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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: 2001558-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: Allegation One: It was reported that an alleged victim (AV1) sustained bruises on his/her torso from a staff person (SP1). Allegation Two: It was also reported that SP1 and another staff person (SP2) aggressively rocked another alleged victim (AV2) in his/her crib. Date of Incident(s): November 18 and 19, 2024. The Minnesota Department of Human Services received this report on January 7, 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 a site visit conducted on January 28, 2025; from documentation at the facility; video footage provided by the facility, FM1, and FM2; law enforcement records; medical records; photos of the AV; a report from a medical facility that specialized in abuse; a written review completed by a board-certified child abuse pediatrician; and through six interviews conducted with a supervisory staff person (P1), SP1, SP2, AV1’s family members (FM1 and FM2), and AV2’s family member (FM3). FM1 reviewed all video footage from the infant room from November 18 to 22, 2024, and provided multiple clips of SP1’s and SP2’s interactions with AV1 and AV2 to the DHS investigator. FM1 did not have concerns with any other interactions in the videos. The DHS investigator was unable to obtain the full video footage of November 18 to 22, 2024, from the facility or other sources. Allegation One: It was reported that AV1 sustained bruises on his/her torso from SP1. According to AV1’s enrollment information, AV1 was five months old and enrolled in the infant room at the time of the incident. SP1 and SP2 were the main staff persons in the infant room. The infant room had bouncer chairs on the floor. The bouncer chairs had straps with buckles for safety purposes. On the day of the site visit, each bouncer chair and buckle were in proper working condition. The report from the medical facility that specialized in abuse and the written review completed by a board-certified child abuse pediatrician provided the following information: · On November 23, 2024, AV1 was brought to a medical appointment for eye discharge and loose stool. During the appointment, FM1 asked the doctor to also look at possible café au lait spots (birthmarks) on AV1’s torso. The doctor saw three small, “pale yellow-green” bruises on AV1’s lower right chest and a singular yellow bruise on the lateral right back. The bruises were “non-patterned” and “less than” 0.5 centimeters. · The doctor explained that they were not birthmarks but bruises. FM1 told the doctor s/he first noticed the bruises during a bath the evening of November 22, 2024. FM1 and FM2 did not know the cause of the bruises or any trauma that might have caused bruising to AV1. · A computed tomography (CT) scan and skeletal survey were completed which showed no signs of additional injuries to AV1. The doctor took photos of the bruises and the photos were consistent with the doctor’s written description. · The board-certified child abuse pediatrician reviewed 12 photos that showed a bruise on the right side of AV1’s mid-back on the right side of the mid spine area and several photos that showed five bruises to the lateral right torso in a “roughly linear fashion starting just below [AV1’s] nipple along the plane of the anterior axillary line and curving more towards the mid axillary line.” The bruising “followed to the area of the lower lateral rib cage.” · The bruising was “concerning” because AV1 was non-mobile and “suggested” that AV1 “experienced trauma involving forces above and beyond those typically experienced through routine care and handling.” The bruising was “clustered and multiplanar and suggestive of placement of a hand around [AV1’s] torso.” There was “no clear pattern that allow[ed] definitive identification of what caused the bruising.” It was not possible to determine when the bruising occurred. · The pediatrician reviewed photos and facility video footage and documented that “it was plausible that the bruising could have been caused” at the facility because there was “several instances where force above and beyond routine care and handling may have occurred.” o In one photo, AV1 and another child sat on a staff person’s lap. Although AV1 was not mobile, s/he was at the developmental age where s/he could “be wiggly and reach for objects.” If the staff person tried to “support and contain” two children, it was possible that the staff person tightened his/her grip and used a “larger degree of force than typical” if a child “suddenly arches or lunges” to keep the child from