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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.”
License Number and Program Type: 1062785-CCC (Child Care Center) Investigator(s): Judie Schwanke Minnesota Department of Children, Youth, and Families 651-539-8268 Suspected Maltreatment Reported: It was reported that a child (C), who was not enrolled at the facility, shut a door on an alleged victim’s (AV) finger. The AV sustained a cut and a fracture on his/her finger. Date of Incident(s): August 11, 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 August 28, 2025; from documentation at the facility and medical records; and through four interviews conducted with the AV’s family member, two supervisory staff persons (P1 and P2) and a facility staff person (P3). This investigator did not talk with the AV. On the day of the site visit the AV was not in attendance at the facility. Facility documentation showed the AV was four years old and enrolled a preschool classroom on August 11, 2025. The facility was located in a large community center that had several different programs. The facility provided care for children six weeks to kindergarten. The AV’s preschool classroom was rectangular with three walls. In the classroom was a door to a small classroom office. The office door had a doorknob that secured the door shut. The end of the classroom without a wall was open and led into a wide hallway. At one end of the hallway was a facility office area. The C was a ten year old family member of P3. On August 28, 2025, this investigator observed the C in the classroom office using an electronic tablet. The FM provided the following information: · On August 11, 2025, between 3:30 and 4 p.m., the FM received a phone call from P3 who told him/her that the AV was playing near the office door in the preschool classroom, and P3 closed the door on the AV’s hand. The AV’s finger was bleeding but did not “seem bad,” and s/he put a band aid on the AV’s finger. · The FM asked to talk with the AV and the P3 put the AV on the phone. The FM stated that s/he could tell by the AV’s voice that s/he was in “pain.” The FM then talked with P3 and told P3 s/he would come and get the AV. The FM asked P3 to apply ice to the AV’s finger to ease his/her pain. · Approximately 40 to 45 minutes later, the FM entered the preschool classroom and saw the AV standing in the middle of the classroom, holding his/her hand up. The FM looked at the AV’s finger and saw it needed “stiches.” The FM cleaned the AV’s finger and applied a new band aid to it. P3 handed the FM and accident report that stated “somebody” closed the door on the AV’s finger. The FM signed the accident report and then a child (later identified as the C) came up to him/her and apologized for closing the door on the AV’s finger. · The FM then left the facility and drove the AV to an urgent care medical facility. The urgent care facility was not able to stitch the cut on the AV’s finger because it went through the fingernail and told the FM that the AV’s finger was fractured. The cut was cleaned, and antibiotics were prescribed. The FM was instructed follow up with the AV’s pediatrician. · On an unknown date, the FM told P1 that the C was in the AV’s preschool classroom “almost every day.” P1 told the FM that s/he was unaware that the C was in the AV’s classroom. The following day, when the FM went into the preschool classroom to drop off the AV, the C was again in the classroom. · Prior to August 11, 2025, the FM addressed any concerns with P1 and P2 and they addressed them “right away.”
A facility Accident/Incident Report form dated August 11, 2025, and completed by P3, stated that the AV was playing near the office door. “Someone” came in the office and closed the door. The AV “stuck” his/her finger/hand in the door and his/her finger was cut and the nail was bleeding. The AV’s finger was washed clean, and a band aid and ice pack were applied to the AV’s finger. The AV’s medical documentation stated that on August 11, 2025, the AV was diagnosed with an “open fracture” of his/her right ring finger. There was a five-millimeter laceration of the AV’s right ring finger with a crack in his/her fingernail, and a “mildly displaced fracture” of the finger tuft. The laceration on the AV’s finger was cleaned and bacitracin and a gauze bandage applied. A splint was applied to the AV’s finger. The AV was prescribed an antibiotic for seven days due to risk of an infection. The facility recommended that the AV was seen by his/her primary care physician in three to four days. On August 14, 2025, the AV was seen by his/her primary care physician. There were no signs of an infection. On August 27, 2025, the AV was examined, and the alignment of his/her right ring finger had not “significantly” changed and a follow up appointment with orthopedics was recommended. P3 provided the following information: · On an unknown date, after afternoon snack, P3 was in the preschool classroom with an unknown number of children, including the AV. The children played around the classroom and the AV played near P3. Another family member entered the classroom to pick up their child and P3 talked with that family member. When that family member left the classroom, P3 turned and saw the AV standing by the classroom office door with his/her hand “folded.” P3 asked the AV if s/he “slammed” his/her hand in the door and the AV replied, “Yes.” · P3 instructed the AV to go to a hand sink and s/he looked at the AV’s right hand and saw that there was blood around the ring fingernail. The AV washed his/her finger, and then P3 applied a band aid to the AV’s finger. P3 then called the FM and told him/her that the AV’s hand got caught in the door and the fingernail was cut. The FM asked P3 to apply ice to the AV’s finger and told P3 that s/he was on his/her way. · As P3 waited for the FM to come, P1 walked past the classroom and P3 told P1 that the AV’s hand had been “slammed” in the door, and s/he had called the FM and told him/her about it. · P3 stated on the day of the incident, the C went into the classroom office and shut the door on the AV’s hand. The C was ten years old and enrolled at another program in the community center and went in and out of the preschool office during the day when s/he needed something to eat or drink or when s/he needed a break from outside. P3 stated that the C was “quite often” in and out of the preschool classroom during the summer and had the facility secure door code. P1 saw the C come into the facility with P3 or saw the C as s/he went in and out of the preschool classroom. Prior to August 28, 2025, P1 never told P3 that the C should not be in the facility and/or in and out of the classroom. · On August 28, 2025, P3 and the C came into the facility together. P3 went to the preschool classroom and the C went to the facility office. P3 heard the C talk and laugh with P2. The C came back to the preschool classroom and was in the classroom office from approximately 9:15 a.m. to 2:30 p.m. Prior