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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: 1055385-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unattended in the gym and was returned to his/her classroom by a maintenance worker (MW). Date of Incident(s): January 26, 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 February 17, 2023; from documentation at the facility; and through six interviews conducted with two supervisory staff persons (P1 and P2), two facility staff persons (SP1 and SP2), the MW, and the AV’s family member (FM). The facility was a multi-level facility with multiple classrooms located along various hallways. Each classroom was named after a country. On the first level there was a gym with a foyer area right outside of it that had stairs leading to a second level. There was an exit door in the foyer that led outside towards a small parking lot. Hwy 55 was 208 feet away from this exit door. On the second level there were two bathrooms across the hallway from the Japan classroom. On the third level there were several classrooms, including the France preschool classroom. The AV was 4 years old at the time of the incident and enrolled in the France preschool classroom. The facility’s Risk Reduction Plan stated, “Supervision Training: Children are withing sight and sound at all times. Head counts are completed before leaving the classroom, during the transition, and when the class arrives at their new classroom.” On January 26, 2023, the MW walked downstairs to the foyer area outside of the gym and saw the AV at the bottom of the stairs alone. The MW asked the AV what s/he was doing there and the AV’s name. The AV replied, “I belong in France.” The MW asked, “Where is you teacher?” and the AV replied, “I am going there now.” The MW took the AV’s hand, and the AV led the way. The MW and the AV went up two flights of stairs and ran into P1. The MW stated that the AV did not seem “upset or distressed.” The facility’s Internal Report, P1, and P2, provided the following information: · On January 26, 2023, the France classroom left the gym on the first floor around 11:30 a.m., went up the stairs, and stopped at the bathrooms right outside of the Japan classroom on the second floor. While SP1 waited with a group of children in the hallway, SP2 had the rest of the children in the bathroom, and they were switching out children as they finished their bathroom time. At one point, SP1 took his/her group of children upstairs to the third floor, counting 13 children. SP2 had 6 children in the bathroom with him/her that SP2 brought back to the France classroom when they were finished. · Around 11:45 a.m. P1 ran into the MW who walked the AV back to the France classroom. The MW told P1 s/he found the AV in the foyer. P1 thanked the MW and brought the AV back into the France classroom. P1 said it looked like the children had just started table activities, and it was evident they just returned. P1 said SP1 and SP2 were “shocked.” P1 told SP1 and SP2, “You need to make sure you do a head count when you return to the room.” P1 left to go find P2. · The AV told P1 and P2 s/he was waiting in the hallway with SP1, got “bored,” and wanted to try out “flips” and there was not enough space in the hallway, so the AV went back down to the gym. · P1 said that SP1 said s/he had 13 children and SP2 said s/he had 6 children. They did not communicate. P2 said “each one assumed that the other teacher had leftover kids. Neither one confirmed the amount the other one had.” P2 said s/he did not believe a head count was done when all the children returned to the France classroom, otherwise SP1 and SP2 would have noticed they were “short a kid.” SP1 and SP2 told P1 they did not do a head count once in the France classroom. Based on when the France classroom left the gym and when P1 returned the AV to the France classroom, P1 and P2 estimated it was between 5 and 15 minutes that the AV was left unsupervised. The FM was aware of what had happened and was grateful that the AV did not go outside in the cold. The AV told the FM the class was just standing there, and the AV wanted to do “flips.” The FM explained that when the AV did “flips” it was really just the AV running and jumping. The FM said there had not been issues before with SP1 and SP2. Facility documentation showed that on January 26, 2023, the France classroom had 12 of one gender of children in attendance and 8 of the other gender. SP1 and SP2 provided the following information: · SP1 and SP2 provided consistent information that on the day of the incident, they left the gym and stopped with the children at the two bathrooms on the second level. · SP2 stated that s/he did the full headcount of all 20 children that day when the France classroom left the gym. SP2 led the way and SP1 followed behind the group. · SP1 said the AV was telling SP1 that s/he wanted to do “flips” as they were leaving the gym. SP1 said the group went into the two bathrooms based on gender. SP1 had one gender and SP2 had the other. The AV was in the bathroom with SP1 and when that group was done, they lined up in the hallway. SP1 told SP2, s/he was taking his/her group back to the France classroom. SP1 did not tell SP2 how many s/he was taking but based on how they split the group up by gender SP2 would have the remaining children. · SP1 thought s/he had 13 children in her group when s/he went upstairs to the France