falling. There was no evidence that this occurred, but the “mechanism” was “plausible” based on how AV1 was seated. o Video footage that showed AV1 was “roughly picked up” by SP1 from a bouncer chair was “more concerning.” SP1 did not attempt to unbuckle AV1 prior to lifting him/her and there was “clearly enough force utilized to lift [AV1] and the chair off the ground” while SP1 continued to hold AV1 by the torso and “manipulate” AV1 so the chair fell off AV1’s legs. There was a grasp and lift typical to lift a child but then a “need to tighten the grip when there is unexpected pull” from AV1’s legs stuck in the chair, in addition to the weight of the chair and the pull of gravity. This type of “handling and activity could absolutely result in force above and beyond typical handling of [AV1] and result in bruising.” FM1 and FM2 stated approximately one month prior to the November 23, 2024, medical appointment, AV1 had his/her four-month-old medical appointment. During that appointment, FM1 asked the doctor to look at a “soft faint yellow spot” on AV1’s chest. The doctor said it was a café au lait spot so FM1 asked the doctor at the November 23, 2024, appointment to check another spot on AV1’s torso that looked the “exact same” as the previous spot on AV1’s chest. The spot on AV1’s torso was diagnosed as a bruise. Prior to November 23, 2024, FM1 and FM2 did not have previous concerns with the facility or staff persons. Video footage provided by FM1 and FM2 showed the following: · On November 18, 2024, at 8:23 a.m., SP1 walked over to AV1 who laid in a bouncer. SP1 placed each of his/her hands on AV1’s upper arms and lifted AV1 out of the bouncer. SP1 then turned AV1 to face outward while SP1 moved one hand to AV1’s left torso. SP1 carried AV1 with one hand a few steps to chairs at a table. SP1 then used both hands on AV1’s torso to set AV1 in the chair. · On November 19, 2024, at 9:01 a.m., AV1 laid on his/her stomach on the floor. SP1 walked over, placed one of his/her hands on AV1’s left upper arm and the other on AV1’s left ankle and flipped AV1 onto his/her back. SP1 adjusted AV1’s clothing then walked away. · On November 19, 2024, at 9:39 a.m., AV1 laid buckled in a bouncer chair that was on the floor. Without unbuckling the strap, SP1 walked over and picked up AV1 by his/her upper arms. While SP1 lifted AV1 up in the air, AV1’s legs were caught on the strap which was still buckled. The bouncer chair was in the air while SP1 held AV1 in the air and moved AV1 up and down twice so that the chair fell to the floor. Toward the end of the video, it was unclear where SP1’s hands were on AV1. P1 provided the following information: · On a previous unknown date, P1 received an email from FM1 and FM2 about possible bruising on AV1. Two other supervisory staff persons (P2 and P3) spoke to SP1 and SP2 and asked about the bruising on AV1’s torso and they each said they did not know how AV1 could have received the bruises. SP2 said on November 21, 2024, s/he saw bruises on AV1’s torso when changing AV1’s diaper but did not write an incident report or tell anyone about it. P2 told P1 that s/he looked for an injury report for AV1 but there was none regarding the bruises. P1 did not have previous concerns with SP1’s and SP2’s interactions with children including AV1. · P1-P3 reviewed video footage of the infant room from November 18 to 22, 2024. P1 stated that some areas of the classroom were outside the camera view, including the diaper changing tables. P1 saw SP1 and SP2 rock infants while lying in their cribs so s/he provided additional training. However, P1-P3 did not have additional concerns, and did not see any interactions between SP1 or SP2 and AV1 that could have resulted in an injury. · At some point, law enforcement came to the facility and reviewed the same video footage and told P1 s/he did not have concerns with staff persons interactions but P1 should save the videos. Law enforcement specifically pointed out a part of the video on November 19, 2024, where FM1 or FM2 picked up AV1 because it was where the bruises appeared. · When this investigator had P1 review the video footage provided by FM1 and FM2, P1 said the video was zoomed in closer then when s/he independently reviewed it. P1 said SP1 grabbed AV1 by one arm out of a bouncy chair and when AV1 was still buckled SP1 “pull[ed]” on AV1 which was not consistent with training that SP1 previously received. The facility provided multiple video clips of interactions between FM1, FM2, and AV1 at drop off and pick up. There were no concerning physical interactions between FM1, FM2, and AV1. When this investigator requested the full video footage