|
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: 1120376-CCC (Child Care Center) Investigator(s): Kim Anderson Minnesota Department of Children, Youth, and Families 651-539-8226 Suspected Maltreatment Reported: Incident One: It was reported that an alleged victim (AV1) stopped breathing during naptime and then threw up a cottage cheese-like substance with blood on two occasions. Incident Two: It was reported that an alleged victim (AV2) was found in his/her crib not breathing, with blood on his/her crib sheet. Date of Incident(s): September 19 and 22, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clause (2); subdivision 18, paragraph (a); and subdivision 23, paragraph (a): 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 from a site visit on October 16, 2025, documentation at the facility, law enforcement records, and medical records; and through six interviews conducted with a facility administrator (P1) and four facility staff persons (P2, P3, P4 P5 and P7). Multiple attempts to interview a facility management person (P6) were made, but P6 declined to interview with this investigator. Attempts to contact the SP for an interview were made but the SP did not respond. The following observations were made during the site visit: · The facility was located in a two-level standalone building and provided care for infant through preschool aged children. On the first level of the facility was a kitchen, an office, a toddler classroom, and an infant classroom. There were two full doors that led into the infant classroom from the toddler classroom. · The infant classroom was an enclosed classroom with a countertop along one wall, a cupboard with a countertop and diaper changing area along a perpendicular wall, and a play area in the middle of the room. Along the wall with the countertop was a half door that led to a crib room. Above that countertop was an interior window into the crib room. That window was partially covered with papers and posters. Just outside the crib room was an adult chair. On the cupboard countertop there was a cordless phone. Throughout the room there were toy shelves and toys. · Inside the crib room there were five cribs and an outside window with a pull-down shade. AV2’s crib was in a corner of the crib room next to both the interior and outside windows. · On the opposite side of the classroom from the crib room there were four cribs separated from the play area by a half wall with a transparent top portion. AV1’s crib was in this area, in a corner of the room. AV1’s Registration Form stated that AV1 was five months old at the time of the incident and enrolled in the facility’s infant classroom. AV1’s Infant Questionnaire stated that AV1 slept on his/her back. AV1’s Health Care Summary dated June 23, 2025, stated that AV1 was a “healthy infant.” AV2’s Registration Form stated that AV2 was eleven months old at the time of the incident and enrolled in the facility’s infant classroom. AV2’s Infant Questionnaire stated that AV2 did not cry when going to sleep and that s/he slept on his/her back. AV2’s Health Care Summary dated February 11, 2025, stated that AV2 had zero health problems and did not have any conditions that could result in an emergency. The facility’s Child Care Center Serious Injury & Death Reporting Form dated September 19, 2025, stated that at 2:26 p.m., AV1 was taking a nap in his/her crib and began crying. The SP went to the crib to check on AV1 but AV1 started to cry harder and proceeded to throw up. At that time, AV1 was choking, turning blue, and not breathing. The SP took AV1 out of his/her crib and handed AV1 to a facility management person (P1). P1 administered hard taps on AV1’s back while the SP called 9-1-1. AV1 began to breathe on his/her own but his/her breaths were “very shallow.” AV1 threw up again. An emergency response team arrived at the facility and took over care of AV1. AV1 was transported via ambulance to a local hospital with his/her family members. The facility’s Update to Child Care Center Serious Injury and Death Reporting Form dated September 24, 2025, stated that AV1’s family member contacted a facility management person (P6) on the evening of September 19, 2025, and told P6 that AV1 was diagnosed with brief resolved unexplained event (BRUE). (According to MedlinePlus, a brief resolved unexplained event (BRUE) occurred when a young infant stopped breathing, had a change in muscle tone, turned pale or blue in color, and was unresponsive suddenly and lasted less than one minute. BRUE was diagnosed when there was no explanation for the event