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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: 830650-CCC (Child Care Center) Investigator(s): Danielle Morrison/Thomas Nixon Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised on a playground when two staff persons (SP1 and SP2) brought the classroom inside. Date of Incident(s): October 24, 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 8, 2022; from documentation at the facility; and through five interviews conducted with three staff persons (SP1, SP2, and P2), a supervisory staff person (P1), and the AV’s family member (FM). The AV was unable to provide information about the incident due to his/her age. The facility was located in a strip mall and had a playground located behind the strip mall immediately adjacent to a parking lot and a mall road. Single-family housing was also near the playground. The playground was enclosed with a chain-link fence that had plastic strips throughout that minimized a person’s ability to see through the fence and was divided into two (preschool and toddler) by a chain-link fence that did not have the plastic strips. The facility had a toddler classroom and an infant classroom that were connected via a door and each had windows in the classroom that looked onto the preschool playground. The toddler classroom also had a glass door that opened onto the preschool playground. The toddler playground was accessed from the preschool portion of the playground through a gate. The preschool playground had a slide that was approximately eight feet tall. The AV was 20 months old at the time of the incident and enrolled in the toddler classroom. At the time of the incident there were 13 toddlers the toddler classroom. According to Weather in Bloomington, October 24 – Detailed Weather Forecast for October 24 in Bloomington, Minnesota, United States (world-weather.info), on October 24, 2022, at 11:00 a. m. it was cloudy and 55 degrees Fahrenheit. The facility’s Risk Reduction Plan stated, “Staff are trained in how to position themselves in order to supervise all areas of the playground,” and “Staff are trained in Name to Face and utilize at every transition.” Staff persons were to complete a Name to Face protocol to ensure an accurate count of the children upon arrival and departures, during each transitions time, when moving to and from Special Classes, and during field trips. The Name to Face protocol form included the names of the children present and for staff to initial verifying the children are within sight and sound supervision of the staff person during the required instances. The FM said that P1 called him/her within one hour of the incident telling the FM that the AV was left on the preschool playground unsupervised for approximately five minutes. The FM was told the AV was “fine” and currently eating lunch. The FM had no other concerns about the program. P2 provided the following information: · On the day of the incident, P2 was working in the facility’s infant classroom and saw out the window that the AV was on the preschool playground alone without a staff person. P2 went into the toddler classroom and told SP1 and SP2 that the AV was outside alone. At that time, SP1 and SP2 were in the process of lunch. SP1 and SP2 did not say anything to P2. · P2 then went out to the playground and got the AV who was halfway up the steps to a slide. P2 brought the AV inside to the toddler classroom. · At that time, P2 looked at a clock and noted that it was 11:15 a.m. P2 said that based on the usual transition times, the AV was likely outside unsupervised for up to 15 minutes. P2 said the AV was smiling and laughing during the incident. P2 then told P1 about the incident. The Toddler Room Daily Schedule from the facility showed the toddler schedule for outside either 10:15 to 10:45 a.m. followed by stories from 10:45 to 11 a.m. or outside from 10:30 to 11:00 a.m. For both options, lunch was scheduled from 11 to 11:30 a.m. SP1 and SP2 did not recall the exact time they went outside on October 24, 2022. SP1 provided the following information: · On the day of the incident, SP1 and SP2 were working in classroom with thirteen toddlers. SP1 did not remember what time they went outside, but thought they were outside on the toddler playground for 25 to 30 minutes prior to lunch time. Approximately five minutes after getting to the playground, SP2 returned inside to prepare for lunch, which was typical. This left SP1 out of ratio supervising thirteen children on the playground. When it was time to go inside, SP1 counted the thirteen children on the toddler playground. As the group walked through the preschool playground towards the door, SP2 opened the door from inside the toddler classroom and allowed the children to enter prior SP1 counting the children a second time. At that time, SP1 noticed that two children, not including the AV, were still on the preschool playground and not walking inside with the others. SP1 encouraged them to come inside by saying, “Goodbye,” and “I’m leaving,” trying to get them to follow. The two children came and at that time, SP1 did not notice that the AV was still outside. · SP1 stated s/he did not have an opportunity to count the children when s/he returned into the classroom because s/he removed his/her coat and assisted children to remove their jackets and wash their hands. At this time, SP2 also washed the children’s hands and got ready for lunch. SP1 and SP2 then saw that there was an extra place setting for lunch and discussed why and whether they had made an extra one. As they were talking, P2 entered the room and stated the AV had been left outside. SP1 believed the AV was outside for no longer than five minutes and upon return the AV showed no signs of distress. · SP1 said s/he had not completed the Name to Face protocol during the incident, which would have been going down the list and calling out each child’s name and marking their presence during the transition to a new area. SP1 instead attempted to do a headcount during the incident. · SP1 stated s/he was never trained that it was okay to come inside early to set up items for lunch. A week prior to the incident, SP1 brought a child who was not feeling well inside and s/he was talked to about the need to be in ratio. At