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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: 2000326-CCC (Child Care Center) Investigator(s): Van Mulheron Minnesota Department of Children, Youth, and Families 651-539-8253 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was restrained on his/her cot by a staff person (SP). Date of Incident(s): September 3, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); and subdivision 18, paragraph (a): 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. "Physical abuse" includes the use of any aversive or deprivation procedures, or regulated interventions, that have not been authorized under section 125A.0942 or 245.825.
Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility, law enforcement records, and medical records; and through three interviews conducted with a supervisory staff person (P1), the SP, and the AV’s family member (FM). Attempts were made by phone, email, and U.S. mail to contact and interview two additional staff persons (P2 and P3). These attempts were unsuccessful and neither responded to the requests. At the time of the incident the AV was three years of age and was enrolled in preschool classroom A (pre-A). The AV had an Individual Child Care Program Plan for epilepsy. At the time of this investigation the AV was not available for an interview. The facility provided care for infants through school-age children. There were two preschool classrooms (pre-A and pre-B) connected by a door. Both classrooms had a door that opened to a hallway with a window in the door and a full length window next to the door. The pre-B classroom had tables for activities and separate areas of play that had shelves and toys. Across from the connecting door was a counter that teachers used. The pre-B classroom was also used as a nap area with the children’s cots placed around the classroom. The facility used ProCare, a mobile application (app) platform used to communicate with families and streamline administrative functions. Medical records stated that on September 4, 2025, the AV was brought into an emergency care center by a family member, not the FM. The family member said that on September 3, 2025, the FM picked up the AV from the facility and saw a staff person sitting on the AV’s back. Another staff person told the FM that s/he saw on camera that the AV had been slammed on the ground before being sat on by the staff person. The AV said his/her ears and nose hurt after that incident. Upon examination the AV was alert, playful, and interactive. Examination of the AV’s face was grossly normal. There was a small amount of blood in the AV’s right ear with no other abnormal findings. The healthcare professional noted that it was not certain that the blood in the right ear had anything to do with the incident, but it was possible. Law enforcement records and a law enforcement officer (LEO) provided the following information: · The FM said that on September 3, 2025, s/he arrived at the facility at 2:30 p.m. to pick up the AV. When s/he entered the facility s/he heard the AV “screaming.” The FM walked to the pre-A classroom and was directed to the pre-B classroom by a staff person. When the FM walked to the pre-B classroom s/he looked through the door window and saw the AV lying face down in a “planking” position on a cot with a blanket covering his/her head. The SP was sitting on the AV’s back while the AV was “crying and screaming.” The FM walked into the classroom and the SP asked if s/he was the AV’s family member. · The FM said that the AV’s shirt was wet with the AV’s sweat, the AV’s face was “smooshed” into the cot and the AV had “snot” on his/her face as if his/her face had been in that position for a “long time.” The FM then took the AV and spoke with P1. The FM demonstrated how the SP sat on the AV by having the AV’s sibling lay on the floor in a plank position and the FM demonstrated by sitting with his/her buttocks towards the center of the child’s back. · The LEO asked the AV how s/he felt when the SP sat on him/her. The AV told the LEO that s/he was “hurt”, “scared”, and that s/he also felt “happy.” · The facility provided a video of the preschool classroom timestamped September 3, 2025, from 2:21 to 2:27 p.m. that provided the following information: o At 2:21 p.m., the SP picked the AV up and carried the AV under the SP’s right armpit parallel to the ground, to be placed on a cot. The AV was placed faced down with the SP’s left hand positioned on the center of the AV’s back so the AV could not move. o At 2:21 p.m., the SP repositioned the cot in the room. o At 2:22 p.m., the SP placed two blankets on the AV fully covering his/her body including his/her head. The SP then placed his/her right hand towards the AV’s buttocks and his/her left hand towards the center of the AV’s back. With his/her left hand the SP made several “aggressive” pats to the back of the AV then pinned the AV’s legs with the SP’s right forearm continuing the strikes. o At 2:22 p.m., the SP took both of the AV’s hands, positioned them behind the AV’s back together and held onto them with his/her right hand, then covered the AV back up with a blanket and continued to “aggressively” pat the AV on the back with his/her left hand. o From 2:23 – 2:24 p.m., the SP continued to hold the AV’s hands behind his/her back with the SP’s right hand while “aggressively” patting the AV with the SP’s left hand. The SP then switched to holding the AV’s hands behind the AV’s back with the SP’s left hand to pin the AV’s legs down with the SP’s right forearm. o At 2:25 p.m., the AV was released from the hold and it appeared that the SP was saying something to the AV. o At 2:25 p.m., the SP covered the AV back up with a blanket and continued to “aggressively” pat the AV’s back with his/her left hand on the center of the AV’s back. o At 2:26 p.m., the FM appeared at the classroom door which had a glass panel and was looking into the classroom. Shortly after this the SP sat on the AV’s buttocks on the floor right up against the cot, with SP’s back facing the classroom door, the SP then placed both of his/her legs over the AV and at one point pinned the AV’s head to the cot with the SP’s left hand. With the SP’s legs draped across the AV’s back, the SP had both of the AV’s hands positioned on the ground; after viewing the footage LEO believed there was a “substantial amount of pressure” being placed onto the AV. o At 2:26 p.m., the FM entered the classroom and the SP immediately looked at the door. The SP got off the AV, removed the blankets, stood, and started to fold the blankets “very neatly and nervously.” o At 2:27 p.m., the FM took the AV and exited the classroom. · This report was closed with no charges pending. The FM provided the following information: · On September 3, 2025, at 1:45 p.m., another family member called the FM and said that the facility had called him/her to speak with the AV about toileting behavior. The FM said that s/he would pick the AV up between 2:15 to 2:30 p.m. that day. · The FM arrived at the facility at 2:30 p.m., and when the FM entered the front door s/he heard the AV “screaming from the top of [his/her] lungs” and that it was “muffled.” The FM walked to the pre-A classroom and looked through the window into the room for the AV. A staff person in the room looked at the FM and pointed to the pre-B classroom. The FM walked to the pre-B classroom and saw that the lights were off. Some children sat near a corner of the classroom and the FM heard the AV “screaming.” · The FM entered the classroom and saw the SP “sitting” on top of the AV. The SP looked up when s/he saw the FM and the FM asked, “Why are you sitting on my kid?” The SP stood up and said that the AV had been “so bad today. I told [him/her] to take a nap and [s/he] said no.” The FM then said, “So you sat on my child.” The SP replied, “I’m sorry. I did not know what to do.” · The FM walked to the AV and saw the AV’s blanket covering him/her. The FM said that the SP had “flipped” the AV over. The AV’s face was covered in “snot and spit” and the AV had “marks” that were indented on his/her face. The AV kept saying, “my ears” and “my nose.” The FM took the AV and went to speak to P1. · The FM took the AV to the police department where the AV said that the SP tried “to break [his/her] arm” and was “hurting” his/her nose, face, and head. The AV said that s/he was “scared” and “sad.” · The FM said that s/he took the AV to a hospital because the AV had blood coming out of both ears. The FM said that the doctors did not know where the blood came from but that there were concerns about a “traumatic brain injury.” · The FM said that the pre-B classroom was not the AV’s typical classroom and that the SP was not his/her typical teacher. The facility provided a video of the pre-B classroom timestamped September 3, 2025, from 2:10:58 to 2:27:39 p.m. Information from the video was consistent with the law enforcement report. The video also showed that during the majority of the incident, the AV’s head was covered with a blanket, and that the AV occasionally struggled against the SP. The SP provided the following information: · On an unspecified date the SP and P2 were in the pre-B classroom with 12 children. Before naptime the AV, who was enrolled in the pre-A classroom, was moved to the pre-B classroom for naptime along with six other children which increased the number of children to 19. This was the first time the AV had napped in the pre-B classroom with the SP. The SP was told by a pre-A teacher that the AV and another child needed to go to sleep first or they could “possibly harm other children” or “disrupt” other children that were sleeping or laying quietly on their cot. The SP said that the AV had a history of being sent home early due to “behavior issues” and was not aware of any medical conditions for the AV. · At approximately 12:30 p.m., as the children went to their cots the SP told the children that they could either sit or lay on their cots, get a book to read on their cot, or have a toy on their cot but that they must be quiet so that the other children in the classroom could sleep. The SP then sat between the AV’s and another child’s cot and began to pat their backs. The SP patted the AV’s back for 45 to 60 minutes, but the AV would not go to sleep. P2 told the SP that s/he needed to go on his/her break. The SP said that when s/he left the classroom all the children, including the AV, were on their cots. · The SP took a 45-minute break and when