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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: 1110695-CCC (Child Care Center) Investigator(s): Rebecca Mesto Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left alone in the facility’s restroom while the other children and staff persons went outside. The AV was found by a community person (CP). Date of Incident(s): July 27, 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 September 8, 2022; from documentation at the facility; and through six interviews conducted with the CP, three facility staff persons (P1, SP1, and SP3), an administrative staff person (P2), and a family member (FM) of the AV. This investigator met and talked with the AV, but s/he did not supply any information pertaining to this investigation. This investigator left messages for, and sent letters to, another staff person (SP2) requesting an interview, but no response was received. The AV was three years old and was enrolled in the facility’s preschool room. The facility was located in a community building that was previously a public school. The facility utilized two rooms (preschool and prekindergarten) as classrooms, as well as a gym. The main entrance to the building opened to a hallway. On the left side of the hallway was the preschool room, prekindergarten room, a city office, a kitchen, and the gym. On the right were two rooms utilized by the fire department, a storage room, and two restrooms. The restroom closest to the classrooms (involved in this incident) was across from the kitchen. The facility had a playground located outside of the building. To get to the playground from the preschool and prekindergarten rooms, persons would have to go into the hallway and out the main entrance. The facility was not locked and open to the public and the hallway and restrooms were accessible to the public. The CP provided the following information: · The CP worked in the city office, which was located down the hallway from the classrooms and across from the restroom. · On the day of the incident, the CP was sitting in his/her office and heard a child (the AV) “faintly” crying and yelling for help. After one to three minutes, the CP left his/her office and walked closer to the restroom. The CP peeked into the restroom and saw that there were no staff persons with the AV. The CP heard children in the gym and went into the gym and told an unknown staff person (P1) that there was a child in the restroom that needed help. P1 then followed the CP down the hallway towards the restroom and P1 attended to the AV while the CP went back to the office. · There were no staff persons within sight of the AV, and because of the level of noise the children in the gym were making, any staff persons in the gym would not have been able to hear the AV. P1 provided the following information: · At the time of the incident, P1 was with a group of eight children in the gym when the CP came to the door of the gym and told him/her that there was a child in the restroom who was crying. P1 then brought the eight children from the gym to the restroom and found the AV in the restroom. The AV said that s/he needed help “wiping.” P1 assisted the AV and comforted him/her. Then P1 (and the children) brought the AV outside to the playground where SP2 and SP3 were monitoring the rest of the preschool children and P1 told them that the AV had been in the restroom by him/herself. SP2 and SP3 were both “confused.” The AV went back to his/her typical “happy” self. Then P1 sent SP1 a message regarding the incident and SP1 messaged P1 back, “apologizing.” · After the incident, P1 talked to SP1, who said that prior to leaving on break, s/he had taken two children, the AV and another child (C), to the restroom. When the C was finished, SP1 brought the C back to the group and SP3 came to give him/her a break. SP1 told P1 that s/he “completely forgot” that the AV was still in the restroom and did not tell SP3. · The facility had an app that was used to take attendance of the children. Typically, staff persons counted the children during transitions. Children were to be supervised while in the restroom and were never to be unsupervised. · P1 did not have any concerns with how staff persons supervised children. P2 stated that s/he was not at the facility at the time of the incident, but talked to staff persons afterwards. Prior to going outside, staff persons did not count the children as required. Staff persons were to count the children during transitions and children were to be supervised within sight and hearing. SP1 provided the following information: · On the day of the incident, SP1 and SP2 were supervising a group of children in the preschool room. The AV and the C needed to use the restroom, so SP1 told SP2 that s/he was going to take them to the restroom. Around that same time, SP3 came into the preschool room so SP1 could go on a break. SP1 told SP2 that s/he also needed to talk to P1 in the gym, but would come back into the room to help take the children outside to the playground. SP1 then brought the AV and the C to the restroom. While they were using the restroom, SP1 walked across the hallway and stood in the doorway to the gym and talked to P1. The C walked out of the restroom to the preschool room and then SP1 went into the preschool classroom and saw that SP2 and SP3 were getting the children ready to go outside. SP1 was going to count the children, but s/he did not have the opportunity to do so because some children were already starting to go outside. SP1 did not communicate with SP2 or SP3 regarding where the C or the AV were. SP2 or SP3 did not count the children. SP1 went on his/her break.
