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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: 1057572-CCC (Child Care Center) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) were observed on video interacting with children in a manner that caused injuries, including bruises and fractures, to multiple children. Date of Incident(s): Ongoing prior to July 19, 2024 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); subdivision 18, paragraph (a); and subdivision 23, 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" 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 July 25, 2024; from documentation at the facility, law enforcement records, and medical records; and through 14 interviews conducted with a supervisory staff person (P1), three staff persons (P2, P3, and P4), AV1’s family members (FM1 and FM2), AV2’s family member (FM3), AV3’s family member (FM4), AV4’s family member (FM6), AV5’s family member (FM8), AV6’s family member (FM10), AV7’s family member (FM11), AV8’s family member (FM12), and a medical doctor (MD). Attempts were also made to contact and interview two staff persons (SP1 and SP2) but via their attorneys, SP1 and SP2 each declined to be interviewed. During the course of law enforcement’s investigation, multiple parents whose children previously attended the facility came forward with concerns about injuries that their child had sustained while at the facility and in the care of SP1 and SP2. The focus of this investigation includes only the children who were currently attending the facility and/or seen in the video. The facility had multiple classrooms, including an older infant room and younger infant room, which were across a hall from one another. The younger infant classroom typically had children who were six weeks to six months old, but at times had children up to ten months old. Both infant rooms were near the front entryway, the facility front desk, and P1’s office. There were two windows in the younger infant room that faced the hallway/front desk area/P1’s office. The facility had video cameras in the classrooms, including in the younger infant room. The footage saved for seven days and was also available via live feed on a computer at the front desk that staff persons had access to. The footage did not have sound. Additionally, the facility used an application (app) called Procare to communicate with parents. SP1 and SP2 typically worked in the younger infant room. SP1 and SP2 each worked at the facility for two years. AV1 to AV8 were each enrolled in the younger infant room. AV1 was five months old, AV2 was approximately five months old, AV3 was approximately five months old, AV4 was approximately ten months old, AV5 was approximately five months old, AV6 was 12 months old, AV7 was approximately eight months old, and AV8 was approximately six months old. The MD, FM1, and FM2; photos from FM1 and FM2 of AV1’s injuries; law enforcement records; video footage from the facility; Procare documentation from the facility dated July 15, 2024; and the Midwest Children’s Resource Center (MCRC) for AV1 dated July 16 and 30, 2024, provided the following information: · On July 15, 2024, around 7 a.m., FM2 brought AV1 to the facility. At that time, AV1 did not have any bruising. At 4:40 or 4:50 p.m., FM1 picked AV1 up from the facility and everything “seemed fine.” At approximately 6 p.m., while changing AV1’s diaper at home, FM1 noticed “odd bruising” on the front “creases” of AV1’s legs where AV1’s thighs met his/her hips. FM1 asked FM2 to look at the bruises and FM1 and FM2 also noticed “slight bruising” on other areas including AV1’s pelvic bone, buttocks, legs, and the left side above his/her “diaper line.” · Because FM1 and FM2 did not know what caused the bruising, FM2 sent a message to the facility via the app at 6:19 p.m., stating that s/he noticed “significant bruising” near and on AV1’s genital area. FM2 said that it was “alarming” to see and that s/he did not see the bruising the prior night while giving AV1 a bath or that morning. SP2 responded that s/he was “sorry to hear that” but that s/he did not see any bruising. However, SP2 told FM2 that AV1’s genital area was “quite red” at AV1’s last diaper change. FM2 responded to SP2 and said that s/he “wondered” if AV1’s diapers were “too tight” and that s/he would “size up.” · On the morning of July 16, 2024, FM1 and FM2 brought AV1 to the facility and “looked for answers” for the bruising, including from a supervisory staff person (P5) who was not aware of the bruising but said that s/he would talk to other staff persons and “review footage.” · FM1 and FM2 then left the facility and notified AV1’s doctor about the bruising and AV1’s doctor told them to take AV1 to the hospital for “possible” physical abuse. FM1 and FM2 then returned to the facility to take AV1 to the doctor. While picking AV1 up from the facility, P1 told FM1 and FM2 that s/he thought that the bruising was from an infant chair or swing that had leg holes and straps that could have “possibly” applied pressure and caused the bruising. However, FM1 later showed law enforcement photos of AV1 in both the chair and swing and law enforcement said it was “apparent” that the leg holes and straps were not tight enough to cause any marks or bruising. · The MD said that on July 16, 2024, s/he saw AV1 because AV1 had “severe bruising” on