s/he returned to the classroom P3 was in the classroom and only three children were still asleep, and the other children were playing. P3 then left the classroom. The AV was running back and forth from his/her cot, jumping on his/her cot, and playing with other children’s toys. The SP messaged P1 for help through ProCare. The SP told the children they needed to go back to their cots and to be quiet and gave them the quiet time choices again. The SP said that when s/he asked the children to go to their cots the AV began to “cuss” and “threaten” the SP and the other children. The AV began to spit at the SP and “threaten” to expose him/herself and to “pee” on them. The SP messaged for help again through ProCare and P1 replied that s/he was coming to help. After five minutes P1 had not yet arrived. The SP said that s/he was “overwhelmed” with the number of children still awake and the AV’s behavior because s/he did not have any help. · The SP told the AV that s/he needed to get on his/her cot and that it was naptime and the AV needed to “relax” his/her body. The SP led the AV to his/her cot, covered the AV’s body but not his/her head with a blanket, and began to pat the AV’s back. The AV began to laugh “maniacally” and threatened to “kill” the SP and his/her friends. The AV then said that s/he was going to “bite and scratch” the SP and began to “flail” on his/her cot. The SP said that s/he was worried that the AV would harm the other children and give him/herself bruises from flailing his/her arms. The SP “secured” the AV’s hands together against the AV’s body with the SP’s hands. · The SP held the AV’s hands for a “little bit” and then let go of the AV’s hands. The AV would “flail” his/her arms and scratched the SP so the SP held the AV’s hands again. The AV began to kick his/her legs so the SP placed his/her legs over the cot so that the AV would not hurt him/herself. The SP said that the AV’s cot had a “dip” in it. When the AV lay on his/her cot the AV was below the bar of the cot due to the dip. The SP’s legs were on the cot bars and not directly on the AV. The SP said occasionally s/he moved his/her legs and hands off the AV, each time the AV would spit and scratch the SP or “cuss” and “threaten” the other children. The AV went from screaming to grinning and from crying to laughing. The SP received scratches on his/her wrist from the AV. The FM entered the classroom and took the AV out of the room. · The SP denied sitting on the AV or the cot, patting the AV’s back roughly, restraining the AV’s arms against his/her body, or restraining the AV’s body in any way. The SP said s/he was “protecting” the AV from “harming [him/herself] by putting [his/her] arms and body parts to [him/herself] so that [s/he] would not hurt [him/herself].” The SP was “overwhelmed” by the lack of support from P1 and supervisory staff when s/he was alone in the classroom with 16 children awake and with the AV trying to harm him/herself and others. P1 said that on September 3, 2025, at 2:19 p.m., s/he received a message from ProCare asking for help with the AV. At 2:26 p.m., P1 messaged back that the FM had arrived to pick up the AV. The FM then entered the office with the AV, who looked “pretty sweaty” and said that s/he had walked into the classroom and that a staff person was “sitting” on the AV and had a blanket on the AV. After the FM left, P1 watched video footage of the pre-B classroom and provided information that was consistent with the LEO report. P1 then sent the SP home. P1 had no prior concerns about the SP. The ProCare app showed that there was a message sent for help with the AV at 1:21 p.m. and at 2:19 p.m. In the 1:21 p.m. message, the SP wrote, “[the AV] keeps taking off [his/her] diaper and exposing [him/herself]. [S/he’s] yelling and saying [s/he’s] going to put poop away. Now [s/he] was just walking around with no pants on saying [s/he’s] going to was going to (sic) pee on the kids and toys. [S/he] needs to go.” The facility completed an internal review which included an interview with the SP. The SP provided information that was consistent with this investigation and gave a clarification of how the AV threatened the SP and the other children. The SP said, “Threatened in the sense of, like just saying [s/he] was going to, you know I hate you. I’m going to pee on you. I’m going to, like just saying that.” According to Aiken et al, prone restraint compromises a person’s ability to breathe due to possible blockage of the mouth, nose, or both; compression of the ribs which limits the ability to expand the chest; and possible pushing up of the internal organs which increases pressure on the diaphragm. “Consequently . . . simply restraining an individual in a prone position may be seen as restricting the ability to breathe.” Applying pressure to the back during a prone restraint is “particularly hazardous” and “a procedure of extremely high risk for any individual.” People under age 20 are at an increased risk during restraint due to their physiological development. Aiken, F., Duxbury, J., Dale, C., & Harbinson, I. (2011). Review of the medical theories and research relating to restraint related deaths. Caring Solutions (https://cdn.websitebuilder.service.justice.gov.uk/uploads/sites/21/2024/03/Caring-Solutions-UK-Ltd-Review-of-Medical-Theories-of-Restraint-Deaths.pdf) The facility’s Nap and Rest Policy stated the following: · “Sustained holding of a child in a face-down, prone position for the purpose of falling asleep at rest time is prohibited.” · “Toddlers, preschoolers, and prekindergartners who sleep on a cot and use a blanket for nap, must keep their heads uncovered at all times. If a child’s head becomes covered during the rest period, a staff member must remove the blanket from the child’s head. Staff members should not cover a child’s head with a blanket for the purpose of falling asleep. This is not applicable to infants as infants sleep in cribs and without blankets.