|
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: 1099182-CCC (Child Care Center) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised on the facility playground between 5 and 10 minutes. Date of Incident(s): November 16, 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 2, 2022; from documentation at the facility; and through four interviews conducted with three facility staff persons (SP1, SP2, and P1) and a supervisory staff person (P2). Attempts were made via phone and U.S. mail to contact and interview the AV’s family member (FM), but the attempts were not successful. The AV was not present at the facility at the time of the site visit. According to the Risk Reduction Plan, the facility had separate playgrounds for each age group, including a preschool playground (which was at the back of the facility near the staff parking lot). The play areas, including the preschool playground, were fenced in and away from “high traffic areas.” The children were walked to the fenced area for outside play. Children were to be supervised at all times while outside and staff persons were to position themselves so that they were in view of children at all times. The children were to form a line when transitioning from one area to another, with one staff person at the front of the line and one at the back. Children were to be counted using a name to face headcount before entering the play area and then every 15 minutes when in the play area. Additionally, children were counted when leaving the play area and when transitioning back to the classroom. The Playground Rules said that “everyone” needed to be actively watching the children. Children were to “always have supervision.” Staff persons were to walk around the playground and have “all areas supervised.” This included the side of the building on the preschool playground where staff persons were not able to see “around the corner.” The AV was approximately four years old at the time of the incident and enrolled in the pre-K classroom. The AV liked cars and using the sensory table. The Internal Investigation Notes and the Accident Report Form provided the following information: · On the afternoon of November 16, 2022, SP1 and SP2 were getting ready to go outside with the pre-K children, including the AV. As they were getting ready to go outside, a preschool aged child from another classroom was added to their class (but only for the outside time and then was to be returned to his/her classroom). SP1 and SP2 then took the children outside. · When it was time to come inside, SP1 and SP2 said that they lined the children up against the playground gate and then counted the children prior to exiting the playground. The AV was a part of this count. SP1 and SP2 then opened the playground gate to begin walking inside. SP2 led the children in while SP1 was at the back of the line. SP1 then shut the gate behind the class as they exited. · Once inside, SP1 and SP2 began assisting the children with taking off their winter gear in the hallway prior to returning to the classroom. The extra student was also returned to his/her classroom. SP1 and SP2 then counted the children again and realized that the AV was not with the class. SP1 then went outside and found the AV “hiding” on the side of the building inside the gated playground. There was no injury to the AV. · SP1 and SP2 “believed” that after the head count on the playground, the AV “ran off and hid” in a corner off to the side of the building where there was no “visibility” from the gate area. · A supervisory staff person (P3) viewed video footage of the incident (which P3 sent to this investigator but did not work). Video footage showed that around 4:15 p.m., the AV was unsupervised for four minutes and 22 second in the “enclosed gated playground.” Video footage showed that SP1 and SP2 “did well supervising” the children. While they were outside, two children were picked up by their parents to go home. SP1 and SP2 then lined the children up to go inside. However, during this time, another parent came to pick up a child so one staff person (it was not identified if this was SP1 or SP2) was “checking out” that child (while still in the play area). During this, the AV was seen walking out of view from the camera towards the other side of the playground. SP1 and SP2 then went inside. · With the child count being changed four times during the time they went outside, a “miscount appeared to happen.” · SP2 had just started working at the facility around the time of the incident. However, SP1 was “familiar” with the “routines.” · The AV had special needs and had “multiple” instances of “running off” and hiding. [Note: A Behavior Incident Report dated May 10 and 13, 2022, showed that the AV ran out of the classroom and on June 15, 2022, the AV “ran away” from staff persons, including running out the classroom door.] The AV was a “flight risk.” The facility had “expressed concerns” to the FM regarding their “ability to provide appropriate care” to the AV as s/he had “such high needs.” The FM was “open to feedback” and “agreed to complete a special education variance.” The facility also notified the AV’s special education teacher to continue “discussions” for needs, accommodations, and supports. P1 provided the following information: · On November 16, 2022, around 4:15 p.m., the AV’s classroom came inside from the playground. Once SP1 and SP2 helped the children get off their snow gear, SP1 and SP2 asked P1 (who was in his/her own classroom) if the AV was “still here.” The AV’s classroom and P1’s classroom typically combined at the end of the day, which they were doing when the AV’s class came inside. P1 told SP1 and SP2 that the AV was in their class and that s/he had not seen the AV. SP1 and SP2 then looked on the classroom app and saw that the AV was “still clocked in.” · SP1 and SP2 then ran outside. When they returned, SP1 said that the AV was standing at the gate of the playground, in the enclosed part of the playground. · P1 was told that the AV was in line prior to coming inside so P1 did not know what happened that the AV was left unsupervised. P1 then told supervisory staff persons, including P3, about the incident.