from the facility for the week of November 18 to 22, 2024, the facility said it had been “recycled” and no longer had access to it. SP2 did not remember the date, but on a previous occasion, s/he saw two small, yellow spots on AV1’s stomach and right side. SP2 did not write an incident report or tell any other staff persons but did tell FM1 about them. FM1 responded that s/he was bringing AV1 to a doctor anyways for other concerns and would discuss those spots. SP2 denied that AV1 had a spot on his/her chest approximately one month prior. SP2 did not have concerns with SP1’s interactions with the children including AV1. SP1 provided the following information: · Around the week of November 18 to 22, 2024, SP1 did not remember seeing any injuries, including bruising, on AV1. SP1 was trained to pick up AV1 and other children by placing his/her hands on AV1’s torso near the waist. · SP1 and this investigator reviewed video of SP1’s interactions with AV1. SP1 said in one of the videos, s/he picked up AV1 “too fast,” SP1 did not unbuckle AV1 from the chair, and AV1 was “stuck” as SP1 lifted AV1 by his/her arms. In another video, SP1 “flipped” AV1 over by grabbing one arm and one leg. SP1 acknowledged that s/he was not trained to pick up and move children that way. According to the facility’s Prohibited Actions Policy, staff persons were prohibited from subjecting a child to corporal punishment, which included: rough handling, shoving, hair pulling, ear pulling, shaking, slapping, kicking, biting, pinching, hitting, and spanking. All staff persons, including SP1 and SP2, were trained on the facility’s Prohibited Actions Policy and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0055, subpart 1, item A, state that the license holder must develop behavior guidance policies and procedures; and see that the policies and procedures are carried out. The policies and procedures must ensure that each child is provided with a positive role model of acceptable behavior. 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 person: 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 Allegation One: A. Maltreatment: Video footage showed on multiple occasions on November 18 and 19, 2024, SP1 handled AV1 in a manner SP1 and P1 said was inconsistent with SP1’s training, and that the board-certified child abuse pediatrician described as “instances where force above and beyond routine care and handling may have occurred.” This handling included SP1 picking up AV1 by grabbing AV1 by his/her upper arms, lifting AV1 from a bouncy chair and pulling on AV1 who was still buckled into the chair until the chair fell off AV1; and picking up AV1 by his/her left ankle and arm and flipping AV1 onto his/her back. SP1’s actions of handling AV1 in an unsafe manner were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, were a violation of the facility’s policies and were violations of Minnesota Rules, part 9503.0055, subpart 1, item A, and Minnesota Rules 9503.0055, subpart 3, item A. Given the lack of control of AV1’s body and neck associated with AV1’s age, and SP1’s repeated handling of AV1 in a manner which subjected AV1 to a substantial risk of injury, there was a preponderance of the evidence that SP1’s pattern of handling of AV1 represented threatened injury to AV1. 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. Facility documentation showed that SP1 received training on the Reporting of Maltreatment of Minors Act and the facility’s Prohibited Actions Policy prior to the incident. SP1 was responsible for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. 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 physical abuse for which SP1 was responsible did not meet statutory criteria to be determined as serious or recurring. SP1’s pattern of behavior was considered a single incident of abuse. In addition, although AV1 had a bruise around the time of the incidents, there were no visible interactions on video that were directly linked to AV1 sustaining the bruises. Allegation Two: It was also reported that SP1 and SP2 aggressively rocked AV2 in his/her crib. According to AV2’s enrollment information, AV2 was nine months old and enrolled in the infant room at the time of the incident. Each child in the infant room had an assigned wooden crib that had wheels. Undated video footage provided by FM1 and FM2 showed AV2 in a crib. SP2 placed one hand on AV2’s left ankle and one hand on AV2’s left wrist and flipped AV2 from his/her stomach to his/her back. SP2 then used both hands to roll the crib back and forth on the floor six times in approximately eight seconds while AV2 was on his/her back. AV2 rolled side