after a thorough health history and exam.) AV1 was released from the hospital the same day. AV1 returned to the facility on September 22, 2025. On September 22, 2025, during the “early morning,” P4 called P6 stating that AV1 was throwing up blood again. AV1’s family members were contacted and took AV1 to the local hospital. Due to the event that occurred with AV2 later on September 22, 2025 (described below), the local hospital referred AV1 to a local children’s hospital for more testing. AV1’s medical records provided the following information: · On September 19, 2025, AV1 arrived at the emergency department after an episode of apnea that lasted thirty to sixty seconds, causing AV1 to turn “blue.” AV1 vomited after the episode and had a bloody nose. At the time of arrival, AV1 was awake and presenting appropriately for his/her age. AV1 was evaluated for acute medical emergencies and was “clinically” diagnosed with no further acute medical concerns. AV1 was discharged to home with a diagnosis of BRUE. · On September 22, 2025, around 8:15 a.m., the facility informed AV1’s family members that AV1 was experiencing episodes of vomiting. AV1’s family members picked up AV1 from the facility around 8:30 a.m. and drove AV1 to a hospital emergency department. Around 10:30 a.m., AV1’s family members received information that AV2 was presenting with similar symptoms at the facility and as a result, AV1 was transferred to a children’s specialty hospital. · On September 22, 2025, a medical professional’s notes stated that AV1’s exam and laboratory reports were all normal. Possible causes of bleeding from the nose and mouth in an infant included accidental trauma, non-accidental trauma, or suffocation. Accidental trauma was “unusual” for a non-ambulatory infant such as AV1. An exam on September 22, 2025, was negative for traumatic injuries, but the presence of superficial injuries to AV1 on September 19, 2025, were not ruled out because these injuries can heal quickly. In summary, AV1’s apnea and bleeding on September 19, 2025, and recurrence of bloody emesis on September 22, 2025, were considered “highly concerning for inflicted injury or non-accidental trauma.” The facility’s Child Care Center Serious Injury & Death Reporting Form dated September 22, 2025, stated that AV2 was in his/her crib taking a nap, and fell asleep at 9:40 a.m. P1 sat in the chair outside the crib room feeding a bottle to another child while AV2 was sleeping in the crib room. At 10:08 a.m., the SP told P1 that AV2 was crying and asked P1 to check on AV2. P1 looked into the crib room and saw AV2 on his/her stomach with blood on his/her crib sheet and a “white substance” coming out of his/her nose and mouth. At that time, AV2 was “unresponsive and floppy.” The SP called 9-1-1 and P2 and P3 entered the infant classroom. P3 grabbed AV2 and began cardiopulmonary resuscitation (CPR). P4 entered the room and took over CPR measures until an emergency response team arrived and took over care of AV2. An automated external defibrillator (AED) was used on AV2 for several minutes before s/he was transported to a local hospital with his/her family member.
· On September 22, 2025, at approximately 10:10 a.m., law enforcement officers received a call stating that a child, identified as AV2, was at the facility and not breathing. Paramedics responded but lifesaving efforts were unsuccessful and AV2 was later pronounced dead. Law enforcement initiated an investigation. · An autopsy was performed on AV2. The official autopsy report was not yet available as of the date of this report. However, the medical professional who performed the autopsy told law enforcement that s/he “did not find anything immediately apparent for a cause and manner of death.” · On January 13, 2026, the SP admitted to law enforcement that s/he intentionally choked AV2 by putting two fingers into AV2’s throat to “put [AV2] to sleep.” Afterward, the SP turned on music and left the crib room so AV2 could sleep. The SP later told P1 that AV2 was crying because the SP “thought” s/he heard AV2. · When asked if s/he was involved in the incidents involving AV1, the SP stated that on September 19, and again on September 22, 2025, s/he did the same thing to AV1 that s/he did to choke AV2 on September 22, but that AV1 was “fine” afterward. · The SP said that when s/he choked AV1 on September 19, 2025, P1 was sitting approximately five feet away from the SP, feeding another child in the rocking chair, but the SP had his/her back to P1. When the SP choked AV1 on September 22, 2025, P4 was changing a child’s diaper in