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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: 1074733-CCC (Child Care Center) Investigator(s): Kim Anderson/Alice Percy Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left a classroom without the knowledge of a staff person and was found by a community person (CP) in the community building where the facility was located. Date of Incident(s): Although the incident occurred on an unknown date in July or August 2021, the incident was not reported to the Department of Human Services until October 15, 2021. 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 for this investigation was obtained remotely, including documentation from the facility; and through three interviews conducted with two facility staff persons (P1 and the SP) and an administrative staff person (P2). The AV was approximately 19 months old and enrolled in the toddler classroom at the time of the incident. The facility was located in a large community church and used various classrooms around the perimeter of the building. There were other rooms also around the perimeter that were not used by the facility and were not licensed for facility use but were used by the church. The building had a meeting room that was referred as the High Five room which was located between the preschool classroom and the kitchen. The High Five room was not typically used as a classroom and was not licensed for use by the facility. There were two exits from the High Five room. One that lead to a set of stairs and a hallway that had a door to the church sanctuary, a door to the kitchen, and a door that lead outside. The second door lead to a hallway that lead around the building to access various rooms and included a door that lead outside and a door to the preschool classroom. Down the hallway were also additional doors to the preschool room, a facility office, bathrooms, rooms not used by the facility, and the main church lobby with several additional doors leading outside. According to the Fire Marshal’s order, the doors to the High Five room were not allowed to be closed. The church frequently had community persons visiting and working in other areas of the building. P1, P2, and the SP, and the facility’s documentation provided the following information: · At the time of the incident, the toddler and preschool classrooms were being re-carpeted, so for approximately two weeks, the toddler children and the preschool children were all using the High Five room as a combined classroom. P2 stated that at the time of the incident, there were five children enrolled in the toddler class. The SP stated that at times the toddler and preschool groups were combined, but at other times the groups were separated within the classroom. P1 believed that at the time of the incident, the SP would have been responsible for supervising the toddler children while s/he was responsible for supervising the preschool children. The SP stated that at the time of the incident, s/he was responsible for supervising the toddler children. · The SP stated that on one unknown date in July or August 2021, at approximately 3 p.m., s/he was setting up the room for snack, when the CP brought the AV back to the High Five room after finding him/her in the community building. The SP was “thankful” the CP brought the AV to the room because the SP did not know that the AV had left the room. The CP did not tell nor did the SP ask where the CP found the AV. The SP was uncertain how long the AV was unsupervised in the church building, but believed it was “a short time.” P1 stated that s/he went to the bathroom and was not in the classroom when the CP returned the AV to the classroom. Another staff person came to the classroom to take P1’s place while s/he went to the bathroom, but neither P1 nor the SP recalled the name of the staff person. While s/he was in the bathroom, a community person asked P1 if s/he knew that a child “escaped” from the High Five room and that another community person returned the child to the room. · When P1 returned to the High Five room, s/he asked the SP about the incident, but P1 did not recall what the SP told him/her. P1 did not know the name of the person who found the AV. The SP did not believe that s/he told the FM or P2 about the incident and was “thankful” that the AV was safe. The SP currently believed that s/he made a mistake in not telling anyone about the incident. The SP stated that the AV was not strong enough to open the doors leading outside from the community building. P2 stated that the SP did not tell P2 about the incident until several months after the incident occurred. P2 did not know the name of the person who found the AV or where the AV was found. P2 was uncertain if the FM was told about the incident and the AV no longer attended the facility. According to the facility’s Supervision policy, the staff persons were to ensure that all of the children were within sight and hearing at all times. Facility documentation showed that P1, P2, and the SP 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. Minnesota Rules, part 9503.0155, subpart 4, item B, stated that indoor and outdoor space to be used for child care must be designated on a facility floor plan. This space must be exclusively used for child care by the center during the hours of operation. The initial application for licensure and the center’s administrative record must contain a floor plan of the center. Precise scale drawings are not required. The plan must indicate the planned use of each area. Conclusion: A. Maltreatment: On an unknown date in July or August 2021, at approximately 3 p.m., the SP was setting up the High Five room for the toddlers’ snack, when the CP brought the AV back to the room after finding him/her alone in the community building without the supervision of a staff person. The AV being in the community building without staff knowledge and unsupervised was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The SP was “thankful” the CP brought the AV to the classroom because the SP did not know that the AV had left the classroom. The CP did not tell the SP where s/he found the AV and the SP was uncertain how long the AV was unsupervised in the community building, but believed it was “a short time.” The SP did not tell the FM or P2 about the incident. Given the amount of time between when the incident occurred and when it was reported, the details of the incident were unclear, but consistent information was provided that the AV was found unsupervised in the community building. P1, who was supervising the preschool children that day, was not in the High Five room for a few minutes around the time of the incident and another staff person was responsible for supervising the preschool children while P1 was out of the classroom. Because the incident occurred several months earlier, neither P1 nor the SP recalled who the other staff person was. Neither P1 nor the SP recalled additional details about the incident. Consistent information was provided that the High Five room was not the children’s regular classroom and the room was not licensed to be used as a classroom which was a violation of Minnesota Rules, part 9503.0155, subpart 4, item B,. Being unsupervised in the community building gave the AV access to community dangers including unknown hazards 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 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 the SP received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. Although the toddler and preschool classes were combined in one room at the time of the incident, P1 and the SP provided consistent information that at the time of the incident, the SP was responsible for supervising the five toddler children, including the AV. 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 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 policies were adequate, but were not followed by the staff persons. After the incident, all of the staff persons reviewed the facility’s policies and additional training on active supervision was scheduled. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP 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 of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On September 23, 2022, the facility was issued a Correction Order for the violations 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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