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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: 1048370-CCC (Child Care Center) Investigator(s): Kimberly Huettl Anderson Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left in a classroom without two staff persons’ (SP1 and SP2) knowledge or supervision for seventeen minutes. Date of Incident(s): October 19, 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 for this investigation was obtained remotely, including documentation from the facility; and through six interviews conducted with the AV’s family members (FM1 and FM2), and facility staff persons (P1, P2, SP1, and SP2). The facility was a stand-alone building that consisted of eleven classrooms. The AV’s preschool classroom was next to two classrooms with a door leading to the hallway and another door leading to a playground. The doors to the playground were locked. The facility had one primary entrance door that was secured with a security code that was only given to persons affiliated with the facility.
The AV’s enrollment file showed that the AV was 33 months old and enrolled in one of the facility’s preschool classrooms. FM1 and FM2 each stated that P2 called them about the incident right after it happened. According to FM1 and FM2 the AV exhibited some “processing delays” and was in the process of testing and/or diagnosed. FM1 and FM2 were “upset” about the incident and did not understand how SP1 and SP2 did not notice that the AV was not in their care for an extended amount of time because the AV’s delays made the AV “identifiable” to staff persons. FM1 and FM2 each stated that until the day of the incident, they had no concerns about the program. Facility documentation and interviews with P1, P2, SP1, and SP2 provided the following information: · The facility’s Incident or Accident Report stated that on October 19, 2022, at approximately 10:56 a.m., SP1 and SP2 transitioned children out of the classroom and into another classroom. Approximately seventeen minutes later, P1 walked by the first classroom and saw the AV in the classroom alone. The AV was crying and pacing around the classroom. P1 got the AV and walked the AV to SP1 and SP2 and left the AV in their care. · On the day of the incident, there was a special visitor who performed a Halloween story-telling show for the children. The AV’s preschool classroom was scheduled to watch the show from 10:55 to 11:25 a.m., with another preschool classroom. The show was being held in the classroom next to SP1’s and SP2’s classroom. · According to P1, P2, SP1, and SP2, the AV required “a little” more attention from staff persons then the other children in the classroom. SP1 and SP2 were required to assist the AV with transitions and following directions. · P1 stated that at 11:13 a.m., s/he was walking through the hallway when s/he noticed that the AV was in the classroom alone with the lights off. According to P1, when s/he entered the classroom, the AV was crying and “looked lost.” P1 hugged the AV and checked him/her for a sign of an injury and then walked the AV to the next classroom with the other children. P1 stated that SP1 and SP2 did not know that the AV was not in their care and were “shocked” when s/he brought the AV to them. SP1 told P1 that s/he conducted a name-to-face count when s/he transitioned the children out of the classroom at 10:56 a.m., but that SP2 was the last staff person out of the classroom and that s/he did not know the AV was left behind. · SP1 stated that on the day of the incident, SP1 and SP2 were supervising thirteen children, including the AV, in the preschool pathways classroom. There was a special visitor so SP1 told the children to line up by the door so they could go to the classroom next door to watch the show. SP1 stated that all of the children lined up by the door so SP1 went into the hallway and asked SP2 to hold the door open while SP1 counted the children walking through the door. SP1 stated that s/he did not conduct a name-to-face count but touched each child’s head as they walked through the doors. After SP1, SP2, and the children entered the classroom, SP1 transferred the children to the new classroom on the facility’s iPad tracking application without conducting a name-to-face count. · SP2 stated that on the day of the incident, SP1 asked the children to line up by the door. SP2 was behind the children and holding the AV’s hand when SP1 asked SP2 to hold the door open for the children. SP2 stated that s/he “must have” let go of the AV’s hand to hold the door open and did not notice that the AV did not transition to the new classroom. SP2 stated that s/he was standing in the hallway holding their classroom door open and SP1 was standing in the hallway holding the other classroom door open. · SP2 said that s/he counted the children as they were going out the door, but lost track of the number of children because the transition was “too fast.” SP2 did not conduct a name-to face count because SP1 “rushed” the transition, had the iPad in his/her possession, and counted the children’s heads. · SP1 and SP2 each stated that they did not know that the AV was left in the classroom without supervision until P1 brought the AV to them. SP1 and SP2 each stated that they did not conduct the transition between the two classrooms accurately or according to their training. · According to P1, P2, SP1, and SP2, and facility’s Staff Supervision of Children and Name-to-Face policy, the facility utilized an application on an iPad to track attendance, transition children, combine classrooms, and maintain name-to-face recognition during transitions. Prior to leaving a location, staff persons were to count the number of children in their care, then identify the child with a name by looking at the child and finding the child on the iPad application. Once the staff person checked the child off on the iPad, the child was allowed to cross the threshold. This process was to be done for every threshold crossed. · The facility’s Risk Reduction Plan stated that staff persons were instructed to maintain a high level of awareness during times of transitions to ensure that “proper” supervision was maintained. Staff persons were to maintain an accurate attendance list of children under their supervision and were to use a name-to-face attendance when children transitioned from one location to another. Staff persons were trained that “proper” supervision required that a staff person be within sight and sound of a child at all times. The facility’s personnel files showed that P1, P2, SP1, and SP2 were each trained on the facility’s Staff Supervision of Children policy, Name-to-Face policy, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act 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: On October 19, 2022, the AV was left in the classroom without SP1’s or SP2’s knowledge or supervision for seventeen minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. P1 walked by the classroom and noticed the AV alone in the classroom. P1 stated that the AV was crying and pacing around the room. Although the AV was in his/her classroom, unable to access outside, and not injured during the time, the AV was not able to provide for his/her safety and it was more likely that no staff person would have been aware that the AV was alone in the classroom in the event of an emergency. 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 could seriously endanger the AV’s physical health. 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 supervision of the AV at the time of the incident. SP1 and SP2 were each trained on the facility’s Risk Reduction Plan, Staff Supervision of Children, and Name-to-Face policies and on the Reporting of Maltreatment of Minors Act prior to the incident. Although SP2 was holding the AV’s hand just prior to leaving the classroom and let go of the AV’s hand, SP1 and SP2 each did not count the children upon their arrival to the new classroom or ensure that all of the children were with them in the classroom. Therefore, SP1 and SP2 were each responsible for the 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 because it was a single event and it was not serious because the AV did not sustain an injury that required medical care. However, information obtained by the Department of Human Services, in combination with this report, resulted in SP2 being disqualified for recurring maltreatment. SP2 was disqualified from providing direct contact services. 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 conducted an internal review and determined that their policies and procedures were adequate but not followed at the time of the incident. All staff persons were retrained on the Name-to-Face and Staff Supervision policies. SP2 no longer worked at the facility. 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 disqualified from a position allowing direct contact with, or access to, persons receiving services from 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. The determination that SP2 was responsible for maltreatment and the disqualification of SP2 are each subject to appeal. On December 28, 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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