nine different areas of his/her body including groin area, thighs, shins, buttocks, and abdomen and the MD provided photos to law enforcement which showed this bruising. AV1 had an erythematous (blue or purple) bruise on his/her left shin that was approximately two and a half centimeters that was “somewhat linear” and appeared “consistent with a grip injury.” Additionally, AV1’s right front thigh had two “faint erythematous” bruises that were “somewhat linear” and were parallel to each other, that were approximately one centimeter long. There was “faint possible bruising” on AV1’s right lower leg. In AV1’s “inguinal folds bilaterally [groin area]” were dark red-purple linear bruises that were each about two centimeters long. Additionally, there was a four-to-five-centimeter area of “petechial” bruising on AV1’s left lower abdomen. · The MD said that the bruising was “extremely concerning” due to AV1’s age (five months). The MD also said that the chair and swing would not have caused AV1’s injuries. It was noted that “any bruise in a nonmobile infant must raise significant concern for inflicted injury and child physical abuse” and AV1’s bruises were “highly concerning for inflicted injury.” In addition, some of the bruises had a pattern that was “consistent with a squeeze type injury.” There was no indication that AV1 had a bleeding disorder to cause the bruises with routine cares or minor trauma. It was not possible to date or age the bruises due to their appearance. However, AV1 did not have any bruises on the morning of July 15, 2024, but had them in the evening. On July 30, 2024, AV1 had a follow up exam which noted that since AV1 stopped attending the facility on July 16, 2024, AV1 had no further bruising. AV1 also had a complete skeletal survey and no fractures were found. However, this did not “decrease the level of concern for abuse.” · FM1 and FM2 also said that AV1 had prior episodes of bruises or scratches including on May 9, and 28, 2024, that were bruises and scratches on AV1’s lower abdomen and bruising on AV1’s right shoulder (respectively). On June 17, 2024, FM2 sent the facility a “message” stating that they noticed “marks” on AV1’s left arm and above his/her belly button. On June 21, 2024, FM1 and FM2 had a phone conversation with SP2 and a supervisory staff person (P6). FM1 and FM2 told SP2 and P6 that they thought that AV1 caused the marks on his/her belly button from his/her fingernails. After the phone conversation with P6 and SP2, the marks “stopped” until July 15, 2024. FM1 and FM2 had photos of these bruises which the MD said were “highly concerning for child physical abuse.” · FM1 and FM2 did not have any other concerns regarding AV1. However, in approximately June 2024, FM2 was in his/her car in the facility parking lot and could see into the younger infant classroom. FM2 saw SP1 wiping an unknown child’s face “a little aggressive” and then SP1 put the child into a seated position “a little more aggressive” than was necessary. However, FM2 also said that s/he could not “see a lot” but said it “looked weird.” · On July 16, 2024, law enforcement spoke to staff persons at the facility regarding AV1’s injuries, including P1. P1 said that s/he was aware of AV1’s injuries from FM1 and FM2, including around AV1’s pelvic area and two small symmetrical bruises on both sides of AV1’s buttocks. P1 told law enforcement that SP1 and SP2 worked with AV1 and were “good employees.” P1 was not aware of any concerns with either SP1 or SP2. · Law enforcement then spoke to SP2. SP2 said that on July 15, 2024, s/he arrived at the facility at 8:30 a.m., and observed a scratch on AV1’s left arm. At some point after SP2 was done working, s/he saw that FM1 and FM2 had sent a message on the classroom app regarding bruising on AV1. SP2 did not see bruising but said that AV1 had “redness” in the “creases” between his/her thighs and pelvis and on his/her buttocks and that s/he applied diaper cream to those areas. SP2 told law enforcement that on the morning of July 16, 2024, s/he saw bruises on both sides of AV1’s pelvic area and said that FM1 and FM2 picked AV1 up later that morning to take AV1 to the doctor. SP2 had “no idea” what caused the bruises but “suspected” it was “possibly” from a chair or a swing in the classroom because the “education” that week was having children, including AV1, work on “sitting up.” Law enforcement observed the chair which did not have straps but the swing had a “harness system.” · SP2 also said that a month or two prior, FM1 and FM2 had “questioned” marks on AV1’s stomach that were “suspected” from being from AV1’s car seat. When law enforcement asked SP2 if s/he had any concerns with SP1’s interactions with children, SP2 said that s/he “did not recall.” · Law enforcement then spoke to SP1 who said that on July 15, 2024, around 8 a.m., s/he arrived at the facility and brought AV1 from the older infant room, where AV1 typically was each morning prior to SP1’s and SP2’s arrival, to the younger infant room. At some point, SP2 told SP1 that AV1 had “redness” on his/her buttocks but SP1 did not see any marks or redness besides “possibly [a] scratch” on AV1’s arm. SP1’s “best guess” as to how the “marks” occurred was a swing or chair in the classroom because AV1 “slumps” in the chair. However, SP1 never saw bruising and said that AV1 “acted normally” on July 15, 2024. SP1 did