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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: 1026207-CCC (Child Care Center) Investigator(s): Alice Percy Suspected Maltreatment Reported: It was reported that a staff person (SP) left an alleged victim (AV) unsupervised on the facility’s playground for approximately 25 minutes. Date of Incident(s): August 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 September 15, 2022; from documentation at the facility; and through six interviews conducted with three facility staff persons (P1 – P3), an administrative staff person (P4), the SP, and the AV’s family member (FM). The AV was two years old and enrolled in the three-year-old classroom at the time of the incident. The facility was located in a residential area next to a two-lane street that had a posted speed limit of 30 miles per hour (M.P.H.). The facility’s parking lot ran along the front of the building and extended to an adjacent strip mall. The preschool playground was located on the end of the facility and along the side of the parking lot, on the opposite end from the strip mall. The playground was enclosed by a chain link fence and had a gate that was located on the side next to the parking lot. The gate had a latch, but did not have a lock. The staff persons used a carabiner clip to keep the children from opening the latch. A large plastic climbing structure was located in the playground near the end of the building and several smaller plastic toys were placed around the playground. Information was provided that on the day of the incident, a “bouncy house” was located at the end of the playground near the gate. A second gate at the back of the playground accessed a smaller toddler playground that was located along the back of the facility. A door at the back of the facility accessed the smaller toddler playground. The preschool playground was visible to persons driving or walking by the facility and those parking at the strip mall. P1, P2, P3, P4 and the SP, and the facility’s documentation provided the following information: · On the morning of August 26, 2022, several of the children at the facility went on a field trip with P2, P3, and P4. The SP remained in the three-year-old classroom at the facility with the preschool children who did not go on the field trip. The SP had a list of all the children in his/her group, but the list was not current, so the SP updated the list and at that time s/he had seven children present. At approximately 10 a.m., the SP took the seven children outside to the playground. The SP had one child from his/her four-year-old classroom as well as six children, including the AV, from the three-year-old classroom. The SP did not know the children from the three-year-old classroom, but used a computer app to match the children’s names to their photograph on the app. Shortly after arriving at the playground, another child was dropped off, leaving the SP with eight children. The SP marked the child on the list as arriving at 10 a.m. At some point, a family member of another (C) dropped off clothing for the C and the C became upset and lay on the ground screaming when the family member left. · At approximately 11:20 a.m., the SP decided to take the children back into the facility and picked up the C, led the children to the gate, counted eight children, and led the children into the facility through the front door. The SP stated that s/he did a name-to-face count of the children while they were lined up at the gate and the AV was one of the children in line. As s/he stood at the gate, the SP looked back at the playground from the gate, but did not see any child left the on the playground. The SP dropped the carabiner clip as s/he attempted to place it on the gate latch, but could not bend down and pick it up since s/he was carrying the C, so s/he left it on the ground. The C continued to yell and attempted to kick the SP as s/he carried the C into the facility and back to the three-year-old classroom. The SP stated that s/he did a “head count” as the children entered the room and believed that s/he counted eight children. Within “two minutes” of entering the classroom, before the SP had time to do a name-to-face count of the children, the other children who had gone on the field trip returned to the facility and entered the three-year-old classroom. P4 stated that they arrived at the facility at approximately 11:30 a.m. P2 and P3 told the SP to take his/her group of children back to his/her classroom, which the SP did. P3 stated that the SP told P2 and P3 how many children were in the group prior to leaving the classroom. · P3 stated that when s/he and P2 entered the classroom, they began to assist the children who went on the field trip with changing from their swim suits to their play clothes. P3 was in the classroom for “maybe two minutes” before being asked to work in another room. P3 stated that the children were wet and cold and were “rolling on the carpet” with their wet swim suits. It was also difficult to keep the children in the bathroom while they changed because they wanted to run around the classroom without clothing. P2 was still assisting the children with changing clothes when P3 left the classroom. P2 stated that s/he did not count the children while s/he was in the classroom, because s/he was