder looked like a “bite mark,” and that the AV’s right shoulder looked “worse” than the left shoulder. The palm of the AV’s right hand was “bright purple.” P1 called P5 into the classroom to look at the AV’s marks and P5 thought the AV’s hand looked like “hand, foot and mouth [disease]” or “some kind of infection” and the marks on the AV’s shoulder looked like “bite marks.” SP3 then came into the room and P1 told SP3 that FM1 wanted them to know about the AV’s marks and P1 told SP3 to “check them out.” SP3 looked at the AV’s hand and said, “Oh that is weird.” P1 told SP3 that s/he thought that the AV’s hand might have been stained from “art work” and SP3 told P1 that they had not done any art the day prior. P1 stated that other than that, they did not talk much about it. · SP2 stated that on February 13, 2025, SP2 was in the Duck classroom when FM1 came in and showed SP2 pictures of “a big mark” that looked like “teeth marks” on the AV’s back and of the AV’s hand that was “purple.” FM1 asked SP2 if s/he knew what had “happened.” SP2 told FM1 that s/he had not seen the “marks” on the AV · P3 and P5 stated that on February 13, 2025, P5 asked P3 to call FM1 and/or FM2 and tell them that the “marks” on the AV’s hand look like it could be an infection. P3 then looked at the marks on the AV and thought that the marks on one of the AV’s shoulders looked like a “bite” mark and the other shoulder had a “small bruise.” The AV’s right hand looked like s/he had “touched” something “hot or cold.” P3 called FM2 and provided the information to FM2 as directed by P5. · P5 talked separately with P4, P6, SP1, SP2, and SP3 and asked if any of them had dropped the AV, fallen while holding the AV, if a child had bit the AV, or if they had seen anything happen to the AV. None of them recalled “seeing or remembering anything” happening to the AV. · On February 14, 2025, P5 told P3 and P6 that FM1 and FM2 told him/her that the AV had a “skull fracture.” Additional information: · P4 stated that some staff persons described the AV as “happy and smiley,” but when s/he worked with the AV, the AV was “always crying.” The AV was “fine” when s/he was held but cried when s/he was put down. SP2 and SP3 complained to P4 that the AV cried and they would tell the AV to “stop crying.” SP2 and SP3 were not “mad” at the AV, “just annoyed.” · SP1, SP2, SP3, P2, P4, P5, P6, and P7 were trained that if staff persons became frustrated they should ask for help or “step out” of or leave the classroom and each felt comfortable doing this. Prior to this incident, P1, P2, P3, P4, P5, P6, P7, SP1, SP2, and SP3 did not have concerns with any staff persons interactions with the children. · SP1, SP2, SP3, and P6 each denied causing any injuries to the AV and each did not know how the AV sustained his/her injuries. P1, P2, P3, P4, P5, and P7 did not know how the AV sustained the injuries. Law enforcement investigated the incident and it was still open and pending at the time of this report. In the facility’s Team Member Handbook, the Behavior Guidance Philosophy stated that staff persons never used physically or mentally abusive forms of punishment. Prohibited actions included rough handling, shoving, hair pulling, slapping, ear pulling, shaking, kicking, biting, pinching, hitting, and spanking. Staff persons completed and Accident/Incident Report whenever an injury occurred. For minor injuries, staff persons “filled out” a half sheet Accident/Incident Report. When an injury that may need further treatment occurred, staff persons performed “immediate First Aid,” and notified the child’s family member. In the event of an emergency, staff persons called 9-1-1. If a child “received a bump on the head in any way,” staff persons completed a Head Bump Notice, and the notice was given to the child’s family member. The facility’s Program Plan stated that the facility maintained a “safe, inviting environment with consistent caregiving to provide a quality experience for infants.” Infants developed best when provided a balance of “security” from “caring and attentive” staff persons and the “freedom to explore and learn at their own rate.” Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0055, subpart 3, item A, states that the license holder must have and enforce a policy that prohibits the following actions by or at the direction of a staff persons: Subjection of a child to corporal punishment, which includes, but is not limited to, rough handling, shoving, hair pulling, ear pulling, shaking, slapping, kicking, biting, pinching, hitting, and spanking. Conclusion: A. Maltreatment: Information obtained showed that on February 13 and 28, 2025, the AV was diagnosed with multiple injuries including bruises, possible bite marks, and fractures of the skull, rib, and both bones in his/her right arm. Medical records showed that all of the injuries likely occurred around the same time. The local county child protection investigated and believed that the AV’s injuries were sustained at the facility. Given that prior to going to the facility the morning of February 12, 2025, the AV had no bruising or injuries; that on February 12, 2025, after the AV attended the facility, the AV had bruises and what appeared to be a bite mark, it was most likely that the AV sustained the injuries on February 12, 2025, while at the facility. The AV’s medical records showed that a medical doctor documented that the injuries in a child the AV’s age (four months old), who was not “independently ambulatory” were “highly concerning for child abuse” including: o The type of “patterned” bruises on the AV’s shoulder were seen with an “abusive squeeze by an adults hands;” o The bruise on the AV’s right palm was seen in “abusive squeezing,” and “may have” caused the distal radial and ulnar fractures; and o The AV’s rib fracture was an injury “associated with trauma such as squeezing or compression mechanism.” In addition, it was noted that fractures in non-ambulatory children were “highly concerning” for physical abuse in children under four years of age, “as well as any bruise occurring in an infant” under five months of age. The AV’s injuries were “clinically diagnostic of child physical abuse.” Information from all staff persons showed that none knew how the AV sustained the injuries and none had concerns regarding any staff persons interactions with the AV. However, not all staff persons interactions with children including the AV were observed by others and the AV’s injuries could not have occurred by accidental means. A staff person inflicting injury on the AV was a violation of Minnesota Rules, part 9503.0055, subpart 3, item A. Given the nature of the AV’s injuries, that medical professionals determined it was “highly concerning for child abuse” and “clinically diagnostic of child physical abuse,” and that there was no other explanations regarding how the AV may have sustained the injuries, there was a preponderance of the evidence that a staff person caused physical injury to the AV by means other than accidental. It was determined that physical abuse occurred. ("Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury.) 