not have any concerns with SP2. · Law enforcement spoke to P2 who worked with AV1 in the older infant room “early” on the morning of July 15, 2024. On that date, P2 arrived at the facility around 7:20 a.m. and said that AV1 was in a crib the “entire time” prior to moving to the younger infant room with SP1 and SP2. P2 did not recall changing AV1’s diaper that day and never saw the marks. P3 was also in the older infant room during that time. · Law enforcement spoke to P3 who worked in the older infant classroom with AV1 and P2 on the morning of July 15, 2024. P3 arrived at the facility around 7:30 or 7:35 a.m. and said that AV1 was already in the older infant room sleeping. P3 said that s/he “possibly” picked AV1 up out of the crib but did not change AV1’s diaper and did not see any marks. Information from law enforcement, including documentation regarding video footage from July 15, 2024, provided the following: · SP2 used “excessive” force with AV1, including “grab[bing]” AV1 by his/her thighs and “violently flip[ping]” AV1 from his/her stomach to back. Additionally, SP2 was not “gentle” while changing AV1’s diaper and appeared to “squeeze” AV1’s upper thighs. SP1 was present during these interactions but did not intervene. · Law enforcement continued to watch the video footage, which showed SP2 engaging in similar behavior with AV3, including “roughly” holding a cloth over AV3’s mouth, “grip[ping]” AV3’s neck “firmly” and shoving a bottle into and out of AV3’s mouth. Additionally, SP2 “forcefully” lifted AV3 during a diaper change, while AV3 was crying and upset. · The video also showed that SP1 “slammed” a child into the floor, “aggressively” picked up AV1 and pressed down “hard” on AV1’s torso and abdomen, picked AV4 up by one arm to lift him/her out of a crib, and “forced” a bottle into AV4’s mouth. · After watching the video footage, law enforcement spoke to SP1 and SP2 again. SP1 did not have an explanation for his/her actions but stated that his/her behavior was “wrong” and “disgusting.” SP2 initially said s/he was trying to help AV1 learn to roll over, then became “emotional” and began crying. SP2 “apologized” for his/her “behavior.” Additional information from law enforcement, including documentation regarding video footage on other dates provided the following additional information: · There were several dates observed on video when SP1 and SP2 engaged with other children in a forceful manner. This including “slam[ming]” a child onto a mattress and pressing down on his/her back, “flip[ping]” a child from side to side on the floor, “drag[ging]” a child on the floor by the leg, and not intervening when capable to do so, resulting in a swing hitting a child on the head. · When P1 entered the room, SP1’s and SP2’s “attitude and treatment” of the children “changed to an appropriate level.” The law enforcement officer noted that SP1 and SP2 were “very capable” of caring for children when other staff persons were in the classroom but when it was just the two of them, they were “malicious,” “cruel,” and used “excessive force.” Neither SP1 nor SP2 held one another accountable when they witnessed the other treating children “maliciously,” despite them both being “mandated reporters.” · SP1 and SP2 were charged with malicious punishment of a child, 3rd degree assault, and malicious punishment of a child under four years old. Information from the AVs’ family members provided the following: · FM3 said that AV2 had a “few episodes” of bruising while at the facility but none that required medical attention. One bruise was observed above AV2’s right eye, and AV2 also had a “mark” on his/her torso and one on his/her thigh or calf that FM3 stated looked like a thumbprint. FM3 received incident reports for these which were “attributed” to AV2 scratching him/herself. · FM4 observed bruising on AV3 several times after AV3 started attending the facility. When s/he asked SP1 and SP2 about the bruising, they would “brush it off” and stated that they did not know what happened or speculate about things that could have caused it. When FM4 brought AV3 to the older infant room for drop off, P2 and P3 were present but said that they did not know about the bruises because they were not with AV3 for the majority of the day. · On December 11, 2023, AV4 returned from the facility with bruises on his/her abdomen. P1 stated s/he did not know how the bruises occurred, and that s/he spoke with staff persons who worked with AV4, including SP1, SP2, and P3, who also did not know. P1 stated that s/he would “monitor” going forward. · On an unknown date in approximately June 2024, when AV5 returned home from the facility, FM8 and another family member (FM9) observed that AV5 had an elongated yellow or light green bruise on his/her sternum. There was no incident report from the facility. · On January 5, 2024, AV6 had “some kind of skin lesion” on the left side of his/her neck. Facility staff persons stated they did not know what happened. On another date, AV6 also had a scratch on his/her abdomen, and in April 2024, AV6 had “multiple little cuts” in his/her genital area that were bleeding. FM10 did not know if supervisory staff person were aware of the concerns. · FM11 never observed any bruises or injuries on AV7 but SP1 and SP2 told him/her that AV7 refused bottles or only drank a small amount while at the facility. Additionally, AV7 