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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 Anderson Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on the playground without for approximately four minutes without two staff persons’ (SP1 and SP2) supervision or knowledge. Date of Incident(s): June 3, 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 June 22, 2022; from documentation at the facility; and through six interviews conducted with the AV’s family member (FM) and facility staff persons (P1, P2, P3), SP1, and SP2. At the time of the incident, the AV was three years old and enrolled in the facility’s preschool classroom. The facility was a stand-alone building with a large parking lot at the front of the building. The surrounding area included busy community roads on three sides, multi-family housing, and businesses. The facility had two playgrounds that were adjacent to the building and next to each other but divided by a chain link fence. The entire playground was also enclosed with a vertical iron fence. The playground was partially visible to passersby and visible to an apartment building that overlooked the playground. Facility documentation and interviews with facility staff persons provided the following information: · The facility’s documentation regarding the incident, written by a facility management staff person (P1) stated that on June 3, 2022, the AV was left on the playground unsupervised for approximately three minutes before being seen by another staff person (P2) who was on an adjacent playground. · At the time of the incident, P2 was providing staff persons in another preschool classroom with five minute breaks and had been on the adjacent playground for approximately ten minutes before s/he saw the AV standing alone. SP1 and SP2 were on the playground when P2 first went outside, but P2 did not notice when they took the children inside. P2 thought that the AV was outside without supervision for less than five minutes. · P2 knocked on SP1’s and SP2’s classroom door to let the AV inside. According to P2, SP1 and SP2 were “shocked” that the AV was outside without their knowledge. · P1 stated that when s/he talked to SP1 and SP2 about the incident, they each stated that they did not know the AV was left on the playground without supervision. SP1 and SP2 each told P1 that a name-to-face count was completed before they went inside so that they did not know how the AV was missed. · A second facility management person (P3) was responsible for training and onboarding all of the staff persons. P3 stated that s/he trained SP1, SP2, and all of the staff persons on the facility’s supervision policy and how to conduct name-to-face attendance. Staff persons were trained to conduct name-to-face while the children were in line at each threshold and then to recount the number of children as they moved in and out of an area. Staff persons used an iPad and an attendance application to track the name-to-face transitions and attendance. · After P1 and P3 became aware of the incident, they checked the iPad information for SP1’s and SP2’s classroom and discovered there was no documentation stating that the name-to-face count had been completed when they transitioned inside to the classroom. SP1 provided the following information: · At the time of the incident, SP1, SP2, and twelve children were on the playground. When it was time to take the children inside, SP1 asked the children to line up by the door. SP1 conducted a name-to-face count by calling each child’s name and having them respond with “bike day.” SP1 saw the AV in line but was not sure if s/he went in. SP1 described the day as “hectic” and stated that s/he did not conduct the name-to-face transition. · Approximately three minutes after SP1, SP2, and the other children transitioned into the classroom, SP1 heard a knock on the door leading to the playground. When SP1 opened the door, s/he saw P2 and the AV standing on the playground. SP1 stated that s/he was “shocked” to see the AV outside and “quickly” escorted him/her into the classroom. According to SP1, the AV was not upset when s/he came inside and easily rejoined the other children. · SP1 was trained to use a name-to-face attendance application on the iPad when s/he transitioned children from one area of the facility to another. SP2 provided the following information: · SP2 did not normally work in the preschool classroom with SP1, but was substituting in that classroom on the day of the incident. SP1 and SP2 took twelve children out to the playground before lunch. When it was time to transition the children inside, SP2 heard SP1 counting and calling the children’s names as they lined up along the wall. SP2 stated that SP1 counted twelve children. SP1 held the door open and went inside first with four children. Then SP2 held the door and counted the rest of the children. SP2 stated that s/he counted twelve children. · SP2 stated that s/he completed a visual check of the playground, but did not see any children. There was a ball cart on the playground by the classroom door and SP2 thought that the AV could have been behind the ball cart when s/he went inside. · Once the class was back inside, SP2 was assisting a child with the bathroom when s/he heard a knock on the door. SP2 did not answer the door, but P2 brought the AV into the classroom. SP2 stated that s/he believed the AV was on the playground without supervision for approximately one minute to three minutes. · According to SP2, the transition from the playground to inside was “chaotic” and s/he did not know how the AV was left on the playground. SP2 was trained on using the facility’s name-to-face counting when s/he transitioned children from one area to another. The FM stated that she was told of the incident by the facility and that the AV was left outside for a couple of minutes. The FM didn’t have any concerns regarding the incident. The facility’s Staff Supervision of Children policy and the Risk Reduction Plan stated that staff persons were to supervise children by sight and hearing at all times, even when children are going to sleep, napping or sleeping, are beginning to wake up or are indoors or outdoors and that staff persons were to “regularly” count children using a name-to-face process at every transition and whenever leaving one area and arriving at another. The facility had a “My Primrose Manager” application that was used to take attendance, transition children, combine classrooms, and maintain name-to-face recognition during transitions. The facility’s personnel files showed that SP1 was trained on the Risk Reduction Plan, the Staff Supervision Policy, and the Reporting of Maltreatment of Minors Act on March 3, 2022. SP2 was trained on the Risk Reduction Plan, the Staff Supervision Policy, and the Reporting of Maltreatment of Minors Act on January 12, 2022. 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 June 3, 2022, SP1 and SP2 were on the playground with twelve preschool children, including the AV. When SP1 and SP2 transitioned the children inside, the AV was left on the playground without SP1’s or SP2’s knowledge or supervision for three minute, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although another classroom and staff persons were on the playground adjacent to the playground the AV was on, those staff persons were not aware that the AV was on the playground and therefore not in a position to intervene to protect the AV. Leaving a three year old outside without a staff person’s knowledge or supervision exposed him/her to community persons, vehicle traffic and other hazards. Therefore, there was a preponderance of evidence that there was a failure to supply the AV with the necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental 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 responsible for the supervision of the AV at the time of the incident. SP1 and SP2 received training on the facility’s policies and procedures, including Risk Reduction Plan, Staff Supervision of Children, and the Reporting of Maltreatment of Minors Act prior to 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 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 SP1 being disqualified for recurring maltreatment. SP1 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 were adequate but not followed at the time of the incident. Staff persons were retrained on name to face while each child crossed a threshold. Action Taken by Department of Human Services, Office of Inspector General: SP1 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 SP1 was responsible for maltreatment and the disqualification of SP1 are each subject to appeal. SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, 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 SP2. The determination that SP2 was responsible for maltreatment is 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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