the classroom but the SP’s back was to P4. When the SP choked AV2 on September 22, 2025, s/he was facing the door of the crib room and saw P1 come into the classroom to replace P4. · The SP said s/he did not harm any other children at the facility. Interviews conducted by law enforcement with P2, P3, P4, P5, and P7 provided the following information: · P3 stated that on the morning of September 22, 2025, s/he heard someone yell about AV2 not breathing and P3 entered the infant classroom. P1 was sitting in the chair holding AV2. P3 did a finger sweep on AV2 and “foam” was coming out of AV2’s mouth and nose. P1 handed AV2 to P3, who performed another finger sweep to try to clear any obstruction. P3 laid AV2 down and performed CPR until the emergency team arrived. P3 observed that the SP was calm during the incident while everyone else was visibly upset. · P4 stated that on September 22, 2025, s/he put AV2 in his/her crib for a nap at approximately 9:40 a.m. and that around 9:55 a.m., the SP went to check on AV2 because s/he was not asleep. P4 stated that the SP was in the crib room with AV2 for approximately five minutes before P4 left the classroom for a break. · P2 stated that his/her own child was enrolled in the infant classroom and prior to September 22, 2025, P2 did not have any concerns with P4 or the SP. On September 22, 2025, P2 heard a yell from the infant room stating that AV2 was not breathing. P2 went to the infant room and saw P1 holding AV2 and patting his/her back. · P5 and P7 worked in the toddler classroom next to the infant classroom. P5 and P7 were not in the infant classroom when the incidents occurred and did not have any information relevant to the incidents. P1 provided the following information through an interview with this investigator and through email communication with the LEO: · On September 19, 2025, P1 was working in the classroom with the SP. While the SP was putting AV1 down for a nap, P1 was sitting in a rocking chair feeding another infant, with his/her back toward the SP and AV1. P1 heard AV1 “fussing” but did not think the fussing was unusual for a sleepy infant. A few minutes passed by then the SP said that AV1 was not breathing. P1 took AV1 from the SP and noted that AV1 was breathing but the breathing was “shallow” and AV1 had mucus “tinged” with blood coming from his/her mouth. P1 held AV1 while the SP called 9-1-1, and P1 attempted to make AV1 comfortable until the paramedics arrived. · AV1 returned to the facility on the morning of Monday, September 22, 2025, and AV1’s family members said AV1 was “fine” over the weekend. · P1 was not at the facility at the time of AV1’s September 22, 2025, incident, but P6, P4 and the SP told P1 that AV1 experienced the same symptoms as s/he did on September 19, 2025. · On September 22, 2025, P1 entered the infant classroom shortly before 10 a.m. to allow P4 to take a break. P1 assumed that AV2 was sleeping because s/he was not in the play area with the other children. P1 sat in the chair directly outside of the crib room where AV2 was sleeping and fed a bottle to another child. At 10:08 a.m., the SP said that s/he heard AV2 and asked P1 to check on AV2. P1 looked into the crib room and saw that AV2’s crib had blood on the sheet and that “something was terribly wrong” with AV2. P1 stated that s/he “panicked” as s/he picked AV2 up from the crib and started screaming for help. P1 was in “shock” and could not remember how to start CPR. P1 held AV2 and called for help until P3 took AV2 and began CPR. · According to P1, the SP was trained on the facility’s policies and procedures, had a complete background study check, and completed all required training before working in the infant classroom. The SP had displayed a few incidents of insubordination toward P1 prior to the incident, but P1 used them as “teachable” moments. Prior to the incident, P1 did not have any concerns about the SP’s interactions with the children. The facility’s Risk Reduction Plan stated that children were supervised at all times when they were in the crib room. The facility’s Behavior Guidance policy stated that a staff person was prohibited from subjecting a child to corporal punishment. The facility’s personnel files showed that P1-P7 and the SP each had compliant background studies at the time of the incident. P1-P7 were each trained on first aid and CPR prior to the incident. The SP had not been employed with the facility for 90 days and therefore was not yet required to be trained in first aid or CPR at the time of the incidents. All staff persons were trained on the