moved to a different classroom soon after they returned from the field trip. P3 stated that s/he did not immediately count the children because s/he was immediately involved in helping the children change clothes. · P2 stated that it took approximately ten minutes to assist the children with changing out of their swimsuits after P3 left the classroom. When all of the children were dressed in their play clothes, P2 began preparing for lunch. As P2 placed the plates on the table, s/he counted the children to ensure that s/he had the correct number of plates, but there was one less child present than was on the class list. P2 recounted the children and then asked P1, who worked in the toddler classroom, if the AV had been moved to their classroom, but they told P2 that the AV was not in their classroom. At the time P2 asked about the AV, the toddler class was on the toddler playground. Before P2 had time to ask anyone else about the AV, P1 entered the classroom with the AV. · At approximately 11:45 a.m., P1 was on the toddler playground with a group of toddler children when s/he heard a child crying on the preschool playground. P1 opened the gate and saw the AV on the playground. The AV was crying and “hard to calm down.” P1 took the AV into the facility to his/her classroom and gave him/her to P2. P2 stated that the AV was crying and shaking. P2 asked P1 to notify P4. P4 stated that s/he was working in the kitchen when the toddler teachers called for him/her to go to the toddler classroom. P4 believed that it was between 11:45 and 11:50 a.m. when s/he went to the classroom. P2 was holding the AV, who was calm. P1 told P4 that s/he found the AV unsupervised on the playground. · P4 then talked to the SP and P1 about the incident, who provided information to P4 consistent with the information provided to this investigator. The SP was unaware that the AV had been left on the playground prior to being told by P4 that P1 found the AV on the playground. P4 also contacted the FM to tell him/her about the incident. The AV was unable to provide information about the incident. · P4 stated that s/he drove the vehicle that took the children on the field trip. At 11:30 a.m., they arrived back at the facility and s/he did not see anyone on the playground at that time. P2 and P3 each stated that they did not see the AV on the playground when they arrived at the facility. P1 - P4 each stated that the AV was “easily distracted” and sometimes left the group because s/he was not paying attention. After the incident, P4 talked to all of the staff persons about the need to supervise children at all times. The FM stated that prior to the incident, s/he had no concerns about the care the AV received at the facility and there had been no previous incidents at the facility. According to the facility’s Employee Handbook, the staff persons were to keep the children within sight and sound at all times and were to “pay special attention” to areas that were difficult to supervise, such as the large outdoor playground structure. When the staff persons took the children to the playground, they were to count the children as they left the building and as they entered the building to ensure that all children were accounted for. Facility documentation showed that P1, P2, and the SP 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. Conclusion: A. Maltreatment: Consistent information was provided that on August 26, 2022, the AV was left on the on the facility’s fenced-in playground without the knowledge or supervision of a staff person for approximately 25 to 30 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The SP was not aware that the AV remained on the playground when s/he took the other children into the facility, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Being unsupervised on the facility’s playground, which was visible to passersby, for 25 to 30 minutes gave the AV access to community dangers including unknown community persons, parking lots, businesses, and streets. 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 and P2 received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. Although P2 took over the supervision of the children in the preschool classroom once s/he returned to the facility from the field trip, s/he immediately assisted the children with changing from their swim suits into their play clothes and then began to prepare to serve lunch. Although s/he did not count the children until that time, s/he was engaged in caring for the children and had no reason to believe that a child had been left on the playground prior to his/her return to the classroom. When s/he became aware that a child was missing, s/he began to ask the other staff persons if the AV had been picked up or moved to another classroom. At that point, P1 found the AV on the playground and returned him/her to the preschool classroom. Therefore, P2’s responsibility was mitigated. The SP was responsible for the care and supervision of the AV when the AV was left on the playground. Therefore, 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 SP. After the incident, the SP was retrained on the facility’s policies. 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 November 23, 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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