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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: 1101665-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 for approximately three to five minutes. Date of Incident(s): October 18, 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 28, 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 (FM) who also worked at the facility. According to the AV’s enrollment information, the AV was 18 months old at the time of the incident. The facility had a toddler room that had a door that led out to a toddler playground. The toddler playground had equipment including a treehouse that children were able to play inside of. The toddler playground was enclosed with a vertical rod iron fence. Surrounding the facility were roads and other businesses. The playground was visible to passers-by from the street. Each room had an IPad that staff persons used to do a name to face count of the children. P2 and the SP provided the following information: · On October 18, 2022, at approximately 4 p.m., P2 and the SP were outside on the toddler playground with approximately eight toddlers, including the AV. P2 went inside with two children to change their diapers while the SP stayed outside with the rest of the children including the AV. · The SP stated that the IPad was inside the toddler room so when s/he had the children line up by the door, instead of doing a name to face count of the children, s/he counted their heads when walking through the door. The SP stated s/he had “never” just counted children prior to this incident. · P2 and the SP each stated when the SP came inside with the rest of the children, P2 was still diapering the two children. The SP assisted the toddlers for approximately three to five minutes with taking off coats and was about to start reading to the children when s/he realized the AV was not in the room. The SP asked P2 where the AV was. The SP ran out of the room to the playground and found the AV inside the treehouse. The SP picked up the AV and brought him/her inside. The SP then went and told P1 about the incident. The SP and P2 each stated that the AV did not have any injuries. P1 stated on the day of the incident, at approximately 4:30 p.m., the SP came to P1’s office and said s/he left the AV outside on the playground for “five minutes or less.” The SP said s/he did not do the name to face protocol coming back inside the facility. P1 did not have previous concerns with the SP. The FM stated that P1 called him/her on the day of the incident and told the FM about it. The FM did not have concerns with the facility. According to the facility’s risk reduction plan, some areas of the playgrounds were difficult to supervise. Staff persons stationed themselves to see children from any angle and circulated the playground. If children left the playground, they were at “a large risk” of leaving the facility, getting lost, or injured by traffic. Children were at risk of being approached or harmed by a stranger walking up to the facility from the sidewalk. Staff persons also completed a name to face attendance when transitioning. According to the Staff Supervision of Children policy, staff persons supervised children “by sight and hearing at all times.” Staff persons conducted a name to face count at every transition; whenever leaving one area and arriving at another; and going inside or outside to confirm “safe whereabouts of every child at all times.” Facility documentation showed that staff persons interviewed in this investigation, including the SP, received training on the facility’s risk reduction plan, the Staff Supervision of Children policy, 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, stated that children are required to have supervision at all times. Minnesota Statute section 245A.02, subdivision 18, stated 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 October 18, 2022, the AV was left alone 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 approximately three to five minutes and was exposed to community dangers, including 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. Although P2 was on the playground on the day of the incident, P2 went inside with two children to change their diapers and remained inside when the SP returned with the rest of the children. Therefore, P2’s responsibility was mitigated. The SP was responsible for the care and supervision of the AV and trained on the facility’s risk reduction plan, the Staff Supervision of Children policy, and the Reporting of Maltreatment of Minors Act. 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 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 policies and procedures were adequate but not followed. 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 November 23, 2022, the facility was issued a Correction Order for the violations 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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