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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: 1047403-CCC (Child Care Center) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left alone on a playground. Date of Incident(s): August 9, 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 August 19, 2022; from documentation at the facility; and through four interviews conducted with a supervisory staff person (P1), two facility staff persons (P2 and the SP), and the AV’s family member (AV). According to the AV’s enrollment information, the AV was 21 months old and in the toddler room at the time of the incident. The facility had an outside playground that was accessible to the toddler room by a glass door. The playground was enclosed by vertical metal fencing that persons were able to see through. There were businesses, roads, and fields surrounding the facility and the playground was visible from the parking lot and roads. Inside the toddler classroom was another door that opened into a hallway with cubbies. Down the hallway and around a corner was an open entrance with a baby gate that went into a large motor room that was located in the center of the facility. The main entrance into the facility was on the opposite side of the large motor room from the open entrance with the baby gate. Consistent information was provided that on August 9, 2022, P2, the SP, and another staff person (P3) worked in the toddler classroom. At approximately 4 or 4:30 p.m., the SP and P3 brought some of the toddler children, including the AV, outside while P2 stayed inside the large motor room with other toddler children. Once there were seven children left on the playground, P3 left for the day, leaving the SP on the playground with the seven children. At this same time, P2 had approximately five or six toddlers in the large motor room. At some point, the SP took the children from the playground inside to the large motor room. The FM provided the following information: · On August 9, 2022, at approximately 4:30 p.m., the FM arrived at the facility to pick up the AV and saw the AV outside alone on the playground. The FM went inside the facility to the large motor room where the FM saw that P2 was with the toddlers. · P2 greeted the FM and called the AV’s name. When the AV did not respond, P2 became concerned. When the SP walked into the large motor room, P2 asked the SP where the AV was. P2 and the SP both looked around while the FM walked to the toddler room. · The FM walked into the toddler room and saw P1 speaking to a family member of another child. The FM walked through the classroom and to the door that led to the playground. The AV was standing on the outside of the door looking in and was crying. The FM opened the door, got the AV, and left the facility. There was no injuries to the AV. P2 stated that on the day of the incident, at approximately 4:30 or 5 p.m., s/he was in the large motor room with approximately five or six children, when the SP brought approximately six toddlers into the large motor room from outside. P2 was standing by the baby gate and saw the FM come in the front door. P2 then looked around the large motor room for the AV but did not see the AV. P2 looked at the SP, who was standing on the other side of the baby gate with two children in his/her arms, and asked, “Where is [the AV]?” The SP looked at P2 and said, “What do you mean?” P2 told the SP that s/he did not see the AV in the large motor room. The SP stood there “for a couple seconds” while the FM looked “concerned.” The FM and the SP then walked into the toddler room. A little while later, the FM walked out with the AV. P2 apologized and the FM did not respond. P2 stated it was approximately 30 seconds from when the SP came inside with the toddlers to when the FM walked inside. P2 stated the SP should have counted the children at the door from the playground to the toddler room, at the door from the toddler room to the hallway, and then from the hallway into the large motor area. The SP provided the following information: · On the day of the incident, at approximately 4 or 4:30 p.m., the SP was outside on the playground with six children, including the AV. After being outside for approximately 20 minutes, the SP told the toddlers to clean up toys and then line up at the door to the toddler room. There was a new child who had a hard time “keeping up” with the other toddlers so the SP picked up the child to carry him/her inside. The SP started counting the children when lined up and the opened the door to the toddler room. The SP was unsure if s/he finished counting the children because s/he “panicked” when the children started running across the toddler room. · The SP asked the children to wait and the SP “glanced” behind him/herself to the playground and did not see any other children before s/he let go of the door so it would close. The SP walked with the toddlers into the hallway to the baby gate to the large motor room and handed the child in the SP’s arms over the gate to P2. The SP then started counting the toddlers again. As a few of the toddlers ran around the hallway, the SP went to them and brought them to the gate while still counting. The SP had counted five children, when P2 asked the SP where the AV was. The SP then realized the AV was missing so s/he went and checked at the cubby area down the hallway where the AV sometimes sat. But the AV was not there. The SP then went into the toddler room and saw the AV outside looking in through the glass door. · When this investigator asked about realizing the AV was missing when the FM came into the large motor room, the SP stated that was possible. The SP remembered being “panicked” and P2 asking where the AV was. The SP did not notice the FM until s/he walked into the toddler room and saw the AV standing outside alone looking in the door from the playground. The AV was alone outside for less than 30 seconds and did not have any injuries. P1 stated s/he was in the toddler room talking to a family member of another child when the SP and approximately five toddlers came inside from the playground. The SP carried one child, braced open the door from the playground so the other children could walk inside, and then the SP and the children walked into the hallway to go to the large motor area. P1 did not recall if the door from the toddler room to the hallway was open or closed when the SP came inside from the playground. P1 stated that it was less than a minute when P1 saw the FM and the SP walk back into the toddler room at the same time. The SP said s/he “missed” a child and P1 looked and saw the AV standing outside the door on the playground. According to the facility’s Safety Manual, staff persons “never” left children alone. Staff persons counted children when moving from room to room or from outside to inside. Facility documentation showed that staff persons, including the SP, were trained on the facility’s Safety Manual 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 August 9, 2022, the AV was left outside 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. Although the SP provided information that s/he realized the AV was missing when s/he counted the children when entering the large motor room, s/he also stated it was possible that s/he realized the AV was missing when the FM came into the large motor room and P2 asked where the AV was. Given that the AV, who was 21 months old, was left outside without the knowledge or supervision of a staff persons for approximately 30 seconds to one minute and was exposed to community dangers, including businesses, roads, and community persons, 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. Although P2 was working in the toddler room at the time of the incident, consistent information was provided that s/he was not outside on the playground with the AV at the time of the incident. Therefore, P2’s responsibility for the maltreatment was mitigated. The SP was trained on the facility’s Safety Manual and the Reporting of Maltreatment of Minors Act. The SP was responsible for the care and supervision of the AV at the time of the incident and left the AV on the playground. 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 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. The SP did not count the children when s/he left the playground and entered the toddler room. P1 verbally coached the SP after the incident and the SP no longer worked at the facility. 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 28, 2022, the facility was issued a Correction Order for the violations outlined in this report, not completing an incident report, and for failing to maintain staff to child ratios. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal. 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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