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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: 1053430-CCC (Child Care Center) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left alone on the preschool playground. Date of Incident(s): September 26, 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 October 6, 2022; from documentation and video footage from the facility; and through five interviews conducted with a supervisory staff person (P1), three facility staff persons (P2, SP1, and SP2), and the AV’s family member (FM). According to the AV’s Enrollment Agreement, the AV was two years and ten months old at the time of the incident and enrolled in the preschool one room. Consistent information was provided that at the time of the incident, P2 worked in the infant room and SP1 and SP2 worked in the preschool one room. The facility was located in downtown Minneapolis. Surrounding the playground was an apartment building (that the facility was located in), a parking garage, and a road. There was a sidewalk that led from the facility to the chain link fenced in toddler playground and then a chain link fenced preschool playground. Video footage provided by the facility showed the sidewalk along the side of the toddler playground and part of the toddler playground. The preschool playground was at the end of the sidewalk and was not visible. Video surveillance showed that on September 26, 2022, at 5:04 p.m., SP1, SP2, and four preschool children, not including the AV, walked out of the preschool playground and along the sidewalk that led into the facility. At 5:33 p.m., SP1 ran down the sidewalk to the preschool playground. At 5:34 p.m., SP1 and the AV walked out of the preschool playground along the sidewalk back into the facility. P2 stated on September 26, 2022, at approximately 5:30 or 5:45 p.m., P2 pushed an infant buggy down a main hallway inside the facility. During that time, s/he also used an app to verify if the children in each room were checked out for the night. When P2 went to the preschool one room, s/he saw the AV’s name listed as checked in but did not see the AV. P2 asked SP1 and SP2 if the AV had left for the night and both SP1 and SP2 responded that s/he had, so P2 signed the AV out on the app. A few minutes later, while in the hallway, P2 saw SP1 walking in the hallway with the AV from the playground. The AV was “calm” and there was no marks or injuries on the AV. SP1 told P2 that the AV had been on the playground alone for approximately 15 minutes. P2 then went and called P1 about the incident. P1 stated on September 26, 2022, at approximately 5:40 p.m., s/he received a phone call from P2 stating that when P2 walked around the facility updating attendance, P2 discovered that the AV had not been picked up by the FM and so SP1 ran out to the playground and found the AV alone. Right after, P1 called the FM to notify him/her about the incident. SP1 and SP2 provided the following information: · On the day of the incident, after spending time on the playground, SP1 and SP2 had the preschool one children line up at the gate to go back inside the facility. SP1 and SP2 did not see the AV lined up and they each assumed s/he had already been picked up for the day. · SP1 did not look around the playground and did not do a name to face count prior to leaving the playground. SP2 “scanned” around the preschool playground but did not walk around. SP2 stated s/he counted three children who were lined up holding onto a walking rope before walking back to the preschool one room but did not do a name to face count. The Ipad was not outside on the playground for SP1 and SP2 to do a name to face using the facility app. SP2 stated SP1 and SP2 each counted the children when going inside the facility and again when entering the preschool one room. · Once SP1 and SP2 were back inside the preschool one room, the children sat and colored while SP1 brought the garbage outside to a dumpster located in the parking garage. At one point, P2 came inside the preschool one room and asked if the AV left. SP1 and SP2 each responded, “Yes.” SP1 and SP2 then looked at each other and realized that the AV had not left so SP1 ran back outside to the preschool playground and saw the AV sitting inside a white bin. SP1 and the AV then returned to the preschool one room. SP1 and SP2 each stated that the AV did not have any injuries. The FM did not have concerns with how to facility handled the incident. According to the facility’s employee handbook, the safety of the children was of “paramount importance” and was staff persons “first and most important responsibility.” Children were “in sight and sound at all times.” Staff persons “never [left] a child unattended for any reason” and accurately counted the children at each transition. According to the facility’s risk reduction plan, the playgrounds were not attached to the facility. The children used a walking rope and staff persons called each child by name to hold onto the walking rope. One staff person was in the front of the walking rope line and the other was at the back. Staff persons completed a name to face count of all children prior to going outside and as they entered the playground. Facility documentation showed that staff persons interviewed in this investigation, including SP1 and SP2, received training on the facility’s employee handbook, risk reduction plan, and the Maltreatment of Minor’s 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: Consistent information was provided that on September 26, 2022, the preschool one room returned inside from the playground leaving the AV outside on the playground 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 AV was left outside without the knowledge or supervision of a staff persons for 29 minutes and was exposed to community dangers, including a parking garage, traffic, 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 and SP2 were each responsible for the care and supervision of the AV and each were trained on the facility’s employee handbook, risk reduction plan, and the Reporting of Maltreatment of Minors Act. SP1 and SP2 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 and SP2 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. All staff persons received additional training on safety and supervision. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each 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 and SP2. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal. On November 9, 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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