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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: 1109140-CCC (Child Care Center) Investigator(s): Kim Anderson/Hareen Lankford 651-431-6553 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised outside on the playground for one to two minutes. Date of Incident(s): January 18, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. Summary of Findings: Pertinent information was obtained during a site visit conducted on February 10, 2022; from documentation at the facility; and through four interviews conducted with one facility staff person (SP), two administrative facility staff persons (P1 and P2), and one family member (FM). An interview was offered to the AV, but due to his/her age, no interview was conducted. The playground was surrounded by a chain-linked fence with a gate, near the facility parking lot. The preschool classroom was located on the opposite side of the building from the playground, but had a half door which led to another preschool classroom. The other preschool classroom had a door that led out to the playground and large windows where a portion of the playground could be viewed. According to www.accuweater.com, the temperature outside on January 18, 2022, was 11 degrees Fahrenheit with flurries. The AV was dressed in winter gear. The AV was 2 years and 11 months old on the day of the incident. The FM provided the following information: · The FM arrived at the facility to pick up the AV around 4 p.m. and as the FM parked his/her vehicle, s/he noticed the AV standing outside looking through the chain fence. The FM approached the fence, looked around and did not see any staff or other children outside. The AV told the FM to “bring me inside.” · The FM walked to a playground door, got the AV and carried the AV inside. The FM did not ask the AV about how long s/he was outside but the FM said when s/he brought the AV back inside, the other children were still taking off their snow “gear,” so the FM did not think the AV had been outside very long. · The SP saw the FM bring the AV in from outside. The SP said “sorry about that” and then the SP “moved on.” · As the FM left the building, none of the staff said anything to him/her about the incident. · Later that evening, at home, the AV said a “couple of times,” “I was left outside.” · The FM discussed the incident at home with another family member and then spoke to facility management. The FM was told that changes would be put in place to prevent that from happening again, but the FM said because none of the staff at the facility talked to him/her about the incident, the FM made the decision to disenroll the AV from the facility. The SP provided the following information: · The regular classroom teacher was out that day and another aide came to work from 3 to 6 p.m. Around 3:30 p.m. there were seven children left and the SP and the other aide took the children outside. · The SP told the other aide to go inside and clean the classroom, and around 4:15-4:20 p.m. P1 had come outside to pick up his/her child from the playground. At that time there were three children left. · The three children that were left were siblings. The SP thought P1 had brought all of the children inside, because when P1 opened the door all of the children ran inside. Seeing all of the children run inside, the SP ran in after them leaving a backpack with the “name to face” sheet inside out on the playground. · At that time, the SP saw a family member of the siblings and began to talk to that family member for about two minutes and then realized one of the other children was missing. At that time the SP could see through the window and saw the FM go towards a door leading to the playground and not towards the door leading to the classroom. The SP then saw the AV outside with the FM. · The SP told P1 what happened. P1 told the SP not to say anything until P1 talked to P1’s supervisor and P1 did not want to make a big deal of the situation. · The SP had the “name to face” sheet outside but did not bring it back inside as it was in the backpack s/he left outside on the playground. The SP stated that s/he was trained on the policies for supervision but was “caught up in so many other things” and knew to count the children before going outside. P1 provided the following information: · The SP had six children and was outside on the playground alone. · P1 had “clocked out” for the day when s/he brought his/her child in from the playground, and at that time the SP was “rounding up” the other children to bring them in. · When P1 was in the classroom removing his/her child’s snow gear, s/he looked over and the FM was there also removing the AV’s snow gear. During that time, P1 had a conversation about the weather with the FM. The FM did not say anything about what had happened. P1 said pick-up time seemed “normal.” After the FM left the classroom, the SP came to P1 and whispered “I left [the AV] outside on the playground.” · The SP told P1 that s/he did not do a “name to face” count when s/he lined up the children to go back inside. P1 said s/he “figured” the SP had not done a “name to face” count since s/he left a child outside on the playground. · P1 stated that there were transition boxes on the “name to face” sheets which were used to document the starting number of children and the ending number of children. The staff persons said a “kid’s” name and the “kid” answered and “name to face” counts were done every half hour. When the class went outside, the staff were supposed to do a “name to face” count before they left the room and when they arrived on the playground. Coming in, the staff persons lined the children up, did the “name to face” count, went inside and did another “name to face” count in the room. The boxes for the day of the incident were not filled out. So the SP did not do the “name to face” count. “It was no longer than a minute or two that [the AV] was outside.” · The SP had worked at the facility since July 2021 and had been trained on the “name to face” count. · The AV “seemed” fine when s/he came inside. The AV had all of his/her “winter gear” on. P2 stated that the SP did not “follow through” on doing “head count” sheets, and left the AV outside for a “brief period of time.” The FM “got” the AV from outside. P1 was off the clock and getting his/her child ready to go home. The SP was working alone because s/he had ten children. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, state that a child must have supervision at all times and that supervision is defined as occurring when a program staff person is within sight and hearing of a child at all times so that the program staff person can intervene to protect the health and safety of the child. Conclusion: A. Maltreatment: Information was consistent that on January 18, 2022, approximately between 4 and 4:30 p.m., the SP left the AV outside on the playground alone without supervision for about one to two minutes was 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 procedures; and a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the temperature was 11 degrees Fahrenheit on that day, the AV was dressed in winter gear and did not sustain injury. As the FM arrived at the facility to pick up the AV, the FM saw through the fence, standing alone. The FM brought the AV inside the facility, when the SP said “sorry about that.” The SP told P1 that s/he had left the AV and the “name to face” sheet outside on the playground. The SP had been outside with six children. At the time the SP went back inside the facility, s/he believed s/he only had three children. P1 stated the SP had been with the facility since June and had been trained on the policies and procedures for supervision, including the “name to face” sheet. Given that the SP did not follow the facility’s policy and procedures for supervision, and the AV was therefore unsupervised on the playground in 11 degree weather with access to community persons and/or a nearby parking lot, there was a preponderance of the evidence that there was a failure to provide supervision for the AV. It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), 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. Given that the SP was trained on the Risk Reduction Plan and the facility’s policies and procedure for supervision, the SP 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 neglect for which the SP was responsible in this report did not meet statutory criteria to be determined as recurring because it was a single event and it was not serious because the AV did not require medical care. However, information maintained by the Department of Human Services, in combination with this report, resulted in the SP being disqualified for recurring maltreatment. The SP was disqualified from providing direct contact services. 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 conducted an internal review and determined that their policies and procedures were adequate but not followed. The SP did not complete the “name to face” count prior to leaving the playground. All staff were retrained on the policies and procedures regarding supervision, including the Risk Reduction Plan. Classrooms are now required to have two staff when outside on the playground. The SP was no longer employed at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from 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. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. On June 29, 2022, the facility was issued a Correction Order for the violation outlined in this report. 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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