|
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: 1012862-CCC (Child Care Center) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was found unsupervised in the hallway by a parent of another child. Date of Incident(s): October 5, 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 November 1, 2022; from documentation at the facility; and through five interviews conducted with three facility staff persons (SP1, SP2, and SP3), an administrative staff person (SP4), and the AV’s family member (FM1). The AV was 14 months old and enrolled in the older infant classroom at the time of the incident. The facility was located in a large community building which was surrounded on three sides by busy two- and four- lane roads. There were large parking lots on two sides of the building. The community building frequently had community persons visiting and working in the building. The facility was located in one area of the building and the classrooms were located along one hallway. A pair of main entrance doors off of one parking lot entered into the facility/building and were located in the middle of the facility’s hallway. The two entrance doors were heavy glass doors that required a push bar to be pushed in order to open the doors. Consistent information was provided that the AV was unable to open the doors without assistance. Once inside the doors, there were three hallways forming a “T.” The hallway to the left provided access to several stairs that led to the classrooms of the preschool children. One hallway went straight through the building to another set of heavy glass doors that accessed another parking lot. Information was provided that those doors were typically locked. SP4’s office door was on the right side of the hallway a short distance from the main entrance doors. A third hallway to the right provided access to the infant and toddler classrooms. The first and second doors on the left of the third hallway accessed the young infant classroom. The young infant classroom was a small rectangular room with two doors on one wall, the aforementioned first and second doors. In the classroom, across from the first door was a small table and chairs and an adult-sized rocking chair. To the left of the table and chairs, was a changing table was and a small kitchen area on the far side of the changing table. On the right side of the classroom was a row of cribs which were separated from the rest of the classroom by three low bookcases. A gate was located between two of the bookcases to keep children from accessing the crib area. A mirror was placed between the other two bookcases. The mirror was not fastened to the bookcases and could be moved away from the space so that the staff persons could easily access the crib area. The second door to the classroom was located in the crib area. SP1, SP2, SP3, and SP4, and the facility’s documentation provided the following information: · On October 5, 2022, between 7:15 and 7:30 a.m., SP1, SP2, and SP3 worked in the young infant classroom with five children, including the AV, who was the only infant who could walk. The young infant classroom was one of the “opening” classrooms where children would be dropped off in the morning prior to their regular staff persons taking them to their regular classrooms. The AV had recently transferred to the older infant classroom, but was dropped off in the young infant classroom. SP1 was sitting at the table preparing items for his/her preschool children, SP2 was sitting in the rocking chair working on the facility’s computer app and contacting the children’s family members about supplies their children needed, and SP3 was in the kitchen area behind the changing table putting away dishes. · SP4 came to the classroom to tell the staff persons that the facility’s washing machine was broken and stood near the first door. SP4 stated that s/he did not pay attention to what the children were doing while s/he talked to the staff persons. SP2 asked SP4 a question about an upcoming required training and while they were talking, a family member (FM2) of another child walked into the classroom holding the AV. FM2 told the staff persons that s/he found the AV in the hallway near the door to SP4’s office by the main entrance door. The AV was not crying and did not appear to be upset. Consistent information was provided that the AV was unsupervised for two to three minutes. · SP1 stated that at the time of the incident, s/he typically would have left the classroom to go to the preschool classroom, but s/he stayed in the young infant classroom for a few extra minutes because SP4 had information to share with the staff persons. SP1 and SP3 each stated that they last recalled the AV dumping out a bin of toys by the table in the classroom, but then were “distracted” by SP4. SP2 stated that s/he last recalled the AV walking around the classroom throwing balls, but was distracted by entering information on the computer app. · Consistent information was provided that while the staff persons were talking, the AV moved the mirror located between the two bookcases enough so that s/he could access the crib area and then walk out the second to the hallway without staff persons noticing. Consistent information was also provided that the second door was “always” closed, but on the day of the incident, when SP4 arrived at the facility, s/he unlocked and opened all of the classroom doors because the person who usually unlocked the doors was not yet there. SP4 pushed the second door open and the other staff persons did not notice that the door was open. SP3 stated that s/he “assumed” the second door to the classroom was closed. None of the staff persons were aware the AV left the classroom until FM2 brought the AV into the classroom. · The staff persons kept a list of the children as they were dropped off in the classroom in the morning. SP2 stated that the staff persons had written down the name of each child as they were dropped off and the staff persons knew how many children were in the classroom. · After the incident, the staff persons placed a second gate between the two bookcases behind the mirror so that the children were unable to access the crib area or the second classroom door. Consistent information was provided that the staff persons received training on supervision of children at each of their monthly meetings. FM1 stated that s/he had no concerns about the care the AV received at the facility and that s/he was “impressed” with the care the AV received. According to the facility’s Risk Reduction Plan, the church building was large and open to the public. The staff persons were to supervise the children at all times and do frequent head counts. The staff persons were to monitor and engage children at all times. When more than one staff person was present, the staff persons were to “remain spread out and supervising different areas.” The children were not allowed to leave any area of the building without the supervision of the staff persons. Facility documentation showed that SP1 – SP4 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies 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: Information from all sources was consistent that on the morning of October 5, 2022, the AV walked out of the infant classroom, into the hallway without staff persons knowledge or supervision, and was found by FM2 by SP4’s off next to the main entrance door of the facility. It was likely that the AV was unsupervised for two to three minutes. SP1, SP2, SP3, and SP4 were in the classroom and unaware that the AV left the classroom which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; a violation of the facility’s policies and procedures; and a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. There was no injury to the AV. Given that the AV was 14 months old, the AV would not have been able to provide for him/herself in an emergency situation, and being unsupervised in the community building’s hallway gave the AV access to dangers throughout including unknown 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 to protect the AV from conditions or actions that seriously endangered the AV’s 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 and/or 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, SP2, SP3, and SP4 were responsible for the maltreatment of the AV for the following reasons: · Facility documentation showed that SP1, SP2, SP3, and SP4 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. · SP4, who was an administrative staff person, came into the room where a conversation began between the four diverting SP1’s, SP2’s, and SP3’s attention away from the supervision of the children. SP1 and SP3 each stated that they were “distracted” by SP4. · SP4 was the person who unlocked and opened the second door and SP1, SP2, and SP3 were the staff persons who were working in the classroom at the time of the incident and responsible for the care and supervision of the children, including 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, SP2, SP3, and SP4 were each responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and 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 the facility’s policies were not adequate for supervising mobile infant children, but that the staff persons followed the policies in place at the time of the incident. After the incident, an additional gate was installed between the crib area and the main section of the area. The staff persons ensured that the second door to the classroom was closed at all times. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, SP3, and SP4 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, each 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 SP1, SP2, SP3, or SP4. The determination that SP1, SP2, SP3, and SP4 were responsible for maltreatment is subject to appeal. On January 11, 2023, the facility was issued a Correction Order for the violation outlined in this report and for failing to report maltreatment as required. 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.
|
