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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: 1063994-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 an alleged victim (AV) was being carried in a bouncer chair and fell out of the chair hitting the floor. The AV sustained bruising on his/her right shoulder. Date of Incident(s): January 9, 2026 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 January 21, 2026; from documentation at the facility and medical records; and through four interviews conducted with two supervisory staff persons (P1 and the SP), a facility staff person (P2), and the AV’s family member (FM). The AV was three months old and enrolled in a young infant classroom at the time of the incident. Due to his/her age the AV was not interviewed for this investigation. The facility was a stand-alone building. The facility served infants, toddlers, and had a program for before and after school for school-aged children. Upon entering the facility there was an infant room on each side of a main open area in the middle (Infant One to the left and Infant Two to the right). The main open area had a five-foot tall half wall surrounding stairs leading downstairs to the toddler classroom. The Infant One classroom had two doors. One door was a full door farthest from the main entrance, and the door closest to the main entrance was a Dutch door to allow the bottom portion to be closed while the top portion was opened. The Infant One classroom had tile floor with a large area rug. The BrightWheel app (an application used to communicate with families) message dated January 9, 2026, around 8:15 a.m. stated, “Staff was bringing babies over, [the AV] was in a bouncer, staff went to open door of infant room, chair got caught on frame, [the AV] tipped to the right side and hit right side of forehead on floor. Received a red mark, iced, checked over and TLC given! Called [the FM] to inform! Will continue to monitor!” The photo on the BrightWheel app of the AV’s forehead sent to the FM showed a red mark on the right side of the AV’s forehead about the size of a quarter. Video footage from the Infant One classroom on January 9, 2026, at 8:07 a.m., showed the SP and P2 each leave the Infant Two classroom with a bouncer chair in their arms, at the side of their bodies, roughly hip height. The SP opened the bottom portion of the Dutch door and turned as s/he entered the Infant One classroom. Both of the SP’s hands were on the bouncer chair and when the SP crossed over the threshold, the metal base of the bouncer chair caught on the edge of the door frame. The bouncer chair slipped from the SP’s grasp and tipped causing the AV to land face first on the tile floor. The AV did not fall out of the bouncer chair. Based on the view from the camera, and the angle of the SP’s body, it was visible that the SP’s left hand no longer had contact with the bouncer chair, but the SP’s right hand was not visible. The SP bent down to tip the bouncer chair over, took the AV out of the bouncer chair, and held the AV as the AV cried. The SP appeared to check the AV over for injuries as the SP hugged and rocked the AV. At this time P2 entered the Infant One classroom through the back door, which was open, also carrying an infant in a bouncer chair. The FM provided the following information: · On January 9, 2026, at 8:22 a.m., the FM received a telephone call from the SP stating that the AV had a fall. The staff persons were transporting the infants from one room to another, and the AV tipped out of the bouncer chair and hit his/her head. · The FM asked if the bouncer chair had been on the ground, and the SP stated it remained on the ground and the AV tipped out. The FM then reached out to a medical professional to see if the AV should be seen. While the FM was waiting to hear back, s/he received the BrightWheel notification which stated the fall was from a higher distance. · The FM said the SP reviewed video footage and it showed the AV was at hip height when the bouncer chair tipped and the AV landed on his/her head. The AV was “doing well.” The FM was told the AV cried for a “little bit,” was consoled, took a bottle, and fell asleep and the staff persons were checking on the AV. The FM picked up the AV and brought him/her to a medical professional. · The medical professional conducted an exam, and believed the AV was “fine”, so no imaging was ordered. The AV did have bruising on his/her right shoulder about two inches in length, slightly curved, and red which the FM said lasted for a “few” days. The FM provided photos of the AV’s shoulder which were consistent to what s/he described. The SP and P2 provided the following consistent information: · On January 9, 2026, around 8:30 a.m., the SP and P2 were bringing infants from the Infant Two classroom to the Infant Once classroom. The SP went through the front door and P2 went through the back door. The SP was carrying the AV in a bouncer chair, and the AV was strapped in. · The bouncer chair got caught on the door, tipped, and fell out of the SP’s hands to the floor. P2 looked over from the back door and saw the SP turning the bouncer chair over and taking the AV out of it. The AV was crying, so the SP calmed the AV down, looked the AV over for injury, and noticed a mark on the AV’s head. · The FM picked up the AV and brought him/her to a medical professional and it was noted that the AV also had a scrape/scratch on his/her shoulder. The SP and P2 provided the following additional information: · P2 did not see the bouncer chair fall. · P2 did not recall getting trained in how to transport infants from one room to another. After the incident, s/he spoke to another staff person who said that staff persons were not supposed to move infants in bouncer chairs. P2 saw staff persons move infants in a bouncer chair before if they were asleep. If an infant was awake, staff persons took them out and carried the infant separately from the bouncer chair. · P2 said s/he had not read the tag on the bouncer chair, but s/he was “sure” there was a warning on it. The SP was not aware of any warnings on the bouncer chair to not carry infants in them. · The SP said at first, s/he was not