· Staff persons were trained to do name to face counts of the children using the classroom app. Staff persons lined the children up prior to coming inside to make sure staff persons had the “correct number.” P1 normally saw SP1 and SP2 do head counts. · There were no injuries to the AV and P1 was not aware of the AV crying. However, risks to the AV being unsupervised included that the AV was a “climber” and could have climbed the fence and “fallen or gotten hurt.” The AV was dressed appropriately but could have been “freezing” as it was cold outside. The AV could not have opened the gate to open the fence because the “latch” was “way at the top.” P1 did not know how tall the fence was but said that s/he was 64 inches tall and that the gate was taller than him/her. Community persons could have also opened the gate. · The AV was a “flight risk” and “tries to run off” but there were no other incidents where the AV was unsupervised. The AV had a history of leaving the line so P1 normally liked to hold the AV’s hand when walking inside. The AV also liked to go around the corner of the playground so P1 would walk around the playground to supervise all areas. P2 provided the following information: · On the afternoon of November 16, 2022, the pre-K children were getting ready to go outside so P2 assisted the children with getting ready. P2 then returned to the office. · Around 4:30 p.m., P1 told P2 and P3 that the AV was left outside between 5 and 10 minutes. There were no injuries to the AV. P2 said that risks to the AV being unsupervised could have included the AV climbing on things, including a slide. The playground was not locked so it was “possible” that a community person could have opened the gate. However, the playground was “away from view of potential people walking by.” The AV was dressed appropriately for the weather. · P2 then spoke to SP2 who said that s/he lined the children up and “thought” everyone had come inside. · Staff persons had a clipboard with a list of children and staff persons were trained to do name to face head counts. Staff persons were to count when leaving the playground and going into the facility. · At some point after the incident, P2 saw video footage of the incident. The video footage showed the AV’s classroom playing outside and SP1 and SP2 “gathering the kids.” At some point, P2 noticed the AV walking a “little to the right side” and then the AV disappeared from the camera view. P2 did not see the AV go inside with the class. About two and a half minutes later, the AV appeared “back in the camera view” and was “looking around.” SP1 then came outside to get the AV. The AV was unsupervised for approximately four and a half minutes. · There were no similar incidents with children, including the AV. However, the AV was “active” and could be “sneaky” during transitions so staff persons held the AV’s hand or stayed close by as the AV could be “easily distracted.” SP1 provided the following information: · SP1 did not recall the date of the incident but on that date, towards the end of the day, SP1 and SP2 took the children outside. SP1 was “overwhelmed” as it was the end of the day. Additionally, as they were going out, a child from another room was added to their classroom. There were 11 children when the classroom initially went outside (including with the added child) and the classroom was in ratio. However, while they were outside, two children left with their parents, so there were 9 total. SP2 was also a new staff person so SP1 was “teaching” SP2 how to document the head counts on the attendance record. · Around 4 or 4:30 p.m., SP1 and SP2 lined the children up, including the AV, against a wall within the playground prior to coming inside and counted to make sure they had all the kids. SP1 was either at the front or the back of the line and SP2 was at the other end and they took the children inside. Approximately five minutes after getting inside and getting the children undressed, SP1 and SP2 did another head count and noticed that the AV was “missing.” SP1 then “booked it outside” and saw the AV inside the fenced in playground “completely safe.” The AV “laughed” and “apparently had a good time.” SP1 brought the AV inside and then “checked [the AV] over” to ensure that “nothing was wrong.” The AV was “completely fine” and had no injuries. The AV was unsupervised for approximately five minutes. · Risks to the AV being unsupervised included the AV getting injured from the playground equipment. The AV could not have gotten out of the fence because the AV was “definitely not tall enough to reach” the lever to push the gate open. However, someone from the outside could have opened the gate to access the AV. The AV was dressed appropriately for the weather. · SP1 felt “kind of guilty” about the incident as s/he was the “experienced” staff person in the classroom “and did not check” to ensure s/he had the AV prior to coming inside. Staff persons were trained to do head counts prior to going outside and at the gate prior to coming inside, which SP1 and SP2 did. SP1 thought that the AV left as SP1 and SP2 were “gathering the kids” prior to coming inside. When there were two staff persons in a classroom, both staff persons were responsible for doing the headcounts so that they could compare and “check [their] numbers.” SP1 typically checked the playground, including the “hiding hole [corner],” every 5 to 10 minutes. · The AV “liked to run off.” This included that if staff persons left the classroom door open, the AV would “sometimes” run out. Because of this, SP1 said that s/he should have been looking for the AV “more than [s/he] did.” SP2 provided the following information: · The incident occurred on SP2’s second day while working at the facility. SP2 did not recall the date but said that it was a “Wednesday.” At some point in the afternoon, SP1 and SP2 took the children outside. As SP1 and SP2 were lining up at the door to go outside, another child was added to their classroom from the “next door” classroom, as classrooms sometimes combined at the end of the day. With the added child, there were 11 children. Since it was only SP2’s second day, s/he did not know to “add” the additional child to the attendance sheet. SP2 also “did not know” if s/he told SP1 that there was another child added to their classroom. SP2 did not know if the staff person who added the child also told SP1, as SP2 was at the front of the line and SP1 was at the back of the line. SP1 and SP2 then counted the children and went outside. · While they were outside, approximately two to three parents came to pick up their children so the count was “continuously changing.” It was “difficult” because every time that a child left, SP1 and SP2 had to “re-count.” There was a “notebook” to check children “in and out” and there was a “lot going on.” At some point, SP2 asked