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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: 807503-CCC (Child Care Center) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left a playground area of the facility and was found by a community person (CP). Date of Incident(s): July 1, 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 July 11, 2022; from documentation at the facility; and through five interviews conducted with a supervisory staff person (P1), three facility staff persons (P2, SP1, and SP2), and the AV’s family member (FM1). Phone calls made to the AV’s other family member (FM2) were not returned. According to the AV’s enrollment information, the AV was in the toddler room and was 19 months old at the time of the incident. The facility was located in a church in a primarily residential area. The church building had roads along three sides: Xerxes Avenue, a four lane road with a speed limit of 30 miles per hour, and two other roads that had two lanes of traffic. A parking lot was located on the fourth side and the parking lot surrounded three sides of the building. The playground was located on a large grass area, next to the building and parking lot. The playground was visible from the two roads of two lane traffic. The playground had a chain-link fence with a gate that had a U shaped latch that opened to a sidewalk that led to the facility. The facility had two levels and the toddler room was on the lower level. There were stairs and an elevator between the levels. SP1 and SP2 provided the following information: · On July 1, 2022, at approximately 10:35 a.m., SP1, SP2, and nine toddlers, including the AV, went out onto the playground. SP1 recalled seeing the AV playing in the sand area and SP2 recalled seeing the AV in the sunshine while in the playground. Another child (C1) arrived during that time, making it ten toddlers on the playground. SP1 spoke to C1’s family member for approximately three to five minutes. After approximately ten minutes of being outside, SP1 and SP2 had the children clean up the toys and line up at the gate to go back inside. · One of the children (C2) ran toward the furthest side of the playground so SP1 followed. Three other children (C3-C5) ran out of the gate and to the grass area next to the parking lot so SP2 followed C3-C5 and walked them back to the group still inside the gate. Once they were back with the group, SP1 and SP2 both counted nine children before walking out the gate and then again when inside the elevator on the way to the classroom. SP1 looked at an app that family members used to check children in and out of the facility and saw nine children listed for the toddler room (it was not until later on that SP1 realized that one of the children had not been checked in by his/her family member that day.) · At approximately 11:05, lunch came so SP1 and SP2 assisted the children with washing their hands. The children then sat at the table to eat. The AV was on a special diet and when SP1 saw the AV’s food, s/he realized that the AV was not in the classroom. SP1 told SP2 that the AV was not in the classroom so SP2 went and checked the bathroom and did not see the AV. SP2 then went and told P2 that the AV was missing. · When P1 walked past the toddler room, SP1 told P1 that the AV was missing. SP1 stayed in the classroom with the nine children while SP2, P1, and P2 left to look for the AV inside the facility. · SP2 stated at one point while looking around inside the building, s/he passed by the door to outside, and saw a community person (CP) at the door with the AV talking to P2. SP2 eventually brought the AV back to the toddler room. SP1 and SP2 each stated that the AV did not have injuries from the incident. P2 stated s/he was working on a computer in the school age room when SP2 came and asked P2 if s/he saw the AV because s/he was missing. P2 “immediately” stopped what s/he was doing, went up the stairs, and when s/he walked past the front door s/he saw the CP with the AV in his/her arms. P2 took the AV and asked the CP where s/he found the AV. The CP said s/he was driving when s/he saw the AV on the corner of Xerxes Avenue and West 64th Street about to walk onto Xerxes Avenue. The CP stopped his/her car and got out. Because the AV was wearing a t shirt with the facility’s name on it, the CP walked the AV to the front door. The AV was not crying and P2 did not see any injuries. Around that time, multiple staff persons saw the AV and walked over so P2 handed the AV to one of staff persons (P2 could not recall which staff person but thought it was possibly SP2). P1 provided the following information: · At approximately 11:05 a.m., P1 walked past the toddler room when SP1 said to P1 that s/he could not find the AV. P1 asked SP1 when the last time s/he saw the AV was and SP1 responded that s/he was “not sure.” P1 went to the preschool and prekindergarten rooms and told the staff persons that the AV was missing and they needed to look for him/her. P1 also looked in bathrooms, the kitchen, and walked up the stairs when s/he saw P2 coming inside the door holding the AV. The AV was smiling and did not have injuries. · P1 and P2 brought the AV to another area nearby and P2 said that the AV was left outside. P1 then went to the toddler room and told SP1 that the AV was “fine.” P1 asked SP1 how s/he left the AV outside and SP1 told P1 that s/he counted nine children when they were outside but then a tenth child showed up. Before going back inside the building, SP1 counted nine children even though it was supposed to be ten because s/he had remembered nine from the earlier count. P1 then contacted an administrative staff person and FM1. At approximately 1 p.m., FM1 called P1 and P1 told FM1 that the AV was “fine” but had been left outside. FM1 did not have concerns at that time. · At approximately 6 p.m., after P1 left the facility, a staff person (P3) called P1 about the incident and told P1 that the AV was found near Xerxes Avenue by the CP, which P1 had not previously been aware of. Around that time, P1 spoke to FM1 and said s/he was looking into the additional information. P1 then called P2 who provided P1 with the same information as s/he did this investigator. P1 spoke to SP1 and SP2 to get additional information and SP1 and SP2 were not able to tell P1 when the last time they saw the AV prior to the incident. The facility had a front door camera that took photos when a person rang the doorbell. Photos provided from the facility of the front door camera showed the following from July 1, 2022: · At 10:54 a.m., SP1 and some of the children were entering the front door. According to P1, this was when SP1, SP2, and the nine toddlers came inside the facility from the playground. · At 11:16 a.m., a person P1 identified at the CP was holding the AV. FM1 said s/he was concerned because initially P1 did not tell FM1 that the AV was found near a busy street by the CP. P1 was also not able to tell FM1 how long the AV was alone outside for. According to the on the facility’s Risk Reduction Plan: · When transitioning from inside to outside, staff persons lined up and counted children prior to leaving the room. The second staff person checked the room once the children were all out. Children were counted again while outside and then again once at the destination. This process was repeated upon returning. · The facility was in a residential area near a “busy” roads. Children were not allowed near the busy roads without adult supervision and children were not allowed out of sight when outside. Facility documentation showed that staff persons, SP1 and SP2, were trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rules and Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, stated that a child must have supervision at all times and that supervision was 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: Consistent information was provided that on July 1, 2022, the AV was left outside unsupervised without staff persons knowledge, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV was found by the CP at the corner of Xerxes Avenue and West 64th Street about to walk onto Xerxes Avenue. The CP stopped his/her car and returned the AV to the facility. The AV, who was 19 months old, was left outside without the knowledge or supervision of a staff persons for approximately 22 minutes and was exposed to community dangers, including busy roads and community persons. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health when reasonable able to do so. It was determined that neglect occurred (Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).
B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), 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 were trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. SP1 and SP2 were each responsible for the care and supervision of the AV at the time of the incident and each were aware that a tenth child had arrived yet they counted nine children. SP1 and SP2 were each 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 SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the AV 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 and followed. The facility implemented a physical check system where staff persons used a class list that checked all children as they left and entered the building. The staff persons involved also received additional training in active supervision and transition. SP1 and SP2 received one week nonpaid time off from the facility. 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 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 the disqualification of SP1 and SP2. The determination that SP1 and SP2 were responsible for maltreatment is subject to appeal. On August 5, 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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