· When SP1 was on break, s/he received a text message from P1, letting him/her know that the AV was in the restroom alone. The AV typically did not require assistance in the restroom. · Prior to the incident, staff persons “occasionally” watched children walk to and/or from the restroom to the classrooms, particularly if there was only one staff person in the classroom when a child had to use the restroom. SP1 also stated that children were never to be unsupervised and always were to be within sight and sound of a staff person. Staff persons were to count children before and after transitions. After the incident, the facility created an attendance log to track when children were leaving the classroom with staff persons. · SP1 estimated that the AV was in the restroom alone for two to three minutes, and was within hearing distance of the gym. The hallway and restroom was shared by other entities in the building. · SP1 did not have concerns with how SP3 supervised children but had concerns that SP1 did not pay attention to the children and was sometimes on his/her phone while working. SP3 provided the following information: · On the day of the incident, when SP3 arrived at the facility at 10:30 a.m., s/he went into the preschool room. SP2 told SP3 that SP1 was in the restroom with the AV and the C. SP2 and SP3 took the children outside to the playground and when they were outside, P1 came out and said that the AV had been in the restroom alone. SP3 was unsure when the C joined their group, but recalled seeing him/her outside. SP3 was unsure why neither s/he nor SP2 took attendance of the children before going outside because they typically did so. · After the incident, SP1 told SP3 that s/he watched the C walk back to the classroom but “spaced out” where the AV was when s/he went on break. · Prior to the incident, SP3 and other staff persons thought it was “okay,” if they were single staffed, to have children walk to the restroom by themselves if a staff person watched them from the doorway of the classroom. The hallway and restrooms were “very rarely” used by community persons, and the CP was typically in his/her office. · SP3 did not have any concerns with how any staff persons supervised the children. The FM was aware of the incident but the AV did not tell him/her any details about what occurred. According to the facility’s 2021 Staff Handbook & Policies, children were to be taken to the restroom by staff persons. Staff persons were to supervise children at all times, within sight and hearing. No child was to be alone. Staff persons were responsible for knowing how many children were in their care. Facility documentation showed that all staff persons interviewed for this investigation received training on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0045, subpart 1, item A, states that children are required to have supervision at all times. Minnesota Statute section 245A.02, subdivision 18, states that supervision means 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: On the morning of July 27, 2022, the CP was across the hallway when s/he heard the AV crying in the restroom. When the CP went to the restroom to see what was happening, s/he saw that the AV was by him/herself and went to the gym and told P1. The AV and the C being unsupervised in the restroom, the AV being left alone in the bathroom while SP1 was on break, and the facilities routine practice of allowing a single staff person to supervise the classroom and the bathroom via the doorway of the classroom, were violations of Minnesota Rules, part 9503.0045, subpart 1, item A and Minnesota Statute section 245A.02, subdivision 18. The facility was located in a building with other businesses which were accessible to the public and utilized a shared hallway and restrooms. Given that the AV was unsupervised and found by the CP in a restroom in a building shared by other businesses, where s/he was exposed to community dangers, there was a preponderance of the evidence that there was a failure to provide 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. 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). 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. 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, SP2, and SP3 were each trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. At the time of the incident, SP1 and SP2 were working in the preschool room when SP1 told SP2 that s/he was taking the AV and the C to the restroom and did so. SP3 then came to break SP1. While the AV and the C used the restroom, SP1 went across the hall to talk with P1 in the doorway of the gym. When the C came out of the restroom, SP1 and the C returned to the classroom. SP1 then went on break leaving the AV in the restroom alone and unsupervised. SP1 also did not communicate the AV’s whereabouts to SP2 or SP3 prior to going on break and prior to them taking the children outside. Although SP2 and SP3 each did not count the children as they went outside, which may have indicated to them that the AV was not with the group, immediately prior, SP1 took over sole supervision of the AV when s/he took the AV out of the classroom and to the restroom. SP1 left the AV in the restroom unsupervised and did not ensure the AV’s safe return to the group. Therefore, SP2’s and SP3’s responsibility was mitigated and SP1 was responsible for the 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 was responsible did not meet statutory criteria to be determined as recurring because it was a one-time occurrence and was not serious because the AV did not require care from a medical professional. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were not followed when a child was “inadvertently” left in the restroom when a staff person left for a break and all children were not accounted for. Staff persons were retrained on counting children during transitions and throughout the day. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. On October 26, 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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