would “scream and cry” when SP1 or SP2 changed his/her diaper and was pulling at his/her hair, which was “unusual.” · On April 2, 2024, AV8 returned home with bruising on the left side of his/her abdomen. Photos of the bruising showed “squared off purple patterned bruising” on the left side of AV8’s abdomen. FM12 and FM13 told P2 and P3 about the bruising at drop off. P2 and P3 told SP2 “right away” and SP2 messaged FM12 via the app and said that AV8 “might have rolled over onto a toy” which FM12 and FM13 thought was “strange” because AV8 was not rolling over yet. FM12 and FM13 also had concerns that while at home, AV8 “screamed” whenever s/he had a bib put on and also “slept a great deal” which was “odd.” Since AV8 stopped attending the facility, s/he was “acting normal.” · Multiple parents including FM3, FM6, FM10, and FM11 described SP1 and SP2 as calm, gentle, nice, pleasant, and caring and had not seen SP1 or SP2 harm any children. Additionally, information showed that when parents had concerns, including with unexplained injuries, they typically went to classroom teachers, including SP1 and SP2, instead of to P1. Law enforcement notified the family members of the AVs of the concerns with SP1 and SP2 and encouraged them to take their children to the hospital. Documentation from Midwest Children’s Resource Center (MCRC) stated the following: · AV2 had an exam, and no bruises or evidence of trauma were noted. However, documentation stated that “any bruise in a nonmobile infant must raise significant concern for child physical abuse.” · AV3 had a healing proximal tibial bucket fracture. This type of injury was difficult to date, but the doctor stated it was approximately one to two weeks old and “suspicious for nonaccidental trauma.” · AV4 had two “very faint erythematous linear bruises” approximately two centimeters long that were parallel to one another on his/her right anterior thigh. There were no “falls or drops reported.” · AV6 did not have any observed fractures, but the scratches noted were “concerning for inflected injury and child physical abuse.” · AV5, AV7, and AV8 each had medical exams and there was no bruises or evidence of trauma found. However, it was noted that any bruise in a nonmobile infant raised “significant concern for inflicted injury and child physical abuse.” Additional notes for AV8 indicated that the bruise on AV8’s abdomen was a “very unusual place for accidental bruising” and the “patterned bruise” was “consistent with a squeeze.” Also, despite being told that AV8 rolled over on a toy, at that time, AV8 was not yet rolling over and the bruise was “therefore diagnostic of inflicted injury and child physical abuse.” P2, P3, and P4, provided the following information when interviewed separately: · P2 and P3 each occasionally worked with SP1 and SP2. P2 and P3 each stated that they heard SP1 “yelling” or “scream” at children, and call them names such as “stupid,” “lazy,” or “fucking dumb.” P2 and P3 also stated that SP1 was “aggressive” with children when changing them. P2 stated that SP1 grabbed children’s legs on the changing table and “smash[ed] them down,” and was “very violent” and “flipped” children while giving them a bottle or burping them on a pillow. P3 stated that s/he saw SP1 push forward and “grip” children’s legs while changing them; that SP1 flipped AV4 on his/her stomach in an “aggressive” way during tummy time; and “forced” AV4 to do things s/he did not want to do. · P4 also worked with SP1 occasionally, and stated SP1’s interactions with children were “fairly typical.” However, there were a “couple” of times when SP1 appeared “frustrated” and was “vocal” regarding his/her frustrations. P4 would then step in, and things would be “fine.” P4 saw SP1 lift a child out of a bouncer and then keep “tugging” when the child’s feet were caught instead of repositioning the child’s feet. P4 told SP1 that s/he could “hurt” the children by “tugging” them. · Regarding SP2, P2 stated that SP2 could be “grumpy” in the mornings and that when SP2 was with SP1, his/her behavior changed and s/he was “more negative and down.” P3 stated that at times toward the end of the day, SP2 was “frustrated” including while feeding a bottle to AV1, and handling children “too hard or too aggressive.” Additionally, P3 stated that SP1 and SP2 “picked up on each other’s frustrations” and were “frustrated” when they were around one another. P4 described SP2 as “calm,” “chill,” and “laid back.” P4 did not have any concerns with SP2’s interactions with children. · P2 thought that the infant swings or chairs with buckles caused some injuries because the buckles “pinched” children on their stomach at times and P2 often pinched his/her own fingers when s/he buckled children in. A few months prior to July 2024, AV6 sustained a scratch from the swings or chair while P2 assisted AV6. · P3 told SP1 that his/her interactions were “mean,” “rude,” and that SP1 should “not be doing that.” SP1’s reaction was, “I do not care,” or s/he stated that s/he did not “like” the child involved. P3 said that SP1 “put on a face” when s/he saw others and was “nice” when parents were around, but then would be “frustrated” once s/he was not around other staff persons.
