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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: 1082346-CCC (Child Care Center) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: It was reported that a staff person (SP) left an alleged victim (AV) unsupervised in a classroom for approximately 35 minutes. Date of Incident(s): January 5, 2023 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 January 20, 2023; from documentation at the facility; and through two interviews conducted with a facility staff person (P1) and administrative staff person (P2). Although the SP initially agreed to an interview and a time was set up for an interview, the SP did not respond to the subsequent telephone call and additional messages. Attempts were made to contact the AV’s family member (FM) by telephone and letter, but the FM did not respond to the requests for an interview. The AV was four years old and enrolled in the preschool classroom at the time of the incident. The preschool classroom was a large rectangular room with tables and chairs placed on one end of the classroom near the door to the hallway. Short bookcases were spread around the classroom. Consistent information was provided that during nap time, the children’s cots were placed around the area of the classroom opposite the hallway door. In one area, one of the short bookcases obscured the view of one or two cots placed behind it and it was necessary to walk to the other side of the bookcase to see the cots or the children on them. The AV’s cot was one of the cots placed behind the bookcase. A video camera was located in the preschool classroom near the door to the hallway. A review of a video recording from the time of the incident showed the following: · At the beginning of the video, the time stamp was 3:09 p.m. The SP and P1 were in the classroom, the children were lined up near the door. The cots were on the floor at the back of the classroom. · At 3:09:36, the entire group left the classroom. · At 3:10:12, a child, the child’s family member, and the SP entered the classroom. The child and his/her family member gathered the child’s outerwear and belongings and the SP gathered the other children’s outerwear. · At 3:11:17, the SP left the classroom with the outerwear. · At 3:12:54, the child and his/her family member left the classroom. · At 3:13:05, the SP returned to the classroom. The SP walked around the classroom straightening up items, and picking up toys and putting them away. At one point, the SP placed toys on a book case that was located next to the AV’s cot. · At 3:14:39, the SP left the classroom carrying papers and shoes. · At 3:34:52, the SP entered the classroom, walked to the back of the classroom, and picked up the AV from a cot next to a bookcase. · At 3:35:17, the SP left the classroom carrying the AV. P1 and P2, and the facility’s documentation provided the following information: · On January 5, 2023, the SP supervised one group of 13 preschool children in a preschool classroom during naptime. (This was in accordance with Minnesota Statutes.) P1 worked with another group of four preschool children in another preschool classroom. At approximately 3 p.m., after the children woke from naptime, P1 took his/her group of children to the SP’s classroom to combine the two groups, as P2 had directed him/her to do. However, the SP told P1 to return his/her group of children to P1’s classroom and the SP also took his/her group of children to P1’s classroom. The SP did not tell P1 why s/he wanted P1 to take all of the children to P1’s classroom. P1 stated that when they returned to P1’s classroom, s/he counted the children s/he had in his/her group and the SP counted the children in his/her group. At that time, P1 did not know how many children the SP had in his/her group. P1 and the SP each had a list of the children in their respective group and P1 added the SP’s list to his/her list. While they were in P1’s classroom, the SP left “a couple of times,” but P1 did not know why or where the SP went. At some point, P1 went through the SP’s list of children and saw the AV’s name at the bottom of the list. · While s/he was checking the two lists of children and combining them, P1 asked the SP where the AV was because the AV’s sibling was in P1’s classroom and the two children “always came [to the facility] together.” The SP told P1 that s/he “didn’t think” the AV was at the facility that day. The SP then left the classroom and returned to P1’s classroom carrying the AV. The AV was not crying or upset and was still sleeping. P1 saw the AV and asked, “I thought [s/he] wasn’t here?” and the SP replied, “I didn’t see [him/her].” The SP did not provide any additional information to P1 about where s/he found the AV. P1 was “afraid” to tell anyone about the incident that day, but told an administrative staff person (P3) the following morning. · P2 stated that when P3 learned about the incident, P3 immediately called P2 and told him/her about the incident. The following workday, P2 talked to the SP about the incident. The SP did not have a reason for the AV being left unsupervised in the classroom. P2 stated that s/he also watched the classroom’s video. After taking his/her children to P1’s classroom, the SP returned to his/her classroom at least twice. One time, s/he accompanied a parent who was picking up his/her child when they went to get that child’s outerwear. The SP gathered the other children’s outerwear and took it out of the classroom. The SP also returned to the classroom to pick up toys. P2 said, that according to the video, the SP returned toys to a bookcase next to where the AV was sleeping on his/her cot. · P2 stated that there was no unqualified substitute working in the classroom at the time of the incident and no unqualified substitute list was provided. Prior to the incident, all of the staff persons had recently received training on supervising and counting children during transitions. According to the facility’s Welcome to Day One training, all children must be within sight and hearing at all times and children must never be left unsupervised. The staff persons were trained to always know “the exact number of children you are responsible for, their names, and where they are at all times.” In addition, children “must always be supervised on the playground.” Attendance was to be taken by both counting and name to face recognition during major transitions, including going outside and going back into the facility or when leaving one area and arriving at another. The SP’s job description was signed by the SP and showed that s/he was a child care aide. The first principal duty and responsibility stated, “Supervise and ensure the safety and well-being of children at all times, being alert to the needs and/or problems of the children as individuals and as a group.” Facility documentation showed that the SP, P1, and P2 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 9503.0040, subpart 2, item D, subitem (1) states that the license holder must ensure that staff distributions are met and the first staff member needed to meet the required staff-to-child ratio must be a teacher. Conclusion: A. Maltreatment: Information from all sources was consistent that on the afternoon of January 5, 2023, the AV was left in the facility’s preschool classroom without the knowledge or supervision of a staff person for approximately 35 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The SP was not aware that the AV remained sleeping on a cot in the classroom when s/he took the other children to another classroom, which 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. Although the classroom was designed for the use of preschool children, the AV was unsupervised in the classroom for an extended period of time with no staff person available to intervene if the AV had attempted to do something dangerous, had injured him/herself, or 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 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. At the time of the incident, the SP was responsible for the supervision of the AV while in the classroom. However, there was no other staff person working in the classroom after the children awoke and because s/he was a child care aide, the SP was not allowed to work without a teacher and/or assistant teacher. In addition, P1 was also a child care aide, so when the SP and P1 combined their children into one classrooms they were not allowed to work without a teacher and/or assistant teacher. P2 stated that there was no unqualified substitute working in the classroom at the time of the incident and no unqualified substitute list was provided. Therefore, these were each violations of Minnesota Rules, part 9503.0040, subpart 2. The facility’s failure to ensure staff distributions were met does not mitigate the SP’s responsibility because facility documentation showed that the SP received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident; and the SP signed his/her job description where the first principal duty and responsibility stated in part, “Supervise and ensure the safety and well-being of children at all times . . .” The SP 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 maltreatment for which the SP was responsible in this report was not serious or recurring. However, information obtained by the Department of Human Services, in combination with this report, would result in the SP being disqualified for recurring maltreatment. 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 SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. On March 15, 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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