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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: 1089346-CCCC (Certified Child Care Center) Investigator(s): Alice Percy Suspected Maltreatment Reported: It was reported that two alleged victims (AV1 and AV2) left the facility without staff person’s knowledge or supervision. Staff persons were not aware until another child’s parent told them that two children were on a sidewalk next to a street in front of the facility. Date of Incident(s): September 9, 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 September 29, 2022; from documentation at the facility; and through eight interviews conducted with five facility staff persons (SP1, SP2, SP3, P1, and P2), two administrative staff persons (P3 and P4), and AV1’s and AV2’s family member (FM). AV1 was five years years old and enrolled in the school-age classroom and AV2 was three years old and enrolled in the preschool classroom. AV1 and AV2 were siblings. The facility was located in an elementary school on a corner lot with single family housing, open fields, business, and a creek located nearby. The building had streets on two sides that were each 30 miles per hour but also a school zone (20 miles per hour when children were present). Located across the facility from one street was a high school as well as multiple ball fields used by the high school and across the other street was a middle school. The street with the high school, had one sidewalk on the side of the street with the high school and to access the sidewalk a person had to cross the street. There was not a sidewalk on that street on the side with the facility/elementary school. Parking lots were located directly off both streets separating the elementary building from the streets. The parking lot on the side with the ballfields was the North parking lot. An entrance specifically used by the childcare center was located at one end of the building off the North lot. The main entrance to the school was located near the center of the building off the North lot. Inside the school building, the facility’s classrooms were located along a hallway which ended at the facility’s entrance door. A hallway branched off from the facility’s hallway and led to the elementary school classrooms and the school’s main entrance. At the corner of the two hallways was a multiple purpose room (MPR) that was used by both the school and the facility. The MPR had two doors that opened onto the facility hallway, two doors that opened onto the school hallway, a door that opened into a small kitchen, and a door that opened onto the sidewalk next to the school’s main entrance door. The MPR had a television mounted on one wall and there were several tables set up around the room. The outside wall had large windows which looked out onto the parking lot and street. The building had video cameras located in: the MPR; and three outside including, the pick-up area, north parking lot 1 and North parking lot 2. Consistent information was provided that the video recording’s time stamp was not accurate and was ten minutes behind “real time.” A review of videos taken in the MPR and outside the school building was approximately four minutes long and provided the following: · At 5:22:00 p.m., several children and staff persons were walking around the MPR and seated at the tables. · At 5:22:19 p.m. (5:32:19 p.m.), AV1 and AV2 entered the MPR from one of the school hallway doors. AV1 and AV2 were not accompanied by any staff person. AV1 and AV2 walked across the room to the tables, where most of the other children and staff persons were located. Then they walked past the tables and out of range of the video cameras. The video camera did not show them leaving the MPR. · At 5:24:42 p.m. (5:34:42 p.m.), AV1 and AV2 walked into range of pick-up area camera located outside. They walked on the sidewalk in front of the facility and then walked out of range of the video camera. · At 5:25:55 p.m. (5:35:55 p.m.), AV1 and AV2 walked into range of the North parking pot 1 video camera, walked on the sidewalk in front of the school, and then walked out of range of the video camera. · At 5:26:12 p.m., the video ended. The FM stated that on the day of the incident, s/he had a friend (F), who was authorized to pick up AV1 and AV2, pick up AV1 and AV2, but when the F arrived at the facility, AV1 and AV2 were “gone.” The FM learned about the incident from the F, rather than from the staff persons. However, after the children were returned to the facility, P4 telephoned the FM and told him/her about the incident. Prior to the incident, the FM did not have concerns about the care AV1 and AV2 each received at the facility. AV1 provided “different stories” about why they left the facility, including that s/he “wanted to come home,” that s/he was bored, and that s/he was hungry. P1, P2, P3, P4, SP1, SP2, and SP3, and the facility’s documentation provided the following information: · On the afternoon of September 9, 2022, SP1, SP2, and SP3 worked with the school-age children. P1 and P2 worked with the preschool children. At 4:30 p.m., SP1, SP2, and SP3 took the school-age children to the MPR. SP1 stated that AV1 was present at that time. At 5:20 p.m., P1 and P2 took the preschool children to the MPR and