· P3 stated that P3 did not see “anything” with SP2’s interactions that would have “led to [the incidents] happening” and never saw any other concerns. P3 was “shocked” about SP2 and had “no idea” that things had gotten “that bad.” · On one or two occasions, P4 asked SP1 or SP2 how a child sustained a “mark,” including a “red mark” or “line” on an unknown child’s thigh, and they said that the child “rolled” over something or it happened while the child was crawling. P4 “believed” SP1’s and SP2’s account of what happened at the time and did not “question” the incident reports that were written by SP1 and SP2. · P2 stated that s/he told P1, P5, and P6 about his/her concerns with SP1’s interactions with children in the beginning of July 2024, including that SP1 was “aggressive” and “squeezing” AV4. P1, P5, and P6 told P2 to talk to SP1, which P2 did. P2 stated that P1 and P5 did not watch the video footage, and that s/he did not tell the supervisors all of his/her concerns because s/he feared for his/her job and believed that it would result in him/her being moved to other rooms or a reduction in hours. P2 stated that s/he also talked to SP2 about the concerns s/he observed with SP1, but SP2 denied seeing those things. · P3 stated that prior to July 25, 2024, s/he told P1 about his/her concerns with SP1 and P1 or other supervisory staff persons would talk to SP1 and the conduct would “improve for a few weeks.” P3 stated that P2 also brought up concerns regarding SP1 “being too aggressive” and not supporting children’s heads “properly.” P3 was concerned that P1 did not check the cameras after learning of P2’s and P3’s concerns. · P4 stated that s/he told P1 about his/her concerns because s/he did not want “anything bad to happen.” When P4 told P1, P1 said that s/he would talk to SP1 and after P1 did so, everything “seemed fine.” P4 stated that the facility had video cameras, but no one watched the footage when there were concerns. Additionally, SP1 and SP2 were “so angelic looking” that “no one could believe it.” P1 provided the following information: · On the evening of July 15, 2024, FM1 or FM2 sent a message via the facility app with concerns that AV1 had bruising near his/her genital area. SP2 was responding “back and forth” with FM1 and FM2 that included that there was no bruising observed during diaper changes but that the area was red so SP2 applied diaper cream. P1 typically tried to let the classroom staff persons respond when parents asked questions. Additionally, P1 was already at home when the messages were sent, so s/he did not respond. · On July 16, 2024, at 8:30 a.m., P1 arrived at the facility and P5 told P1 that s/he spoke to FM1 and FM2 who were “upset” that staff persons did not know about the bruising. Shortly after, P1 went into the infant room and woke AV1 to see the bruises on AV1’s genital area. The bruises were “faint” and yellow. P1 also saw two “dots” on AV1’s buttocks. P1 spoke to SP1 and SP2 to see how AV1 could have sustained the bruises but each said they did not know what happened. SP1 and SP2 told P1 that AV1 used a swing and infant chair throughout the day so P1 thought the bruises could have been from those things, including that the swing may have been “too tight.” · Shortly after, FM1 and FM2 returned to the facility to take AV1 to the doctor. P1 told FM1 and FM2 that s/he looked at the bruising and that s/he spoke to SP1 and SP2 who did not know how AV1 sustained the bruising. P1 shared some “thoughts” with FM1 and FM2 about what s/he thought may have happened, including that AV1 sustained them from the swing. P1 also told FM1 and FM2 that s/he was “glad” they were taking AV1 to the doctor to figure out what happened. FM1 and FM2 then took AV1 and left. P1 had SP1 and SP2 write an incident report regarding the bruising, and each said that they did not see the bruising or know what happened.
· Later that same day at an unknown time, law enforcement arrived at the facility. P1 said s/he was “not worried” and was “fully confident” that the bruising was not caused by staff persons. Law enforcement then spoke to staff persons including SP1, SP2, P2, and P3, and asked P1 for video footage. P1 “hardly” knew how to access the video to provide a copy to law enforcement and was not able to provide it to law enforcement that day. · On July 16, 2024, after law enforcement came to the facility, SP2 gave P1 a note that FM4 had “dropped off” on July 9, 2024, when P1 had been on vacation and had been gone for approximately 11 days, returning on July 15, 2024. The note stated that AV4 had “abnormal bruising” and for staff person to document when they observed it. However, P1 did not think there were concerns that the bruising was from staff persons so P1 did not watch video footage to confirm. Additionally, AV4 was not at the facility around that time so P1 told SP2 to document on the note that the bruising “was not from us.” P1 also provided this note to law enforcement. · On July 17, 2024, law enforcement returned to the facility, accessed the video footage, and obtained a copy. P1 again spoke to SP1 and SP2 and did not have any indication that SP1 or SP2 caused the bruising and was “confident” that nothing happened to AV1 while at the facility. P1 also asked SP1 and SP2 if there would be anything concerning on the footage and SP1 and SP2 said that there “absolutely” would not be anything concerning. · On July 18, 2024, law enforcement came to the facility and arrested SP2. P1 did not know why they arrested SP2 and did