SP1 how many children they had as SP1 was “signing” the children that were leaving in and out. · Around 3:30 or 4 p.m., SP1 and SP2 began lining the children up to go inside. At that time, SP2 thought that s/he was in the back of the line. SP1 and SP2 counted the children at that time and SP2 “thought” that s/he and SP1 did the count “right.” SP2 then “looked around the playground” and saw that “every kid within our vision was with us.” SP1 and SP2 then took the children inside and began getting their snow gear off. During this time, SP2 saw paperwork for the AV but did “not see the AV.” SP2 then began looking around for the AV but the AV was “not there.” SP2 then made “eye contact” with SP1 who then said, “Oh no,” and “ran back outside.” SP1 found the AV outside in the enclosed playground sitting and playing in the snow. The gate was shut and there were no nearby cars that could “get to” the AV. · There were no injuries to the AV from being unsupervised. Risks to the AV being unsupervised included the AV being “cold” or getting frostbite as the AV “tended” to “lose” his/her winter gear. However, the AV was dressed appropriately when SP2 saw the AV outside. The AV could have also “fallen,” including off a swing. SP2 did not think that the AV was tall enough to unlock the “child lock” to get out of the play area as the lock was “really tall.” However, a community person could have opened the playground gate. · There was a place on the play area that staff persons could not “see at all times.” The facility was trying to “fix” that spot but needed to wait until the weather was warmer to install a new fence there. · The AV was a “runner” and did not “follow directions.” The AV needed “one to one care” which was “hard” with two staff persons.
· SP2 did not see the video footage but heard that the AV “ran” and was “out of view.” SP1 and SP2 counted correctly but “forgot” that they had the additional child in their class and when they did the count, the AV was “out of view.” · Although it was only SP2’s second day working at the facility, SP2 was trained on the policies and procedures. SP2 also observed staff persons doing head counts. SP2 was not aware that s/he was supposed to do name to face headcounts at the time of the incident and just thought that s/he had to have the “right head count” number that was on the attendance sheet. Facility documentation showed that SP1, SP2, P1, and P2 received training on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. P1 and P2 were also trained on Playground Rules. SP1 and SP2 were also trained on “attendance sheets,” “face to name” checks, and “counting heads throughout [the] day.” Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A, state that “supervision” means 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; and that children are required to be supervised at all times. Conclusion: Information was consistent that on November 16, 2022, the AV’s classroom went outside to the playground with SP1 and SP2. As they were coming in, SP1 and SP2 lined the children up at the gate and counted the children. SP1 said that the AV was part of that count but SP2 said that the AV was “out of view.” They then gathered the children and came inside. P3 said that the video footage showed that while the children were lined up, another parent came to pick up a child and during this, the AV was seen walking out of view from the camera towards the other side of the playground. SP1 said that they did another head count after they were inside and had removed their outdoor gear and realized that the AV was not present. SP1 then went back outside and found the AV on the enclosed playground. There were no injuries to the AV. Video footage reviewed by P3 showed that the AV was unsupervised for 4 minutes and 22 seconds, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A. Minnesota Statutes, section 260E. 30, subdivision 3 states that rather than making a determination of substantiated maltreatment by an individual, the commissioner of human services shall determine that a nonmaltreatment mistake was made by the individual. A nonmaltreatment mistake occurs when: (1) at the time of the incident, the individual was performing duties identified in the center's child care program plan; (2) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; (4) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; and (5) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing requirements relevant to the incident. Although the AV was left unsupervised on the facility playground for 4 minutes and 22 seconds, SP1’s and SP2’s actions or conduct was determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, SP1 and SP2 were each performing job related duties, as require by the facility’s policies, by lining up the children and doing head counts; assisting children with getting their winter gear off; and interacting with a parent during pick up; (2) Neither SP1 nor SP2 had been determined responsible for any previous incident that resulted in a finding of maltreatment; (3) Neither SP1 nor SP2 had been determined to have committed a nonmaltreatment mistake under this paragraph; (4) The AV was uninjured and did not require medical care after the incident; and (5) Except for the period when the incident occurred, the facility, SP1, and SP2 were each in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake to the AV by SP1 and SP2 was not maltreatment. It was not 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. 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.) Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate. However, the facility did not currently have a procedure in place when “temporarily” transitioning a child to another classroom and that was “being reviewed.” Policies and procedures were “partially” followed as staff persons did head counts and supervised the children appropriately while on the playground. However, they were “not upheld” after the three children left with their parents which resulted in an “error in counting” upon returning inside. The facility was completing an “entire review” of policies and procedures. There were no similar instances of the AV being unsupervised. However, the AV had special needs and it was documented the need for “additional supervision due to behaviors and flight risk.” Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which SP1 and SP2 were responsible met the criteria to be determined a nonmaltreatment mistake. SP1 and SP2 were notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP1 and SP2 were responsible might not be considered a nonmaltreatment mistake. On April 26, 2023, the facility was issued a Correction Order for the violation outlined in this report and for failing to develop an individual child care program plan for the AV. 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.
|