to August 28, 2025, P2 never told P3 that the C should not be in the facility and/or in and out of the classroom. · P3 stated that other staff persons brought their school age children into the facility. P2 stated that s/he was in and out of classrooms “a lot” and did not watch staff persons “closely.” Initially, P2 stated s/he saw staff persons’ school age children go in and out of the facility to get food or to say, “Hi.” Staff persons were told that the school age children should not “mix” with facility children because of the facility’s license. Later, P2 stated that on August 28, 2025, s/he saw the C in the facility with P3 and had seen the C in the preschool classroom office a “few times in the past.” P2 stated that another staff person’s two school age children were in the program for one to two hours a day for a couple of weeks during the summer. P1 provided the following information: · On August 11, 2025, at approximately 5 p.m., P1 was in a preschool classroom next to the AV’s classroom and P3 told P1 that the AV got his/her finger “pinched” in the door. P1 asked P3 how it happened and P3 told P1 that the C had walked in from outside and was going back outside when the AV stuck his/her finger in the door. P1 did not recall what s/he said next to P3. P1 then asked the AV what happened, and the AV said s/he did not want the office door shut so s/he stuck his hand in the door. P1 told the AV that s/he could not do that and then asked P3 if s/he called the FM. P3 told P1 that s/he had and was filling out an accident report. P1 went back to his/her classroom. · P1 thought that the C was approximately ten years old. The C was not enrolled in the facility program but was enrolled in one of the community programs located in the same building. “Sometimes” the C went into the preschool room to ask P3 for a charger or to grab food and then went to a “common area” in the community center. The C did not stay in the preschool classroom. · P1 stated that the C should not be in facility classrooms because staff persons did not bring their children to “hang out” in the classrooms. · P1 stated that s/he thought both the C and the AV were responsible for the AV’s hand being shut in the door and that the C “would” know to watch for a hand in the door when closing it. · On August 28, 2025, P1 stated s/he “had no idea” that the C was in the preschool office. The facility’s Program Plan stated that they served infant through preschool aged children. The preschool program maintained a safe, inviting environment to provide a quality experience for the children. The facilities Risk Reduction Plan stated that all doors had pinch guards installed to help prevent closing children’s fingers in doors. (Note: a pinch guard would not have prevented the AV’s injury due to where the AV’s finger was in the door.) Staff persons taught children that only adults opened doors. At least daily, staff persons completed a scan of the program area to ensure potential risks were minimized or eliminated. Because of the proximity to the community center programs, staff persons were trained and on alert to ask unknown adults and children what their purpose was and for identification. The facility was not licensed to serve school age children. Minnesota Statutes, section 142B.10, subdivision 15, paragraph (a), states that a license holder must notify the commissioner and obtain the commissioner’s approval before making any changes that would alter the license information. Minnesota Statutes, section 245B.10, subdivision 14, paragraph (a), states that the license information includes the maximum ages of persons that may receive services from the program. Conclusion: A. Maltreatment: Consistent information was provided from the FM, P1, and P3 that on the afternoon of August 11, 2025, the AV’s hand was closed in the preschool classroom office door by the C. The AV sustained a cut on his/her right middle finger and the tip of the AV’s finger was fractured. The AV received medical care that included a splint and an antibiotic. The facility’s Risk Reduction Plan stated that in order to reduce the risk of children’s fingers being closed in doors, staff persons taught children that only adults opened doors. However, P1, P2, and P3 each stated that P1 and P2 were aware that the C came and went from his/her classroom. In addition, P3 stated that other staff persons’ school aged children were also present in the facility throughout the summer, and P2 acknowledged that s/he was aware of this. The facility’s failure to prevent the C from going in and out of the preschool classroom, and operating outside the terms of the facility’s license by allowing the C’s and other school aged children’s presence at the facility, created an unsafe environment for the children served, and the AV who received a serious injury as a direct result. Therefore, there was a preponderance of evidence that there was a failure to provide the AV with necessary care required 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 and 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 facility’s Risk Reduction Plan stated that in order to reduce the risk of children’s fingers being closed in doors, staff persons taught children that only adults opened doors. However, at the time of the incident, the C, a school age child who was not enrolled in the program, was present in the preschool classroom and closed the door on the AV’s finger. The facility was not licensed to serve school age children. P1 and P2, who were each supervisory staff persons, were aware that on multiple occasions, the C came and went from the preschool classroom and did not prevent the C from moving freely in the facility. P2 was also aware that other facility staff persons’ school age children came and went from the facility. The regular presence of the C and other school age children during the summer was a violation of Minnesota Statute, section 142B.10, subdivision 15, paragraph (a) that stated that the facility must operate under the terms of their license. In addition, by allowing the presence of older children who the facility was not licensed to serve, the facility failed to protect the health and safety of all the children enrolled in the program. Therefore, the facility was 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 was “serious” maltreatment because the injury to the AV’s finger required the care of a physician. 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 adequate but not followed by P3. On September 9, 2025, P3 received a corrective action notice. On September 10 and September 11, 2025, staff persons received training that school age children were not permitted to mix with the younger children. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: On June 29, 2026, the license holder was ordered to forfeit a fine of $5,000 as a result of the substantiated maltreatment for which the 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.
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