not “dawn” on him/her that “something was wrong.” P1 then notified a supervisory staff person who told P1 to “check the footage.” P1 told the supervisory staff person that s/he was not able to watch the footage because s/he had been working in classrooms “all week” but at some point that day, P1 left the classrooms and watched some of the footage from July 15, 2024. P1 clicked on a “random time” between 9 and 9:30 a.m. and observed SP2 “rolling” AV1 “aggressively” on the floor which was “alarming.” AV1 was not able to hold his/her head up yet. SP1 was also present in the room but did not intervene. · Law enforcement then returned to the facility and told P1 that they watched additional footage from July 15, 2024, and there were concerns regarding other children and asked P1 to identify those children. P1 saw SP2 forcing a bottle into AV3’s mouth. SP2 then picked AV3 up as if to burp AV3 but instead held a burp cloth over AV3’s face and began “swinging” AV3 around with the burp cloth over his/her face. P1 described it as “making [AV3] do summersaults in the air.” Additional footage showed SP1 lifting AV4 off a mat “aggressively” by AV4’s wrist and moving AV4 closer to him/her. Once P1 saw this, s/he planned to send SP1 home but SP1 was then arrested. · P1 would not have “suspected” the concerns with SP1 and SP2. P1 had “no idea anything was going on” and said that the incidents made him/her feel “gross.” At times, supervisory staff persons observed classrooms, including the infant rooms, and did not have any concerns. · The facility had cameras but the cameras did not have audio. P1 did not know and was not “told” that s/he needed to watch the footage prior to the incident. P1 thought the footage was for parents to watch the classrooms when they came to the facility because the video footage was live and available at the front desk. At times, a staff person may be at the desk using the computer but staff persons did not typically monitor or watch the cameras. The video footage saved for seven days. P1 said that s/he made a “mistake” by not reviewing the cameras. Additionally, P1 said that parents never brought up concerns to him/her so s/he never thought to look at the cameras. · P1 also spoke to P2, P3, P4, and a staff person (P7) and they were “all shocked” regarding the concerns. · The only concerns P1 was aware of prior to the incident, was that at some point, P2 and P3 told P1 that SP1 called a child “stupid” so P1, P5, and P6 spoke to SP1 and said that was “inappropriate.” SP1 “admitted to it” and said that s/he would not do it again. P1 did not hear further concerns about that. P1 was not aware of SP1 or SP2 calling any other children names and said that would not be appropriate. P1 never heard SP1 or SP2 yelling from the infant classrooms. · Additionally, at some point, P2 told P1 that SP1 set a child down “roughly” but P1 did not recall when that was. P1 asked P2 if s/he wanted to talk to SP1 or if P1 should talk to SP1. P2 said that s/he would talk to SP1. P1 told P2 to let him/her know how the conversation went and a short time after, P2 told P1 that “everything” was “good.” These two incidents were the only concerns P1 was aware of. When P1 was made aware of these concerns, P1 did not watch video footage regarding these concerns. · In December 2023, FM6 parent brought up a concern that AV4 had a “mark” on his/her stomach and P1 “followed up” by talking to staff persons but P1 did not have any concerns that staff persons caused the mark. P1 did not watch video footage during this time. · SP2 worked at the facility since July 2022, and typically worked in the younger infant room. SP2 was one of the only staff persons who “never floated around” to other classrooms. P1 described SP2 as “really gentle,” soft spoken, and knowledgeable regarding the children in his/her room. If SP2 was ever alone in the room, SP2 would ask for help when needed. SP2 was “great” with the children. SP2 typically worked with SP1, P2, and P3. The facility did monthly check-ins with staff persons and SP2 did not bring up any concerns regarding SP1’s interactions with the children. Additionally, no one brought up concerns with SP2’s interactions with children. · P1 described SP1 as “very timid,” “chill,” and that SP1 had good relationships with parents. No parents brought up any concerns with SP1’s interactions with children. P1 did not have any concerns with SP1’s interactions with the children. Additionally, SP1 was the “most flexible” staff person at the facility and often was willing to come in early or stay late. · Staff persons at the facility communicated with the parents “a lot.” If parents brought up concerns to P1, s/he usually asked the child’s teachers about the concerns and had the staff persons follow up because they were in the room “all day” with the child. · Prior to the allegations, P1 would have felt comfortable having his/her own children in SP1’s and SP2’s room and never had concerns that SP1 or SP2 injured children. Additionally, SP1 had watched P2’s and P5’s children and neither had concerns. · After becoming aware of the concerns, the facility had a meeting with parents and staff persons. Some parents had concerns regarding prior incidents and wondered if SP1 or SP2 caused the injuries. Parents were also “questioning” “how far back” the concerns had been going on for. · If staff persons were