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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: 1035820-CCC (Child Care Center) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left alone on the playground without the knowledge or supervision of staff persons and was discovered by a community person. Date of Incident(s): July 5, 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 27, 2022; from documentation at the facility and law enforcement records; and through six interviews conducted with a community person (CP), a supervisory staff person (P), three facility staff persons (SP1-SP3), and the AV’s family member (FM). According to the AV’s enrollment information, the AV was 22 months old and in the younger toddler room. Behind the facility was a playground that was enclosed by a chain link fence. The fence had a gate with a u shaped latch on the same side as the facility. There was a sidewalk between the gate and the door leading into the facility. There was a parking lot, open grass areas, businesses, a two lane highway with a speed limit of 50 miles per hour, and multiple train tracks near the facility. Consistent information was provided that on the day of the incident, there was water damage to the young preschool room so the young preschool and toddler rooms were combined. [Note: The facility had a variance approved by the Department of Human Services, Division of Licensing, Child Care Unit to operate as such.] SP1 and SP2 were the toddler staff and SP3 was the young preschool staff. According to the Daily Attendance Chart, on July 5, 2022, at the time of the incident there were four toddler children including the AV and five young preschool children, totaling nine children. According the law enforcement report: · On July 5, 2022, at 10:43 a.m., the CP saw the AV outside alone. The CP said that s/he called the P and let him/her know that the AV was alone outside prior to calling law enforcement. The CP described the AV and said that the child was approximately two to three years old and possibly in the same room as the CP’s child. The CP was not able to say how long the AV had been outside alone. · Law enforcement went to the facility and met with the P. The P told law enforcement that s/he received a call from the CP so s/he knew which child law enforcement was referring to. The AV was brought to the law enforcement officer and s/he saw the AV did not have injuries and was “not in distress.” The P stated that the children had gone outside at 9:20 a.m. and returned inside at 10:18 a.m. The CP stated on the day of the incident, at approximately 10 a.m., s/he saw a small child (later determined to be the AV) standing inside the fenced in playground at the gate. The CP looked around and did not see staff persons outside so called the facility. The P answered the phone and the CP told the P about the child outside alone. The P was not aware there was a child left alone. The CP stated that it was approximately five minutes from the time s/he saw the AV alone at the gate until the P went outside to him/her. The P provided the following information: · During the morning the day of the incident at 10:21 a.m., the CP called the facility and asked the P if s/he was aware there was a child left alone on the playground. The P responded that s/he was not aware and would go check “right away.” The P immediately hung up the phone and went to the playground and saw the AV standing inside the playground with the gate open and looking “confused.” The AV did not have any injuries. · The P brought the AV inside the facility and left the AV with another supervisory staff person while the P went to the classroom. The P asked SP1-SP3, who were assisting the children with taking off their shoes, if they had all their children, and they all responded, “Yes.” The P then asked a second time and asked them to check the daily attendance sheet. Then SP1-SP3 realized the AV was not in the room. The P reminded SP1-SP3 that they were to count the children before, during, and after transitions inside and outside. SP1-SP3 said that they came inside at approximately 10:17 a.m. and because the CP called at 10:20 a.m., the P thought the AV was alone outside for approximately three minutes. The P then left the AV in the classroom and went to call the FM. SP1-SP3 provided the following information: · SP1-SP3 were outside on the playground and had the children including the AV lined up at the gate door to go inside the facility. SP2 was at the front of the line, SP3 was in the middle of the line, and SP1 was at the back of the line. · SP2 stated the last time s/he saw the AV was when they were lined up by the door to go into the facility but s/he did not remember specifically where in line the AV was. SP2 did not recall if s/he said the number of children out loud when counting them. SP1 recalled holding the AV’s hand while s/he standing in line but then let go of the AV’s hand to close the gate. SP3 was not able to provide information as to when s/he remembered last seeing the AV. · SP1 counted nine children when s/he left the gate and nine children when walking in the door to the facility. SP2 counted eight children when leaving the gate but did not count the children once inside the room because it was a “messed up day” having the rooms combined. SP3 counted the children when lined up at the gate but did not recall how many children were on the playground. SP3 saw the young preschool children in front of him/her when walking into the building. SP3 counted the young preschool children (SP3 did not recall how many children s/he counted) and heard SP1 and SP2 count all the children out loud in the hallway. SP2 did not recall if staff persons discussed the amount of children they counted at that time. · SP1 and SP3 stated approximately two to three minutes after returning inside, while the children were taking off their shoes, the P came into the room and asked if SP1-SP3 had all their children and all three responded, “Yes.” The P told SP1-SP3 to do a head count and when they did, they realized that a child was missing. They looked at the daily attendance chart and determined the AV was missing. The P left and then returned with the AV to the room and SP1-SP3 stated that the AV did not have any injuries. · SP2 provided conflicting information regarding the incident. SP2 initially stated that once inside the facility, the children sat down and SP2 counted seven children and realized that the AV was missing. SP2 told SP1 and SP3 that the AV was missing and SP2 went out to the playground and got the AV. However, when this investigator told SP2 that there was information that the P went outside and got the AV, SP2 stated that the P had found the AV and brought him/her to the toddler room and that was when SP2 realized that the AV had been missing. · SP1-SP3 each stated that staff persons were trained to count twice, when leaving a location and when arriving at a location. The FM was aware of the allegations and said the incident could have been avoided if staff persons counted the children. The FM did not have concerns with the facility. According to the facility’s Risk Reduction Plan, the facility was located near a “busy road.” The facility had a “large” playground near the north of the building that was fenced in by a four foot high fence and had a gate entrance. Staff persons “rotate[d] around” to make sure they saw children “at all times.” When transitioning from one area to another, the children formed a line. One staff was at the front of the line and one staff was at the back of the line. Staff persons counted the number of children transitioning to ensure all children were present. Facility documentation showed that staff persons, including SP1-SP3, were each 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: Although there was different information from staff persons and the attendance chart how many children were on the playground with SP1-SP3, consistent information was provided that on July 5, 2022, after the classroom returned inside from the playground, the AV was left outside unsupervised without staff persons knowledge or supervision, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The CP saw the AV alone on the playground and called the P to notify him/her. The AV, who was 22 months old, was left outside without the knowledge or supervision of a staff persons for between two and five minutes and was exposed to community dangers, including a parking lot, a highway, 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-SP3 were trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. On the day of the incident, the two classrooms were combined so SP1-SP3 were each responsible for the care and supervision of all the children including the AV at the time of the incident. SP1-SP3 provided different information regarding how many children were present and at what point each counted children, yet each failed to realize the AV was missing until notified by the P. SP1-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-SP3 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 but not followed since staff persons did not count the children before, during, and after they left and entered a location. This policy was put into writing for staff persons to reference. The staff persons involved attended an active supervision training. Action Taken by Department of Human Services, Office of Inspector General: SP1-SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1-SP3 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-SP3. The determination that SP1-SP3 were responsible for maltreatment is subject to appeal. On September 14, 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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