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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: 1089432-CCCC (Certified Child Care Center) Investigator(s): Tessa Ripka Suspected Maltreatment Reported: It was reported that an alleged victim (AV) walked to his/her home from the facility playground without staff knowledge. Date of Incident(s): September 20, 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 27, 2022; from documentation at the facility; and through four interviews conducted with three facility staff persons (SP1, SP2, and the P), and the AV’s family member (FM). The AV was four years old at the time of the incident and enrolled in the Preschool classroom. The facility was located in a school building and used one of the schools two playgrounds. The playground used at the time of the incident was located on the side of the building that faced Rockford Road. Rockford Road was two lane traffic (one in each direction) and had a speed limit of 45 miles per hour (mph). However, the distance of the building was a school zone and “when children are present” the speed limit was 25 mph. Between Rockford Road and the playground was a grass berm, a sidewalk, a chain link fence, another grass berm, a single lane frontage road, and then the playground, respectively. The fence did not enclose the playground and the frontage road went around the entire building including through the parking lot at the front of the building. The playground was divided into three sections: two areas with play structures and in between them was a black top area that kids could play. Beyond the playground towards the front of the building was a grass area, the parking lot that had three driving lanes for parking, and a wooden fence/trees. On the other side of the wooden fence/trees was a road that lead to a cul-de-sac and across the road were houses, including the AV’s house. The FM said that at approximately 2:45 p.m., s/he received a phone call from the AV’s nanny telling the FM that the AV was at home. The nanny typically went to the facility to pick up the AV around 3 p.m. The AV told the nanny that s/he was tired and wanted to go home to rest. Over the summer months, the AV went to the facility playground to play many times with the nanny. It was an approximately five minute walk to get to the playground from the AV’s home. SP1 and SP2 provided the following information: · On the day of the incident, at approximately 2:35 p.m., SP1 and SP2 counted and took 15 children, including the AV out on the playground. Shortly after getting outside, a parent picked up a child, so then there were 14 children. · A child on the large play structure was being aggressive with another child and SP1 went over to speak with them for approximately five minutes and had his/her back to the parking lot. SP2 stayed on the black top area with the other children and had them play with chalk. · At approximately 2:41 p.m. while SP1 was still dealing with the aggressive child, s/he got a message on his/her phone from the FM wondering why the AV was at home. SP1 then looked around and realized the AV was not on the playground. After SP1 called and spoke with both the FM and his/her supervisor, SP1 and SP2 brought the remaining children inside. · All children were counted when they exited and entered an area. There was a rule that if the children could not see a staff person, then they could not play in that area. · The AV typically went home between 2:30-3:00 p.m. each day. At pick up time, the FM and/or nanny walked to pick up the AV so the AV was very familiar with the walk from his/her home to the facility. English was not the AV’s native language and SP1 was not sure if the AV always understood what was being said to him/her. The AV had asked prior to going outside, when s/he was getting picked up. The AV had never attempted to leave the facility prior to the incident. The P said the AV had attended the facility for a couple of weeks. The AV was an English language learner and often looked confused when staff persons offered instruction. The P was not sure if the AV understood s/he was not supposed to leave the playground. The Staff Handbook stated that staff persons knew how many children were in their care at all times. Staff persons engaged in active supervision. Staff persons spread out to facilitate better supervision. The Risk Reduction Plan indicated that the outdoor space was “relatively large” and some obstacles impeded lines of sight. Staff persons spread out so that all areas are supervised. “Walkie” communication was used between staff persons. According to www.wunderground.com, the outdoor condition at the facility, on September 20, 2022, at the time of the incident, was “fair” with a temperature of 89 degrees Fahrenheit (°F) and wind speed of 8 miles per hour (mph). This investigator walked at a slow pace from the middle of the playground across the parking lot to the fence that bordered the facility. The walk took approximately 2 minutes. Facility documentation showed that SP1 and SP2 were trained on the facility’s policies, the Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245H.13, subdivision 10 states that staff must supervise each child at all times. Staff are responsible for the ongoing activity of each child, appropriate visual or auditory awareness, physical proximity, and knowledge of activity requirements and each child's needs. Staff must intervene when necessary to ensure a child's safety. In determining the appropriate level of supervision of a child, staff must consider: (1) the age of a child; (2) individual differences and abilities; (3) indoor and outdoor layout of the child care program; and (4) environmental circumstances, hazards, and risks. Conclusion: A. Maltreatment: Information was consistent that on September 20, 2022, SP1 and SP2 took the classroom outside at approximately 2:35 p.m. At approximately 2:45 p.m., the FM called SP1 and said that the AV had walked home. SP1 and SP2 were not aware the AV had left the playground which was a violation of Minnesota Statutes, section 245H.13, subdivision 10. Given that the AV, who was four years old at the time of the incident, walked home without staff person’s knowledge or supervision and was in a location that could expose the AV to community dangers including traffic, there was a preponderance of the evidence that there was a failure to supply care or supervision required for the AV’s physical health when reasonably able to do so and a failure to protect the AV from conditions that seriously endangered his/her 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. SP1 and SP2 were trained on the facility’s policies, the facility’s Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act prior to the incident. Both SP1 and SP2 were responsible for the care and supervision of the AV at the time of the incident. SP1 and SP2 were 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 and did not result in any injury to the AV. 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: All staff persons were trained on supervision/playground safety. 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 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 SP1 or SP2. The determination that the SP1 and SP2 were responsible for maltreatment is subject to appeal. On November 18, 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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