frustrated, they could ask for a break which SP1 and SP2 did at times. · Staff persons were trained to report if they had concerns and there were phone numbers in each classroom to do so. Staff persons were “never expected” to come to P1 but P1 said that s/he would “support” staff if needed. AV1’s Documentation filled out by SP1 said that SP1 never saw bruising on AV1. SP1 said that “all” staff persons “genuinely cared” about the children at the facility. SP1 said that it felt like FM1 and FM2 “blamed” staff persons for “any marks or scratches” on AV1, when the injuries “must” have been from AV1 “accidently” scratching him/herself. SP1 also thought that car seat straps, infant seats, infant swings, and diapers could have caused bruising to AV1. The Small World Learning Center Parent Handbook and Program Plan: Blaine said that all staff persons were mandated reporters and were to report any concerns of suspected abuse in a licensed facility to the Department of Human Services. The Behavior Guidance said that each child was to be provided with a positive model of acceptable behavior and tailored to the developmental level of the children. Staff persons were to respect children and protect the safety of children. Staff persons were to model “positive” behaviors. Prohibited actions included subjecting a child to corporal punishment including rough handling, shoving, shaking, slapping, kicking, biting, pinching, hitting, and spanking. Name calling, shaming, and making derogatory remarks about a child were “prohibited.” Facility documentation showed that SP1, SP2, P1, P2, P3, and P4 received training on the facility’s behavior guidance policy, abusive head trauma, shaken baby syndrome, child development, and the Maltreatment of Minor’s Act, prior to the incident. 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. Minnesota Rules, part 9503.0055, subpart 3, item B, states that the license holder must have and enforce a policy that prohibits the subjection of a child to emotional abuse. Emotional abuse includes, but is not limited to, name calling, ostracism, shaming, making derogatory remarks about the child or the child’s family, and using language that threatens, humiliates, or frightens the child. Conclusion: A. Maltreatment: Regarding physical abuse by SP1 and SP2: On July 15, 2024, after AV1 returned home from the facility, FM1 and FM2 noticed multiple areas of bruising on AV1’s legs, pelvic bone, and buttocks. AV1 did not have the bruises that morning prior to going to the facility. On July 16, 2024, FM1 and FM2 notified their doctor who told them to take AV1 to the emergency room, which they did. The MD said that AV1’s injuries were “consistent with a grip injury.” Video footage from July 15, 2024, showed SP2 “violently flipping” AV1, who was five months old, back and forth. Law enforcement described SP2’s interactions with AV1 as “roughly handling” and “excessive.” SP2 also did not support AV1’s head or face and AV1’s head and face “slammed into the floor mat” several times. At one point in the video, SP1 also “slammed” AV1 into a pillow and pressed down “hard” on AV1’s torso and abdomen. Additional video footage between July 15 and July 17, 2024, showed multiple additional concerns with SP1’s and SP2’s interactions with children that were described as “forceful” and “violent” and included grabbing children, including AV1 and AV3, by various body parts including their neck and arms; putting a cloth over AV3’s mouth and nose where it appeared that AV3 could not “breathe”; slamming AV1 and AV3 “violently” onto a pillow; dropping children, including AV3 and AV4, to the floor from various heights; and multiple other interactions that caused children to cry. Medical records and MCRC reports showed that AV1, AV2, AV3, AV4, AV5, AV6, AV7, and AV8 sustained injuries that were “highly specific for inflicted injury and child physical abuse.” Although SP1 and SP2 did not interview with this investigator, SP1 told law enforcement that his/her interactions were “wrong” and “disgusting” and that s/he was not trained to interact with children in that manner. SP2 “apologized” to law enforcement for his/her “behavior.” SP1’s and SP2’s actions of handling the children in an unsafe manner were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; a violation of the facility’s policies; and violations of Minnesota Rules 9503.0055, subpart 3, item A. In addition, P2 and P3 each stated that they heard SP1 “yelling” or “scream” at children, and call them names such as “stupid,” “lazy,” or “fucking dumb” which was a violation of Minnesota Rules, part 9503.0055, subpart 3, item B. At the time of the incidents AV1-AV8 ranged in age from five to 12 months old. Given the information provided, including video and AV1’s-AV8’s age and lack of control of their body and neck associated with the their age, there was a preponderance of the evidence that SP1’s and SP2’s interactions with AV1-AV8 including picking them up by various body parts, dropping them, flipping them, and slamming them into the floor was not accidental, caused injury and/or represented a substantial risk of injury and threatened injury to AV1-AV8. 