this time, SP1 expressed that s/he was “normally” being left out of ratio by SP2. SP2 provided the following information: · SP2 stated that SP1 arrived to the classroom about 10:00 a.m. and at some point after they brought the children outside to the toddler playground. Around 10:45 a.m., SP2 went inside to prepare lunch as s/he was trained when s/he hired. (Note: P1 denied this was how program staff persons are trained). SP2 said staff “typically” rotated days with one staff person being outside with the children and the other staff person being inside the last 15 minutes preparing for lunch. SP2 went inside and prepared lunch items which included getting the spoons and cups from the kitchen where P1 was working, going to the classroom and setting the table, getting the food ready, and pouring the milk. SP2 believed that around 11:02 or 11:03 a.m., as s/he set up for lunch, SP1 brought the children into the classroom and was in the process of assisting the children with washing their hands and sitting down at the table. SP2 said that typically s/he would have returned to the playground to assist the outside staff person with the transition of children back inside. · While SP2 was assisting the children with their removing coats, washing their hands, and sitting down, SP2 stated s/he did not complete a Name to Face process. SP2 stated s/he and SP1 noticed there was an extra place setting that did not appear to have an assigned child and discussed why that might be. During this time, P2 came into the classroom and stated that the AV was outside on the playground unsupervised. P2 then went outside to the playground and brought the AV back into the classroom. SP2 observed the AV did not appear distressed by the situation and ate his/her meal. SP2 said that the AV was likely on the playground unsupervised for five minutes. P1 provided the following information: · P1 and another staff person were in the kitchen preparing lunch items when the incident occurred. · After distributing lunch, P1 was in his/her office when P2 told him/her that the AV was left outside unsupervised and P2 returned the AV to the toddler classroom. P1 spoke with SP1 and SP2 about the incident and neither provided much information about what occurred. P1 said both SP1 and SP2 had performance issues in the past unrelated to supervision. · P1 said that standard practice was that staff persons would be with the children the entirety of the time while outside, would be in ratio for supervision and transitions, and lunch would be ready when they entered the room. SP1 and SP2 were not involved with preparing of meals and/or food as this was completed by other available staff persons. · Typically staff were to get the plates for meals, assist the children with washing hands, get them sat at the table, and disperse the food. On occasion P1 had seen staff persons come back inside to get plates prepared before the children returned to the classroom, which was no longer than five minutes. That staff person would then return to the playground to assist with the children’s transition back inside the classroom. P1 said this was not how staff were trained and spoke to SP1 and SP2 about the need to stay together and in ratio. · Staff persons were trained through PowerPoint on how to complete the Name to Face procedure for every transition, there was a paper chart for staff persons to utilize to indicate transitions throughout the day, and an app used for child attendance and childcare management. · Even though staff persons were not trained to do so, P1 was aware that staff persons left the playground for up to five minutes to get plates ready, leaving a teacher out of ratio, but that staff persons were to be back outside to transition the classroom inside. SP1 and SP2 were trained on the facility’s policies and procedures, including the Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. Relevant Rules and Statutes: 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. Minnesota Rules, part 9503.0040, subpart 1, states that minimally acceptable staff to child ratio for toddlers is 1:7. Conclusion: A. Maltreatment: On October 24, 2022, around 11 a.m., the AV was left unsupervised on the playground without staff persons knowledge for between five and fifteen minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Leaving the AV, who was 20 months old, unsupervised outside on a playground that was visible and adjacent to community dangers including a parking lot, a mall road, and single-family housing, exposed the AV to community dangers. 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 his/her 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; 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 and SP2 were trained on the facility’s policies and procedures, the Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. Although SP1 and SP2 differed on the amount of time, both provided consistent information that SP1 was left alone on the playground with 13 children, which was a violation of Minnesota Rules, part 9503.0040, subpart 1. However, SP1 was aware that SP2 went inside so this did not mitigate SP1’s or SP2’s responsibility to ensure that all the children arrived back inside. Although SP2 was inside when SP1 and the children came inside, each was responsible for the care and supervision of the children, including the AV, and were responsible for ensuring all of the children returned into the classroom. Therefore, SP1 and SP2 were each 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 or serious, it was a single incident for which the AV did not sustain a serious 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 conducted an Internal Review and found the policies and procedures were adequate, but not followed by SP1 and SP2. SP1 was given a Performance Improvement Plan notice and retrained on the Name to Face procedure. SP2 no longer worked at the facility. Additional Name to Face training was provided by the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were 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. The determination that SP1 and SP2 were responsible for maltreatment is subject to appeal. On February 1, 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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