to side multiple times as SP2 rolled the crib. AV2 did not have control of his/her arms, legs, or head as s/he rolled from side to side. SP2 then placed one hand on AV2’s right ankle and the other hand on AV2’s right wrist to lift and flip AV2 back onto his/her stomach. P1 stated when s/he previously reviewed the video footage for concerns, s/he saw SP1 and SP2 each rock the children in their cribs like they were “dancing” with the children but “too hard.” P1 provided follow up training to SP1 and SP2 regarding rocking the cribs. P1 did not have concerns with SP2’s interactions with children prior to this investigation. This investigator had P1 rewatch the above video footage and P1 said that SP2’s actions were “really harsh” and AV2 rolled around in the crib. SP2’s actions were not how s/he was trained to put children to sleep. P1 did not remember any injuries to AV2 around that time and there was no injury report in his/her file. SP1 stated s/he received additional training from P1 about getting the infants to sleep. Previously, SP1 rocked the children including AV2 while they were inside their cribs so they would go to sleep. SP1 did not “shake” the children but “rock[ed]” them “in a fast motion” to sleep. SP1 did not remember the children rolling from side to side in their cribs when s/he did this. SP2 stated that when s/he started working at the facility, SP1 trained SP2 to rock the cribs back and forth until the children fell asleep. On one occasion, P1 gave SP1 and SP2 additional training to rock the children “smoothly or soft” because they had been “too hard.” SP2 denied rocking the cribs hard enough so children moved. This investigator showed SP2 video footage of the incident and SP2 said AV2’s body was moving from side to side in the crib. AV2 did not have any injuries around the time of the incident but SP2 said the rocking could have caused “buzzing or ringing” in AV2’s head if s/he was rocked too hard. According to the facility’s Nap and Rest Policy, each infant had a determined nap time. Infants were placed in cribs on their backs to sleep. Conclusion Allegation Two: A. Maltreatment: Video footage showed SP2 used one hand on AV2’s ankle and the other hand on AV2’s wrist to lift and flip AV2 two times. SP2 also used both of his/her hands on AV2’s crib to roll the crib back and forth six times for approximately eight seconds while AV2 rolled side to side. AV2 did not have control of his/her arms, legs, or head as s/he rolled back and forth. When P1 watched video footage of the incident, s/he described SP2’s actions as “really harsh” and inconsistent with SP2’s training. Although SP2 provided information that s/he was trained by SP1 to rock the cribs, given that video footage was not provided of SP1 rocking children in the cribs; and that when viewing video footage both FM1 and P1 did not have additional concerns with SP1’s interactions; it was unknown how forcefully SP1 rocked children in their cribs, nor whether it represented a substantial risk of injury. SP2’s actions of handling AV2 in an unsafe manner were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were a violation of the facility’s policies and violations of Minnesota Rules, part 9503.0055, subpart 1, item A, and Minnesota Rules 9503.0055, subpart 3, item A. Given the lack of control of AV2’s body and neck associated with AV2’s age, and SP2’s handling of AV2 in a manner which subjected AV2 to a substantial risk of injury, there was a preponderance of the evidence that SP2’s handling of AV2 represented threatened injury to AV2. It was determined that 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. Facility documentation showed that SP2 received training on the Reporting of Maltreatment of Minors Act and the facility’s Nap and Rest Policy prior to the incident. SP2 was responsible for maltreatment of AV2. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. 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 physical abuse for which SP2 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and AV2 did not sustain an injury. 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 policies and procedures were adequate but not followed. Staff persons were trained to lift children by the torso and not allowed to “push” cribs. SP2 was suspended pending the investigation and SP1 was moved to a different classroom. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal. On June 11, 2025, the facility was issued a Correction Order for the violations outlined in this report and for not completing incident reports. 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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