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). Regarding neglect by SP1 and SP2: Video footage also showed that SP1 and SP2 were each present during the others interactions with children, yet each failed to intervene with the others physical interactions with the children at any point. At the time of the incidents AV1-AV8 ranged in age from five to 12 months old. Given that SP1 and SP2 were each seen on video failing to intervene with the others interactions with AV1-AV8 that included picking them up by various body parts, dropping them, flipping them, and slamming them into the floor, there was a preponderance of the evidence that each failed to supply AV1-AV8 with reasonable and necessary care, and failed to protect AV1-AV8 from conditions or actions that seriously endangered their 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). Regarding neglect by P1: P2, P3, and P4 each said that when they brought up concerns with SP1’s interactions with P1, P1 addressed it, including by talking to SP1, and the interactions would stop. There was no other information that any other staff persons had concerns. P1 was also only made aware of one instance of bruising, which was on AV4, and when P1 became aware, s/he spoke to staff persons, including SP1, SP2, and P3 who said that they did not know how the bruising occurred. Additionally, there was no information that P1 was aware of any concerns regarding SP2. Although P1 did not witness any concerns regarding SP1’s or SP2’s interactions with children, given P1’s role at the facility, P1 did not watch SP1’s and SP2’s entire workday or work directly with SP1 and SP2 in the classroom for any extended length of time. Additionally, information showed, including from video footage, that at times when other staff persons or parents were in the room with SP1 and/or SP2, there were no concerns with SP1’s and SP2’s interactions with children. Therefore, it was reasonable that P1 may not see any concerning interactions. Multiple parents including FM3, FM6, FM10, and FM11 described SP1 and SP2 as calm, gentle, nice, pleasant, and caring. Additionally, information was consistent from parents that when they had concerns, including with unexplained injuries, they typically went to staff persons including SP1 and SP2 and did not notify supervisory staff persons, including P1. Although multiple parents and staff persons had concerns that P1 did not watch video footage at any time even though it readily available and did not watch the video until after law enforcement was at the facility and SP2 had been arrested, there was no requirement in Minnesota Rules or Statutes that child care centers were required to have video footage or if a facility had video, any requirements for any person to watch it. Additionally, the facility did not have a policy that required staff persons to monitor video footage. Given the aforementioned, that P1 stated that s/he would not have “suspected” the concerns with SP1 and SP2 and had “no idea anything was going on;” and that when concerns were brought to P1 regarding SP1 calling a child stupid and setting a child down roughly, P1 either talked to SP1 or ensured that P2 talked to SP1, there was not a preponderance of the evidence that there was a failure by P1 to supply care or supervision required for the AVs’ physical health when reasonably able to do so. It was not 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/or 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), 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 and SP2 received training on the facility’s behavior guidance policy, abusive head trauma, shaken baby syndrome, child development, and the Maltreatment of Minor’s Act, prior to the incident. SP1 and SP2 were responsible for maltreatment of AV1-AV8. 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 abuse and neglect for which SP1 and SP2 were responsible was “recurring and serious” maltreatment given that the incidents occurred with multiple children over multiple dates and that some of those children sustained bruises, scratches, and fractures. 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 that the facility made “adjustments” regarding policies and procedures for incident and accident reports and use of cameras for “security measures.” This included that “directors” would review incident reports and “ask more questions” and check camera footage when there was “any uncertainty” as to what happened. Additionally, policies and procedure were not followed regarding maltreatment of minors. All staff persons were retrained on mandated reporting, the risk reduction plan, and stress management. The incidents were not similar to prior incidents. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were each notified that s/he was responsible for recurring and serious maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that SP1 and SP2 were responsible for maltreatment is subject to appeal. On May 23, 2025, the facility was issued a Correction Order for the violations outlined in this report. Minnesota Statutes, section 260E.06, subdivision 1, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that two staff persons failed to report suspected maltreatment as required. A letter from DHS was sent to each of these individuals regarding their failure to report the suspected maltreatment and potential consequences for future such failures. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine 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 Human Services.
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