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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: 1056006-CCC (Child Care Center) Investigator(s): Alice Percy Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised in a public park. The staff persons were not aware that the AV was missing until a community person (CP) told them that a child was left at the park. Date of Incident(s): June 17, 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 June 28, 2022; from documentation at the facility; and through six interviews conducted with three facility staff persons (SP1 – SP3), an administrative staff person (P), the CP, and the AV’s family member (FM). The AV was four years old and enrolled in the PreK classroom at the time of the incident. The facility was located in a commercial area on the corner of a four lane divided highway with a speed limit of 50 and a two-lane street. The facility shared a large parking lot with four other commercial businesses. Two of the businesses were located next to the facility on the divided highway. Directly across the parking lot from the facility was the Brown County license bureau which was on the corner of two, two-lane streets. Sidewalks were along the two-lane streets that the facility and the license bureau were located. Across a two lane street from the license bureau was a public park (North Park). North Park was used by the facility as the playground and was a large open area approximately a block from the facility. In order to reach the park from the facility, it was necessary to cross the parking lot and then a two-lane street. There were no fences around the park. A splash pad was located in the corner of the park nearest the facility. There were several benches and a small covered area containing several picnic tables near the splash pad. It was possible to see the facility from the splash pad area. A playground area was located next to the splash pad and there were several trees along two sides of the area near the splash pad. A grassy area under some of the trees extended down a small hill to the rest of the park that included baseball fields. Two-lane streets ran along all four sides of the park. A residential area was located across the street from the side of the park nearest the splash pad and there were several businesses across the street from the park on the remaining three sides. The CP provided the following information: · On June 17, 2022, at approximately 11:30 a.m., s/he and his/her family were at North Park at the splash pad when s/he observed the AV sitting alone on a bench near the splash pad. Because of the AV’s young age, the CP “kept an eye on” the AV. While the CP was sitting near the splash pad, the AV approached the CP and sat next to him/her. The AV told the CP that s/he was going to have a party for his/her birthday. The CP asked the AV if s/he was at the park with his/her family members, but the AV told the CP that they were at work. The CP asked the AV if s/he was at the park with a childcare center. The AV looked in the direction of the facility and the CP asked if s/he attended the facility. The AV said s/he did and told the CP his/her first name. · The CP asked several other adults near the splash pad if the AV was with them, but they said s/he was not. The CP then telephoned the facility and asked if a child by the AV’s name attended the center. The staff person who answered the telephone said that s/he “was looking at” a child with that name. The CP told the staff person that s/he found a child at the park who s/he believed attended the facility. The staff person checked with the other staff persons and told the CP that a staff person come to the park to get the AV. When the staff person arrived at the park, s/he hugged the AV and told the AV that s/he was glad the AV was okay. The staff person walked the AV back to the facility. The CP believed the AV was unsupervised at the park for approximately 20 to 30 minutes. The CP did not know the names of any of the staff persons. The FM stated that the staff persons told him/her about the incident. The FM believed that the staff persons “noticed right away” that the AV was not with the group as they walked from the park to the facility. The AV told the FM that s/he was playing “hide and seek” and did not realize that the staff persons and the other children left the park. SP1, SP2, SP3, and the P, and the facility’s documentation provided the following information: · On June 17, 2022, at approximately 9:30 a.m., SP1, SP2, and SP3 took a group of 24 children to North Park. The children played near the splash pad and on the grassy area under some trees. SP2 stated that s/he supervised the children on the grassy area at the top of the hill while they were at the park. There were other community children and adults using the park at the same time as the children from the facility. While they were at the park, another child who was enrolled at the facility was dropped off at the park by a family member. That child typically was not dropped off that early. At approximately 11:30 a.m., SP1 told the children to line up on the sidewalk near the splash pad prior to walking back to the facility. SP2 and SP3 each remembered seeing the AV playing on the grassy area prior to the group lining up to return to the facility. · SP1 stated that after the children lined up, s/he counted 24 children. SP1 stated that s/he “totally forgot” that the other child had joined the group after they arrived at the park. SP1 told SP3 to lead the group back to the facility, while SP1 walked in the middle of the group and SP2 walked at the end of the line and pulled the wagon containing water and supplies. SP2 stated that s/he did not count the children as they lined up because s/he was “focused” on a child who frequently ran away from the group. SP1 believed that it took approximately four to five minutes to line the children up and begin to walk back to the facility. · As the group reached the sidewalk at the edge of the facility’s parking lot, the P walked out of the facility and yelled the AV’s name. SP1 looked for the AV and determined that the AV was not with the group. SP1 stated that s/he “assumed” the AV was still at the park and ran back to the park, where s/he found the AV talking to the CP at the covered picnic table area near the trees. SP1 thanked the CP and walked back to the facility and joined the rest of the group inside the facility. SP1 asked the AV if s/he heard SP1 tell the group to line up and the AV told SP1 that s/he heard SP1, but that the AV was playing hide and seek. The AV told SP1 that it was a “crazy day.” · SP1 stated that it typically took four or five minutes to get the children lined up to walk back to the facility. SP1 believed the AV was unsupervised for approximately 15 minutes. SP2 stated that it typically took several minutes to get the group lined up and ready to walk back to the facility. SP2 believed that the AV was unsupervised for approximately 10 minutes. SP3 stated that it typically took five to ten minutes to get the children lined up and another 10 minutes to walk to the facility’s parking lot. SP3 believed that the AV was unsupervised for 15 to 20 minutes. · After the incident, the staff persons began to use “name to face” counting instead of only counting the number of children present. None of the staff persons recalled any previous similar incidents. The AV typically listened to the staff persons’ instructions and did not leave the group. According to the facility’s Employee Handbook, each child was to be supervised at all times and no child was to be left unsupervised. While on the playground, the staff persons were to spread out around the area so that all areas were supervised. According to the facility’s Risk Reduction Plan, when at the park’s playground, the staff persons were to “circle the park, keep count of children, [and] supervise children while using the bathroom.” The staff persons were not to leave children unsupervised and were to count the children when going to and from any area. Facility documentation showed that SP1, SP2, SP3, and the P each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident.
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 from all sources was consistent that on June 17, 2022, SP1, SP2, and SP3 took 24 children to the park. While they were there, another child was dropped off at the park and joined their group. When it was time to return to the facility, SP1, SP2, and SP3 lined up the children. SP1 counted 24 children and they then walked back to the facility. As the group neared the facility, the CP telephoned the facility and told the P that the AV was unsupervised at the park and was with the CP. The P went outside and called the AV’s name to the group, which was located at the sidewalk at the edge of the parking lot. SP1 looked for the AV, but did not see him/her, so s/he returned to the park, found the AV with the CP, and then returned to the facility with the AV. It was likely that the AV was unsupervised between 10 to 30 minutes. Leaving the AV unsupervised at a community park is 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. Being unsupervised on the unfenced park playground gave the AV access to community dangers including unknown community persons, parking lots, businesses, and streets. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV’s 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 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. Facility documentation showed that SP1, SP2, and SP3 received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies including the supervision policy prior to the incident. At the time of the incident, SP1, SP2, and SP3 were responsible for the supervision of the children at the park, including the AV. SP1, SP2, and SP3 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, SP2, and SP3 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not sustain an injury that required the care of a physician. 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 the facility’s polices were adequate, but were not followed by the staff persons. After the incident, SP1 – SP3 each received re-training on the facility’s policies and Risk Reduction Plan. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, each was 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 SP1, SP2, or SP3. The determination that SP1, SP2, and SP3 were responsible for maltreatment is subject to appeal. On August 17, 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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