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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: 1005122-CCC (Child Care Center) Investigator(s): Kimberly Huettl Anderson/Judith Schwanke Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left in a cubby room without a staff person’s knowledge or supervision for approximately 25 minutes. Date of Incident(s): September 14, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, : 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 22, 2022; from documentation at the facility; and through four interviews conducted with facility staff persons (P1, P2, and the SP) and a management person (P3). Attempts were made to contact the AV’s family members but the family members did not respond. The facility was located in a church and had eight rooms, including a “big room” (nap room), where all of the children, excluding infants, napped, and a “cubby room” where the children’s shoes were stored during nap time. There was a door from the nap room that led into the cubby room. The cubby room had two doors, one led into the nap room and the other led into the hallway. The nap room had minimal lighting and the cubby room was kept dark during nap time. At the time of the incident, the AV was three years old and enrolled in one of the facility’s preschool classrooms. The facility’s Supervision policy stated that staff persons were to do a head count before leaving an area and another head count when they arrive at the other area to ensure that all the children have arrived safely. The facility’s Risk Reduction Plan stated that when moving from one area to another, staff will do a head count as well as call out each child’s name before leaving and again when arriving to ensure that all children are accounted for. Facility documentation and interviews with P1, P2, and P3 provided the following information: · On the day of the incident, at approximately 2:20 p.m., P1 and P2 and the SP were in the nap room. Near the end of naptime, five children were awake and ready to transition into an “awake” classroom. P1 told P2 that there were five children awake and P2 wrote down the names of the five awake children on a piece of paper. (Routine practice was to keep the list in the room until all of the children were awake.) P1 walked the five children to the cubby room door and asked the children to sit on a mat outside the cubby room door. Four of the children were seated on the mat and the AV was standing. · P1 then asked the SP to take the group of children into the cubby room to gather their shoes and then to take them to the awake classroom. P1 stated that s/he was approximately ten feet away from the SP when s/he told the SP that there were five children waiting to go into the cubby room. P1 and P2 each stated that P1 told the SP that there were five children. Neither P1 nor P2 watched the SP and the children go into the cubby room. · There were five children left sleeping in the nap room and when they woke up at approximately 2:45 p.m., they went to the cubby room with P2 where P2 found the AV sitting in the cubby room. P2 asked the AV if s/he was by him/herself and the AV said, “Yes”. P2 recognized the AV as one who had been on the list of five children awake she had written down earlier and should have been with the SP. P2 took the AV with his/her group and reported the incident to the assistant directors. · The facility’s procedure for transitioning children out of the nap room was to write the child’s name on a sheet of paper before the child left the nap room. There was no specific list to know who was in the nap room. Once all children were awake the sheet went back on a clipboard to use for attendance for the remainder of the day. Staff persons did not have a list of the children in their care when they transitioned to an awake room. · The cubby room was kept dark so it was difficult for the children to put their shoes on and for teachers to see children. · The facility management person believed all policies were followed. The AV was left unsupervised because there was miscommunication between staff persons. The SP provided the following information: · On the day of the incident, as the SP was finishing a project, P1 said s/he was going to let the children who were awake get off their cots and when the SP was done, s/he was to take the kids to the awake room. When SP finished the project, s/he walked to the cubby room door and before taking the children into the cubby room, the SP counted four children sitting on the mat. The SP held the door to the cubby room open and counted four children walking into the cubby room, and once in the cubby room counted four children again. The children put their shoes on and lined up by the door that led to a hallway. Before leaving the cubby room, the SP “walked all four corners of the room” to ensure that no one was left behind. When they exited the cubby room, the SP counted four children. · The SP did not see the AV prior to going into the cubby room and did not believe the AV was in his/her group. The SP said that s/he did not hear P1 tell him/her how many children there were and that it could been because P1 and the SP were not near one another in the nap room. The SP completed counts and a walk through and did not believe s/he did anything wrong. Facility records showed that prior to the incident, P1, P2, and the SP received training on the facility’s Risk Reduction Plan; the facility’s Supervision policy; and the Reporting Maltreatment of Minors Act. 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 14, 2022, the AV was left in the cubby room without a staff person’s knowledge and supervision for approximately 25 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was in the facility’s cubby room and not injured during this time, it was more likely that no staff person would have been aware that the AV was in the cubby room 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. P1, P2, and the SP received training on the facility’s Risk Reduction Plan; the facility’s Supervision policy; and the Reporting Maltreatment of Minors Act. On the day of the incident, P1, P2, and the SP were each responsible for the supervision of the children in the nap room including the AV. P1 told P2 that there were five children, including the AV, awake and P2 wrote their names on a piece of paper. That piece of paper remained in the nap room with P1 and P2 and there was no information that the SP saw the list prior to taking children into the cubby room. P1 then walked the five children to the cubby room door, and asked them to sit on the rug. Four children sat down and the AV stood. P1 and P2 each said that P1 told the SP there were five children, but the SP said s/he did not hear P1 tell him/her how many children there were. Information was consistent that the SP and P1 were not near one another at the time, so it was possible that the SP did not hear P1 tell him/her the number of children. When the SP went to the cubby room door, s/he counted four children sitting on the rug and continued to count four children as they transitioned into and out of the cubby room, and into an awake room. Information was consistent that the cubby room was dark during naptime and remained so when the SP and the children were in the room. The SP said that s/he “walked all four corners of the room” to ensure no one remained and counted four children as they left the cubby room. Given that it was possible that the SP did not hear P1 state the number of children to transition; that the SP did not have a list of the names of children s/he was taking out of the nap room; that the nap room and cubby room were kept dark; that the SP said s/he continued to count four children with him/her; and that was not able to be determined at what point the AV went into the cubby room; it was unclear who was responsible for the supervision of the AV when the AV was left unsupervised. Therefore, the responsibility of the maltreatment of the AV was inconclusive. 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 followed but not adequate. The facility revised their policies and retrained staff on the new policies. The facility also added an LED light strip in the cubby room. Action Taken by Department of Human Services, Office of Inspector General: On January 11, 2023, 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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