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, SP2, SP3, P6, and P7 each worked with the AV on February 12, 2025, and each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including the Team Member Handbook and Program Plan. SP1, SP2, SP3, P6, and P7 each denied causing the injuries to the AV and each did not know how the AV sustained the injuries. In addition, prior to this incident, P1-P7, and SP1-SP3 did not have concerns with any staff persons interactions with the children. Although P6 and P7 both worked with the AV, neither was alone with the AV nor supervised the AV without another staff person present and observing their interactions, and no one had concerns regarding their interactions with children. Therefore, it was determined that P6 and P7 were not responsible for the maltreatment of the AV. SP1, SP2, and SP3 each had periods throughout the day when they worked alone with the children in the classroom, including the AV, SP1 from when the AV arrived until 8 a.m., SP3 from 9 to 10:26 a.m., and SP2 from 4 p.m. until the AV left. Although no one had concerns regarding SP1’s, SP2’s, or SP3’s interactions with children, given that each worked alone with the AV not all of their interactions were observed by others, and it was more likely that the AV sustained the injuries during a time SP1, SP2, or SP3 worked alone with the AV. However, without additional information it can not be determined how or when the AV sustained each injury and therefore not determined which staff person/s caused the AV’s injuries. The responsibility for the maltreatment of the AV is inconclusive. 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 their policies and procedures were adequate and followed by staff persons. All staff persons were retrained on mandated reporting, “shaken baby,” “safe sleep,” and prohibited actions. Action Taken by Department of Human Services, Office of Inspector General: On June 6, 2025, the facility was issued a Correction Order for the violation outlined in this report. In addition, if the Department of Human Services receives new or additional information regarding the allegation, it will be reassessed at that time. Administrative Reconsideration: The disposition of the investigation is amended from maltreatment determined as to physical abuse because the AV suffered a physical injury inflicted by a person responsible for the AV’s care other than by accidental means, to determined as to physical abuse due to the injuries suffered by the AV that cannot be reasonably explained by the child’s history of injuries. To the extent that the language in the Administrative Reconsideration conflicts with the language in the remaining part of the Amended Investigative Memorandum, the language in the Administrative Reconsideration controls. The disposition was amended based on the following: Amended Summary of Findings: In addition to findings from the original Investigative Memorandum, DCYF makes the following findings. The clinical notes dated February 14, 2025, contained the following information: [The AV’s] physical examination is notable for patterned bruising on the right and left shoulder. These bruises are in somewhat linear in a possible honeycomb pattern, most noticeable in photographs provided by parents. This type of patterned may be seen with an abusive squeeze by an adults hands (Petska et al., 2019). The bruise on the palmar right aspect of the is in a distribution or pattern that may also be seen in abusive squeezing (Ruiz-Maldonado et al, 2021); and [The AV] is a four month infant who presents with patterned bruising to the left and right shoulder, bruising to the right palm, and right parietal skull fracture with overlying scalp swelling. [The AV] is a non-mobile infant and has not yet started to roll over. Parents first observed the bruising on Wednesday evening after daycare. There is no reported history of trauma from the parents or from the center-based daycare. These injuries in a non-mobile infant with no known history of accidental trauma is most consistent with child physical abuse. The AV’s medical records including those from February 13 and 28, 2025, do not indicate a specific date when the AV sustained his/her injuries. In addition, during a CPS and law enforcement interview, the AV’s five-year-old sibling stated that s/he observed an incident at home where the AV’s head hit the crib when the AV was being taken out of the crib. Amended Conclusion: There is a preponderance of evidence that the AV suffered physical injuries that were not reasonably explained by his/her history of injuries. The definition of physical abuse includes “any physical or mental injury that cannot reasonably be explained by the child's history of injuries.” Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a). As such, maltreatment is determined as to physical abuse. However, there is not a preponderance of evidence to determine the person or persons responsible for the injuries, or when or where the injuries occurred. Amended Action Taken by Department of Children, Youth, and Families, Office of Inspector General: DCYF rescinded the Correction Order issued on June 6, 2025, as the record does not support the violation of Minnesota Rules, part 9503.0055, subpart 3, item A. 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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