classroom from the bathroom. SP2 was still in the bathroom with his/her group. SP1 remembered the AV being with the group at the bathrooms and the AV must have left to go back down to the gym to do “flips” as SP1 led his/her group back to the France classroom. · SP1 did not do a headcount when s/he returned to the France classroom with his/her group. SP2 returned with his/her group of children and SP1 said the children were finding spots for lunch when P1 brought the AV back into the classroom a couple of minutes later. P1 said, “You did not have [the AV] with you and [the MW] found [the AV].” SP1 thought the AV was with him/her. · At the bathrooms SP2 said SP1 stood out in the hallway while SP2 was in the bathroom so they had direct supervision of the children. When they got down to the final six children SP2 told SP1 s/he had six children in his/her group in the bathroom when SP1 said s/he was taking his/her group back upstairs. SP2 “assumed” SP1 had the remaining 14 children. SP2 stated that they would typically split the group up by gender to take them to the bathroom and that day they had six of one gender. · SP2 said when his/her group finished in the bathroom they went to the France classroom. The children were playing with transition toys or reading books before lunch time. It was about three minutes after the whole group was back in the classroom, that SP2 counted and realized they did not have the AV, and as SP2 realized it, P1 walked into the France classroom with the AV. SP2 said neither P1 nor P2 asked SP2 if s/he did a headcount once in the France classroom. SP1, SP2, P1, and P2 each stated that a headcount should have been done when leaving the gym and then when entering the France classroom. SP1, SP2, P1, and P2 were trained on supervision 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 9503.0155, subpart 15, states that kitchen, stairs and other hazardous areas must be inaccessible to children except during periods of supervised use. Conclusion: A. Maltreatment: On January 26, 2023, SP1 and SP2 left the gym on the first floor with the children and stopped to use the bathrooms on the second level. At that point, SP1 and SP2 split the group up to use the bathroom and then SP1 took a group up to the France classroom on the third level while SP2 stayed with the remaining group using the bathroom. It was during this split that SP1 thought the AV went back down to the gym to practice “flips” where the AV was later found by the MW who walked back with the AV to the third level where they ran into P1. P1 then brought the AV back into the France classroom. It was estimated that the AV was without supervision for 5 to 15 minutes which was in violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. In addition, the AV was without supervision on the first level where the gym was while the classroom was on the third level with two sets of stairs between that were accessible to the AV while the AV was not supervised which was a violation of Minnesota Rules 9503.0155, subpart 15. On January 26, 2023, the attendance for the France classroom showed 8 of one gender and 12 of another gender for a total of 20 children. SP2 counted 20 children when the France classroom left the gym and made their way to the bathrooms on the second level. SP1 had the AV in the bathroom with him/her and did a headcount in the hallway before heading to the third level and “thought” s/he had 13 children. SP2 said that when SP1 left with his/her group SP2 had 6 children in the bathroom still. SP1 did not tell SP2 how many children s/he had and SP1 did not do a headcount when s/he returned to the France classroom with his/her group. Although SP2 stated s/he performed a headcount once in the France classroom and realized the AV was not there, just as P1 brought the AV into the France classroom, given that neither SP1 nor SP2 communicated with each other the number of children each had in their care during the transition; they did not perform headcounts every time they should have; the AV was unsupervised for 5-15 minutes with two sets of stairs between the AV and the classroom with the teachers who were responsible for the AV’s supervision; and the number of children each thought they had based on gender did not match the France classroom attendance for that date as well as the inconsistencies between information provided by SP1 and SP2 on how the group went into the bathrooms, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care an 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. 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 supervision and the Reporting of Maltreatment of Minors Act. SP1 and SP2 provided inconsistent information regarding whose group the AV was in or who was responsible for the AV when the AV left the group. However, SP1 and SP2 were each responsible for supervision of the AV at the time of the incident because they were both with the group of children. 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 completed an Internal Review and found their policies adequate but not followed by SP1 and SP2. SP1 and SP2 were retrained on supervision policy. 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 each 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 disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal. On April 26, 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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