sure how far the bouncer chair fell. The SP did not have access to the facility’s video footage, so s/he called P1 and asked him/her to review the video footage. P1 told the SP s/he was holding the bouncer chair below his/her hip. The SP stated that s/he and the AV both tipped to the right, but the AV “never” fell out of the bouncer chair. · The SP did not know of any training on how to transport infants. The SP said “occasionally” staff persons carried infants in a bouncer chair from Infant Two to Infant One. P1 provided the following information: · On January 9, 2026, P1 was at another facility when s/he received a telephone call from the SP stating that as the SP carried the AV from Infant Two to Infant One in a bouncer chair, the SP’s hand slipped off the bouncer chair and the AV fell. · P1 said the SP was “very shook up” and crying, so it was hard to understand the SP. The SP did not say if the AV was buckled in the bouncer chair or not, but P1 “assumed” the AV was. The SP said the AV hit his/her head, but P1 was not sure if it was on the floor, the wall, or something else. · The SP said the AV did not have any symptoms of injury and the SP sent P1 a photo of the AV. The AV’s head was “slightly pink” so P1 had the SP call the FM to notify him/her. The SP told P1 that the AV was at hip height when the bouncer chair fell. P1 had not reviewed the video before speaking with the DCYF investigator due to technical difficulties. · The AV was picked up, brought to a medical professional, and evaluated. The SP told P1 that the AV checked out physically “okay” but had a scratch on his/her right shoulder. · P1 was not aware of any warning label on the bouncer chair. P1 had “never” heard of the staff persons carrying infants in a bouncer chair before. The AV’s medical records showed that on January 9, 2026, around 11 a.m., the AV was evaluated for a head injury. “Beyond a superficial faint red mark on forehead and scratch on shoulder, no abnormalities on physical exam, and behavior is normal. Very low likelihood of serious injury. Recommend monitoring at home for behavior change or abnormality.” No medical treatment was ordered. The manufacturer’s warning label on the front of the bouncer chair stated, “Fall Hazard: Babies have suffered skull fractures falling while in and from bouncers when not used properly. Use bouncer ONLY on the floor. ALWAYS use restraints and adjust to fit snuggly even if baby falls asleep. NEVER lift or carry baby in bouncer.” (Emphasis in original.) Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Minors Act. Relevant Rules and/or Statutes Minnesota Statute 142B.54, subdivision 2, paragraph (e), states the plan shall prohibit the accessibility of hazardous items to children and Minnesota Rules 9503.0140, subdivision 17, states sharp objects, medicines, plastic bags, and poisonous plants and chemicals, including household supplies, must be stored out of reach of children. Conclusion: A. Maltreatment: Consistent information was provided that on January 9, 2026, the SP and P2 transported children from the Infant Two classroom to the Infant One classroom. The SP carried the AV in a bouncer chair and when they crossed through the door to the Infant One classroom, the bouncer chair caught on the edge of the bottom portion of the Dutch door frame. The bouncer chair tipped out of the SP’s hands and the AV landed face down on the floor, while still strapped into the chair. The AV had a mark on his/her forehead. The FM brought the AV to a medical professional for evaluation but no medical treatment was ordered. The SP, P1, and P2 each stated they were not aware of any manufacturer’s warning regarding carrying infants in a bouncer chair. However, there was a warning label on the front of the bouncer chair that clearly stated children should not be carried in the bouncer chair, and the SP and P2 each carried children in bouncer chairs at the time of the incident, making the equipment/situation hazardous which was a violation of Minnesota Statute 142B.54, subdivision 2, paragraph (e), and Minnesota Rules 9503.0140, subdivision 17. Given that the AV was carried in a bouncer chair, which was a known fall and injury hazard for infants; and that the AV was injured as a result, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care required for the AV’s physical or mental health, 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. 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 was responsible for the care of the AV at the time of the incident and transported the AV in the bouncer chair in a manner that was not in accordance with the manufacture’s warning on the front of the bouncer chair. The SP was trained in the Reporting of Maltreatment of Minors Act. The SP was responsible for maltreatment of the AV. Given that the SP had significant administrative and supervisory authority over the operation of the facility and ensuring that the facility maintained compliance with Minnesota Rules and Statutes, and that the SP and P2 stated it was a common practice to move infants in a bouncer chair, the facility was also 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 neglect for which the facility was responsible did not meet statutory criteria to be determined as serious. Although the AV sustained injuries, given that s/he was only assessed by a medical professional and received no medical treatment, the AV’s injuries did not meet the definition of serious injury for neglect. 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 not adequate for transporting infants in equipment. All staff persons were trained to read tags/instructions for infant equipment and to carry infants in acceptable items (car seats) or by carrying the infant themselves. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: On November 13, 2026, the license holder was ordered to forfeit a fine of $1,200 ($1,000 as a result of the substantiated maltreatment for which the facility was responsible and $200 for failure to report suspected maltreatment as required). The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. 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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