the two groups combined and the preschool children put their backpacks in the cubbies. SP1, SP2, and SP3 each stated that neither P1 nor P2 told the other staff persons how many children they brought into the MPR. P1 and P2 each stated that they told SP3 how many preschool children they brought into the room. P2 stated that they also told SP1 how many children they brought to the MPR. · SP1 stated that when the two groups combined, the staff persons looked at the computer app to check which children were present. SP1 was uncertain if the children were counted at that time. When the preschool children arrived in the MPR, most of the school-age children were sitting at the tables. SP2 and SP3 were sitting at the tables interacting with the children and SP1 was “making rounds” within the MPR. At approximately 5:25 p.m., P1 and P2 left the facility since it was the end of their work shift. P1 stated that there were seven preschool children in the MPR when s/he left the facility and s/he believed there were ten school-age children present. P1 did a name-to-face count of the children when they first entered the MPR and counted again before they left the MPR to “make sure” all of the preschool children were present. SP1 and SP3 each believed there were “less than 20” school-age children in the MPR when the preschool children entered the MPR. SP2 believed there were between 25 and 30 children in the school-age group when the preschool children were brought into the MPR. · A few minutes later, another child’s family member (CFM1) entered the MPR from the outside door and told SP1 that there were “two little people” walking down the sidewalk in front of the school. SP1 believed that all of the children were present in the MPR and “didn’t think anything of it” and did not verify that all of the children were present. SP1 stated that there were a lot of children being picked up at the time. SP2 stated that his/her work shift ended at 5:30 p.m., and s/he left the facility prior to anyone noticing that AV1 and AV2 were not present. SP3 stated that s/he saw CFM1 talking to SP1, but did not hear what was said. P3 stated that according to the computer app, at 5:30 p.m., there were 13 children in the combined group. · Approximately five minutes later, a second child’s family member (CFM2) entered the facility and told SP1 that there were two children walking on the sidewalk near the street by themselves. SP1 checked the number of children present with the number on the computer app and realized that the numbers were not accurate and that they were missing two children. SP3 stated that when CFM2 told SP1 about the children on the sidewalk, the staff persons became aware that AV1 and AV2 were not in the MPR. SP1 asked CFM2 to walk back to the children and send a photograph of the children to him/her, which CFM2 did. During that time, the FM’s friend (F), who was authorized to pick up AV1 and AV2, arrived at the facility, but AV1 and AV2 were not at the facility so the F telephoned the FM and left a voice message for him/her. CMF2 walked to the sidewalk in front of the high school building where the children were located and then telephoned SP1 and told him/her that one of the children was AV1. An elementary school staff person was outside and walked back to the facility with AV1 and AV2. SP1 stated that neither AV1 nor AV2 appeared to be upset about the incident. SP1 telephoned the FM and told him/her about the incident. · Later that day, SP1 and P3 watched the facility’s video recording of the incident. P3 also watched the video recording and believed that the AVs were unsupervised for approximately 20 minutes, given the video recording and the time that P1 and P2 clocked out of the facility. P3 stated that the video recording showed that two or three minutes after P1 and P2 brought the preschool children into the MPR, AV1 and AV2 entered the MPR alone from the school hallway. No information was provided as to why AV1 was not in the MPR with the other school-age children or why AV2 did not enter the MPR with the other preschool children. · SP1 believed AV1 and AV2 left the MPR through the door that led to the facility’s hallway and then went out the facility’s entrance door and walked to the street in front of the building. SP1 believed AV1 and AV2 were unsupervised outside for ten to fifteen minutes. Consistent information was provided by SP1, SP2, and SP3 that they did not see AV1 and AV2 leave the MPR. P1 stated that s/he recalled AV1 and AV2 watching a movie on television when P1 left the facility that afternoon. · SP1 stated that the staff persons did not have a written list of the children present, but that there was a computer app that the staff persons used to track which children were present. The computer app was not always accurate because at times the children’s family members did not check the children in or out of their classroom. The staff persons added the information when they became aware that the family members did not do so. P1 stated that prior to leaving the facility that afternoon, s/he ensured that the preschool children were added to the school-age children list on the computer app. P1 recalled looking at the computer app and seeing a total of 17 children, which included seven preschool children and ten