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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: 1063675- CCC (Child Care Center) Investigator(s): Kimberly Anderson/Judith Schwanke Suspected Maltreatment Reported: It was reported that two alleged victims (AV1 and AV2) were on the playground without staff persons’ (SP1 and SP2) knowledge or supervision. AV1 and AV2 were unsupervised for approximately 6 minutes. Date of Incident(s): September 30, 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 remotely, including documentation from the facility; and through four interviews conducted with AV1’s family member (FM1); two staff persons (SP1 and SP2); and a supervisory staff person (P). Attempts to reach AV2’s family member were unsuccessful. At the time of the incident, AV1 and AV2 were two years old and enrolled in the facility’s toddler classroom.
The facility was located in the lower level of a community church that was on the corner of two residential streets. The surrounding area included a college campus, residential homes, gas stations, and restaurants. On one side of the building was a playground fully enclosed by vertical metal fencing and portions of the building itself. The playground was visible from both residential streets. In order to access the building from the playground, one had to go through a gate in the fence, walk a few yards on a public sidewalk, and then enter the building through a locked door. The door was opened by using an attached keypad or by pushing the doorbell and awaiting an answer. Once inside the building entryway, a ramp led to the facility’s main door and a stairwell led to other areas within the church. The facility’s Accident Report Form stated that on September 30, 2022, AV1 and AV2 were unsupervised on the playground. The facility’s policies and procedures, including Risk Reduction Plan, provided the following information: · “All children will be supervised by sight and sound at all times.” · “Teachers will do a name-to-face count during transitions to or from outside ….” · “Teachers should know how many children are in their care at all times and use a [Supervision & Attendance Tracking Form] to track the number of children in attendance.” FM1 stated that initially s/he was told that AV1 was left outside for approximately 90 seconds but later that day s/he received an email from the P stating that AV1 was outside for about 5 minutes before being brought back in by another child’s parent. The P stated that on the day of the incident, the P took a group of children to the playground when a parent of a child from another classroom told him/her that AV1 and AV2 were on the toddler playground without a teacher. The P immediately went and got AV1 and AV2 and brought them to the toddler classroom. Afterwards the P notified their family members of the incident. The P stated that it was the responsibility of staff persons to know how many children are in their care at all times and to do a name to face count anytime the group transitioned. The Supervision & Attendance Tracking Form should be used at all times to assist staff persons in knowing how many children are in their care, and to assist in properly doing name to face counts before, during, and after transitions. SP1 provided the following information: · On September 30, 2022, at approximately 4:00 p.m., SP1 and SP2 were on the playground with 11 children, including AV1 and AV2. SP1 said that as parents started picking up their children, s/he became confused regarding the number of children that remained. SP1 had a list of the children in attendance but did not take the list outside on the day of the incident. SP1 was trained that s/he was supposed to take the list outside with him/her. · At approximately 4:26 p.m., SP1 decided take the children from the playground back to the classroom and asked the children to line up. SP1 then took five children inside and asked SP2 to check for any children who may still be outside. At that time, SP1 did not know how many children were in his/her care but did not see any child remaining on the playground. When SP2 entered the classroom s/he did not have any children with him/her. · Once inside, SP1 was assisting a child in the bathroom when the P came in to the classroom with AV1 and AV2. The P told SP1 and SP2 that AV1 and AV2 were left on the playground unsupervised. · SP1 thought that AV1 and AV2 were outside unsupervised for approximately three minutes. SP2 provided the following information: · SP2 came into the toddler classroom at approximately 3:50 p.m. as the class was getting ready to go out to the playground. At that time, SP2 asked SP1 how many children were in attendance and was told 12. SP2 told SP1 that s/he only counted 11 and then SP1 recalled that one child had left with a parent. While outside, SP2 was playing and supervising children because SP1 was talking with parents who were picking up their children. · About 15 minutes into the outdoor play time, SP2 asked SP1 how many children were in attendance and SP1 did not give an answer. SP2 was engaging with the children and was not keeping track of the children leaving because SP1 was talking with the parents as they picked up their children. When it was time to take the class inside, SP2 was frustrated with SP1 because SP1 did not know how many children were present and was not keeping track of children leaving. SP1 then started to take the children inside and did not wait for SP2 to complete a count again. While SP1 was walking the children inside, AV2 did not want to come off the climber so SP2 gave him/her a minute more to play while s/he walked the playground to make sure no children were hiding. When SP2 was done looking, s/he did not see AV2 and “assumed” s/he went inside with SP1. SP2 was not aware that there was any other children on the playground and SP2 went inside to the classroom. Approximately two to three minutes after SP2 entered the classroom the P came in with AV1 and AV2 and told SP1 and SP2 that they would talk about it later. SP2 thought the children had been outside between three and four minutes without supervision. · There was a written list of children present in the classroom, but SP1 and SP2 did not use the list to track the number of children present. SP2 and staff persons kept track of the number of children by counting in their heads and communicating with other staff persons. SP2 kept track of children mentally and by communicating with other teachers. SP2 was not aware of whether or not the list was to go outside with him/her because SP2 thought it was SP1’s responsibility to cross the children off. Information from all sources was consistent that AV1 and AV2 were not injured during this incident. SP1 received training on the facility’s policies and procedures, including the facility’s Risk Reduction Plan; and the Reporting of Maltreatment of Minors Act on November 29, 2021; and SP2 received training on the facility’s policies and procedures, including the facility’s Risk Reduction Plan; and the Reporting of Maltreatment of Minors Act on December 1, 2020. Relevant Minnesota Statutes and Rules: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states 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: On September 30, 2022, AV1 and AV2 were left on the playground without SP1’s and SP2’s knowledge and supervision for approximately three to six minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. A parent of another child notified the P that AV1 and AV2 were on the toddler playground and the P went and got AV1 and AV2 and brought them back to the toddler classroom. Although AV1 and AV2 were unharmed, given the location of the playground and that it was visible to passersby, leaving AV1 and AV2 outside without staff person’s knowledge or supervision exposed them to community persons, vehicle traffic, and other community hazards. Therefore, there was a preponderance of the evidence that there was a failure to supply AV1 and AV2 with the necessary care and a failure to protect AV1 and AV2 from conditions or actions that seriously endangered their 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). 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. At the time of the incident, SP1 and SP2 were working in the toddler classroom and were responsible for the care and supervision of all the children in the classroom, including AV1 and AV2. SP1 and SP2 were trained on the facility’s policies, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act prior to the incident. SP1 and SP2 were responsible for maltreatment of AV1 and AV2. 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 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident of maltreatment for which neither AV1 nor AV2 sustained an injury that required the care of a physician. However, information obtained by the Department of Human Services, in combination with this report, would result in S2P being disqualified for recurring maltreatment. 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 facility has implemented a new policy that all staff must use their walkie talkie to request administrators when a transition is occurring. SP1 and SP2 are no longer employed. 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. SP2 was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that SP2 was responsible for maltreatment is subject to appeal. On December 16, 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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