Reporting of Maltreatment of Minors Act prior to the incident. Court documents dated January 15, 2026, stated that the SP was charged with 2nd degree murder of AV2, 1st degree assault of AV1, and 3rd degree assault of AV1. Conclusion: A. Maltreatment: Information was consistent that on the afternoon of Friday, September 19, 2025, AV1 began to vomit a bloody substance, choke, turn blue, and experienced respiratory distress. P1 tapped on AV1’s back and the SP called 9-1-1. An emergency team responded and transported AV1 to a hospital where s/he was diagnosed with BRUE. According to documentation, that night, AV1’s family member informed P6 that AV1 was diagnosed with BRUE and was released from the hospital to return home. On Monday, September 22, 2025, AV1 returned to the facility and his/her family members said AV1 was “fine” over the weekend. Information was also consistent that shortly before 8:15 a.m. on September 22, 2025, AV1 began vomiting blood again. AV1’s family members were contacted and took AV1 to a hospital. At 10:08 a.m., while AV1 was still at the hospital, the SP asked P1 to check on AV2, who was in the crib room. P1 did so and found AV2 “unresponsive and floppy,” and saw blood on AV2’s crib sheet and a “white substance” coming out of AV2’s nose and mouth. P1 held AV2 and yelled for help while the SP called 9-1-1. P3 responded and performed CPR on AV2 until emergency responders arrived and took over care of AV2, then transported AV2 to a hospital. Tragically, lifesaving efforts were unsuccessful and AV2 was pronounced dead. Law enforcement records stated that on January 13, 2026, the SP admitted choking AV1 once on September 19, 2025, and once on September 22, 2025; and also admitted to choking AV2 on September 22, 2025, resulting in AV2’s death. The SP told law enforcement that each time, s/he placed two fingers down AV1’s or AV2’s throat. Given the SP’s statements to law enforcement and that the SP was charged with 2nd degree murder of AV2, and 1st and 3rd degree assault of AV1, there was a preponderance of the evidence that a staff person’s actions caused physical injuries to AV1 and AV2 other than by accidental means, and that there was a failure to protect AV1 and AV2 with from conditions that seriously endangered AV1’s and AV2’s physical health. It was determined that abuse and neglect 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. “Neglect” means 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. Information from P1 and facility records showed that at the time of the incident, the SP and P1 – P7 each had compliant background studies and had each completed any required training on first aid, CPR, and the Reporting of Maltreatment of Minors Act. Information from P6 (a management staff person) was not available for this investigation because P6 declined to participate in an interview. However, P1, who was a facility administrator, said s/he did not have any concerns about the SP’s interactions with children prior to the incidents. P2 also stated s/he did not have concerns about the SP. Based on the information available from these sources, there was no apparent reason for the facility to know or suspect the SP posed a risk of harm to children in care prior to the incidents. Therefore, the facility’s responsibility for the maltreatment of AV1 and AV2 was mitigated. The SP was responsible for the care of AV1 and AV2 at the time of each incident and was trained on the Reporting of Maltreatment of Minors Act. The SP admitted choking AV1 and AV2 in their cribs at the facility. The SP was responsible for maltreatment of AV1 and AV2. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Children, Youth, and Families for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate and that the facility followed their policies on hiring, supervising employees, and response to incidents of abuse and neglect. The SP and P6 no longer worked at the facility. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: The Department of Children, Youth, and Families informed the Department of Human Services, Office of Inspector General, Background Studies Division that the SP was determined responsible for maltreatment. The determination that the SP is responsible for maltreatment is subject to appeal. The Department issued a temporary immediate suspension to the facility on September 23, 2025, due to imminent risk of harm as a result of the incidents. The immediate suspension is being lifted upon the completion and issuance of this investigation memorandum. 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.
|