school-age children. P2 also stated that there were 17 children in the combined group and that s/he and P1 counted all the children and compared that number to the computer app prior to leaving the MPR. · SP1 stated that approximately every hour, the staff persons counted the children and compared that number to the number of children listed on the computer app. SP2 and SP3 each stated that they had access to the names and numbers of the school-age children on the computer app, but did not have access to the preschool children information. SP3 stated that the staff persons typically counted the children every ten to fifteen minutes, but since s/he did not have access to the preschool lists, s/he only counted the school-age children. SP2 stated that a preschool staff person typically stayed at the facility after the groups combined, but on the day of the incident, that did not occur. · After the incident, the staff persons kept all of the doors in the MPR closed and ensured that the children were frequently counted using name-to-face counting. The school-age children and preschool children were no longer combined in the MPR at the end of the school day. According to Google Maps, the distance between the facility and AV1’s and AV2’s home was 2.5 miles. In order to walk to their home, AV1 and AV2 would have to walk through town and cross a state highway and a creek to reach their home. According to the facility’s Staff Policies & Procedures, the staff persons were responsible for ensuring that all of the children were accounted for at all times. The staff persons were to count the children using name-to-face counting at every transition, whenever moving from one area to another, and at approximately 15 minutes intervals. Facility documentation showed that SP1, SP2, SP3, P1, P2, and P3 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245H.13, subdivision 10 states that staff must supervise each child at all times. Staff are responsible for the ongoing activity of each child, appropriate visual or auditory awareness, physical proximity, and knowledge of activity requirements and each child's needs. Staff must intervene when necessary to ensure a child's safety. In determining the appropriate level of supervision of a child, staff must consider: (1) the age of a child; (2) individual differences and abilities; (3) indoor and outdoor layout of the child care program; and (4) environmental circumstances, hazards, and risks. Conclusion: A. Maltreatment: Information from all sources was consistent that on September 9, 2022, AV1 and AV2 left the facility without the knowledge or supervision of staff persons and were unsupervised in the community for approximately 15 to 20 minutes. This was a violation of the facility’s policies and procedures and a violation of Minnesota Statutes, section 245H.13, subdivision 10. AV1 and AV2 were not injured during the incident. After the incident, AV1 told the FM that s/he left because s/he “wanted to come home,” was bored, and was hungry. AV1 and AV2 were five and three respectively and being alone in the community for approximately 15 to 20 minutes gave AV1 and AV2 access to community dangers including unknown community persons, parking lots, and streets. In addition, staff persons were not aware that AV1 and AV2 were gone for over 20 minutes until they were notified by a second community person at which time they counted the children. AV1 and AV2 were found on the sidewalk by the high school and in order to walk to their home, which was 2 ½ miles from the facility, AV1 and AV2 would have to walk through town and cross a state highway and a creek to reach their home. Therefore, there was a preponderance of the evidence that there was a failure to supply AV1 and AV2 with necessary care and a failure to protect AV1 and AV2 from conditions or actions that seriously endangered AV1’s and AV2’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. Facility documentation showed that SP1, SP2, SP3, P1, and P2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. After the groups of preschool and school-age children combined into the MPR, P1 and P2 left because it was the end of their work shift. P1 and P2 provided consistent information that when they left the MPR, there were 17 children, including AV1 and AV2, in the combined group. At this time, P1 and P2 were no longer responsible for the supervision of children and SP1, SP2, and SP3 were each responsible for the supervision of the children in the MPR, including AV1 and AV2. Therefore, SP1, SP2, and SP3 were each 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, SP2, and SP3 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and AV1 and AV2 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: After the incident, the facility retrained the staff persons on using name-to-face counting of children, counting the children frequently, and being aware of how many children were in the group at all times. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 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, or SP3. The determination that SP1, SP2, and SP3 were responsible for maltreatment is subject to appeal. On January 20, 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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