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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: 1104279-CCC (Child Care Center) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: It was reported that an administrative staff person (SP1) and a staff person (SP2) released an alleged victim (AV) to the care of a community person (CP) who was a parent of another child (C) enrolled in the facility, even though the AV’s family member (FM) did not give permission for the release of the AV to the CP. Date of Incident(s): November 18, 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 December 8, 2022; from documentation at the facility; and through three interviews conducted with SP1, SP2, and the FM. Attempts were made by telephone to contact and interview the CP, but the CP did not respond to the requests for an interview. The AV was three years old and enrolled in the preschool classroom at the time of the incident. The facility was located on the main floor of a multi-level apartment building. Many of the families who attended the facility lived in the apartments on the upper levels. The CP and the FM each lived in the building. The FM stated that prior to the incident, s/he knew the CP, but the CP was not listed on the AV’s emergency card as a person the AV could be released to and the FM was not “comfortable” with the AV going to the CP’s home. The CP did not have the FM’s phone number and contacted the FM through Snapchat to inform the FM that s/he took the AV to his/her home. None of the staff persons contacted the FM to ask for his/her permission for the AV to go home with the CP. The FM was also concerned that the staff persons did not contact him/her when the AV was upset and crying for an extended period prior to leaving the facility with the CP. Two other individuals’ names, who were authorized to pick the AV up, were on the AV’s emergency card. The FM did not understand why the staff persons did not contact him/her or the other two individuals who were on the AV’s emergency card prior to allowing the AV to leave the facility with the CP. The AV’s Emergency Authorization form listed two persons, besides the FM, who were allowed to pick up the AV. The CP’s name and contact information was not listed as one of the authorized persons. SP1 and SP2, and the facility’s documentation provided the following information: · On the afternoon of November 18, 2022, SP2 worked in the preschool classroom with two children, including the AV. The AV was upset, crying, and “having a meltdown” for approximately 30 minutes. SP2 stated that the AV cried, screamed, threw him/herself on the floor, threw items, and attempted to hit SP2. SP2 was unable to calm the AV. At approximately 4 p.m., SP1 entered the classroom to try to calm the AV, but the AV continued to cry. At approximately 4:30 p.m., the CP entered the classroom to pick up the C. The CP asked the AV, who was still crying, if s/he wanted to go with the CP and the C to their home and the AV nodded, stopped crying, and prepared to leave. SP1 asked the CP if s/he communicated to the FM that the AV was leaving with the CP. The CP told SP1 that s/he texted the FM and told him/her that the AV would be at the CP’s home. SP2 stated that s/he asked the CP if s/he was scheduled to pick up the AV and the CP said s/he was. SP2 stated that s/he had “a gut feeling” that they should not release the AV to the care of the CP, but since s/he recently started working at the facility and SP1 “thought it was fine,” SP2 did not feel comfortable raising questions about the AV going with the CP. SP2 stated that at the time, s/he did not know how to access the FM’s contact information. · The CP had packages, his/her toddler child, the C, and the AV, so SP1 offered to walk with them to the CP’s apartment, to help with carrying items. When they arrived at the CP’s apartment, SP1 watched them walk inside and SP1 then returned to the facility. Approximately five minutes later, the FM arrived at the facility and talked to SP2. The FM was “very upset” that the staff persons allowed the CP to take the AV to his/her home. The FM then talked to SP1 and asked SP1 why s/he allowed the AV to leave the facility with the CP and why s/he did not contact the FM when the AV was upset and crying for an extended period. SP1 stated that s/he “agreed with” the FM’s concerns because the CP was not listed on the AV’s emergency card. SP1 stated that s/he did not call the FM to tell him/her the AV was upset and crying because it “was not something [s/he] wanted to bother [the FM] with.” SP1 “assumed” that the FM and the CP were “friendly” and the CP would not offer to take the AV to his/her home if s/he “didn’t think this was okay.” SP1 said, “It was a lot of assumptions on my part.” SP1 also stated that the CP was not on the AV’s emergency card as an authorized person the AV could be released to. · SP2 stated that later, SP1 told SP2 that the incident was SP1’s “fault.” SP1 and SP2 completed an incident report. SP1 reviewed the facility’s policies on releasing children only to the individuals on the emergency cards. · Consistent information was provided that prior to the incident, the facility’s policies required that before a child could leave the facility with someone other than a family member, the staff persons had to ensure that the individual was listed on the child’s emergency card or that the family member provided permission for that individual to pick the child up. According to the facility’s Parent Handbook, children were to be released from the facility “only to those names listed on the most recent emergency card.” According to the facility’s Risk Reduction Plan, the staff persons were to supervise the children at all times. According to the facility’s Policies, Responsibilities, & Procedures, children were only to be released to people listed on the child’s emergency card and the children would not be released if there was any suspicion of danger to the safety of the child. SP1’s unsigned Job Description Job Summary stated, “This position oversees and supervises staff assigned to a specific Head Start center in compliance with program and agency policies and procedures in compliance with the Head Start Performance Standards, MN Rule 3, and State of Minnesota CACFP regulations and requirements.” SP2’s unsigned Job Description Job Summary stated, “This position is primarily responsible for organizing and maintaining the classroom environment and materials, activity preparation, contributing to curriculum plans, daily participation in program with children, and other activities and duties necessary to support the teacher and classroom. This position also directs small group time and manages a caseload of 4-5 children including home visits, documentation and assessments.” Facility documentation showed that SP1 and SP2 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. Minnesota Rules, part 9503.0125, item D, states that the facility must maintain a record of the names and telephone numbers of any persons authorized to take the child from the facility. Conclusion: A. Maltreatment: Information from all sources was consistent that on the afternoon of November 18, 2022, the AV was upset and “having a meltdown.” Neither SP1 nor SP2 were able to calm the AV. When the CP entered the facility to pick up the C, the CP told SP1 and SP2 that the AV could come with the CP and the C to their home. The AV stopped crying and left with the CP and C. The CP was not authorized to take the AV from the facility. Allowing the AV to leave the facility with a community person who was not listed on the AV’s emergency card as an authorized person to pick up the AV, resulted in the AV being without the supervision of a staff person or a person authorized by the FM for an extended period of time. These were violations of Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A; and Minnesota Rules, part 9503.0125, item D, and was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Being unsupervised by a staff person and leaving the facility with an unauthorized community person gave the AV access to community dangers including other 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. Facility documentation showed that SP1 and SP2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. At the time of the incident, SP1 and SP2 were each responsible for the supervision of the children including AV. However, SP1 was a supervisory staff person who had significant administrative authority over the operation of the facility including maintaining compliance with rules and statutes, and supervising staff persons including SP2. SP1 was in the classroom to help the AV calm, allowed the AV to leave with the CP, and walked with the AV, the CP, and the C to the CP’s apartment and left the AV in the apartment with the CP. Therefore, SP2’s responsibility was mitigated and SP1 was 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 was 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 adequate, but were not followed by the staff persons. After the incident, all of the staff persons were retrained on the facility’s policies. 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 SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. On January 27, 2023, the facility was issued a Correction Order for the violations 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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