“ · “Confinement limitation: A child who has completed a nap or rested quietly for 30 minutes must not be required to remain on a cot or in a crib or bed.“ · “Once 30 minutes have passed or a child awakes, the cot must be put away and the child is allowed to get up.” The facility’s Risk Reduction Plan stated that “Staff may sit next to children and rub and pat their backs. Staff may not use their body to hold the child down to get them to sleep.” The facility’s Prohibited Action Policy stated that the following actions are prohibited: rough handling, shoving, hair pulling, ear pulling, shaking, slapping, kicking, biting, pitching, hitting, and spanking.
Facility records showed P1-P3, and the SP were each trained on the facility’s policies and procedures and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules/Statutes: Minnesota Statutes, sections 142B.52 and 245A.211, states that the use of prone restraints is prohibited in all programs licensed or certified by the Department of Children, Youth, and Families, except in specific instances described in statute (the exceptions did not apply for the incident investigated in this report). “Restraint” is defined as “a physical hold, physical restraint, manual restraint, restraint equipment, or mechanical restraint that holds a person immobile or limits the voluntary movement of a person or the person’s limbs.” “Prone restraint” is defined as “a restraint that places a person in a face-down position with the person’s chest in contact with the floor or other surface.” Minnesota Rule 9503.0055, subpart 3, part F, states that the use of physical restraint is prohibited, other than to physically hold a child when containment is necessary to protect a child or others from harm. Conclusion: A. Maltreatment: The SP said that s/he did not restrain the AV but held the AV’s hands and placed his/her legs over the cot bars and not on the AV and to prevent the AV from hurting him/herself and the other children. However, information from video footage, medical records, and the FM’s account was consistent that on September 3, 2025, for approximately four minutes, the SP placed the AV on his/her cot stomach down; covered the AV’s body, including the AV’s head, with a blanket; restricted the AV’s movement with the blanket, the SP's hands and the SP’s legs; and used his/her hands to hold the AV’s hands behind his/her back. According to the FM, the AV’s face was “smooshed” into the cot during the incident and when the AV was released from the restraint, the AV’s shirt was wet with the AV’s sweat In addition, the AV had blood in one or both of his/her ears after the incident, although it was unknown whether it was related to the incident. The AV told the FM that the SP was “trying to break [his/her] arm,” that the SP was “hurting” his/her face, nose, and head, and that s/he was “scared” and “sad.” The SP’s actions were inconsistent with his/her training; inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Children, Youth, and Families; and seriously endangered the AV’s physical or mental health. Therefore, there was a preponderance of the evidence there was a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health. In addition, there was a preponderance of the evidence that the SP used a prohibited intervention on the AV that was not authorized under section 125A.0942 or 245.825. It was determined that neglect and physical abuse 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; and use of any aversive or deprivation procedures, or regulated interventions, that have not been authorized under section 125A.0942 or 245.825). 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 was responsible for the care of the AV during naptime. The SP was trained on the facilities Nap and Rest Policy, Risk Reduction Plan, Prohibited Action Policy, and on the Reporting of Maltreatment of Minors Act. The SP acknowledged that s/he was “overwhelmed” with the number of children in his/her care and with the AV’s behavior and asked for assistance from other staff persons more than once. However, this did not mitigate the SP’s actions during the incident, which conflicted with his/her training and with facility policies and procedures. 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 that their policies and procedures were adequate but not followed. The SP no longer worked at the facility. 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 is responsible for maltreatment is 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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