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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: 1037699-CCC (Child Care Center) Investigator(s): Kyle Youker/Anna Parkin 651-431-4056 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left the facility without the knowledge of two staff persons (SP1 and SP2). The AV was found in a parking lot. Date of Incident(s): March 8, 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 March 20, 2023; from documentation at the facility; and through six interviews conducted with SP1, SP2, two staff persons (P1 and P2), a supervisory staff person (P3), and the AV’s family member (FM). The AV was three years old and enrolled in the pre-school classroom. The AV was non-verbal and had autism. The AV liked climbing and listening to music. The AV had an Individualized Education Program that was developed by the school district and available to staff persons stated the AV had a history of leaving out open doorways and had a staff person assigned to him/her until 2:00 pm or 3:00 pm, depending on the date. (P3 stated that the facility did not have an Individual Child Care Program Plan for the AV which was a violation of Minnesota Rules, part 9503.0065, subpart 3, which stated if a license holder admits a child with special needs, the license holder must ensure that the individual childcare program plan is developed, must be in writing, specify methods of implementation, and be reviewed and followed by all staff who interact with the child.) The facility was in a school district administrative building that was located a single-family residential neighborhood and was bordered on three sides by two lane streets each with a speed limit of 30 miles per hour. The fourth side was the front of the facility and had a parking lot with four parking lanes for cars. Cars could enter on either side of the parking lot from two of the adjacent streets. The facility had its own section of the building, had its own entrance, and did not share any hallways or classrooms with the other building tenants. The facility had multiple classrooms connected by an L-shaped hallway. The classroom was half carpeted, and half tiled, with the tiled portion nearest the door leading to the hallway. The hallway began at the front door, which was two single pain glass doors with a vestibule in between. (Video showed that at the time of the incident, the interior glass door was propped open with a door stop.) At the other end of the L, was the classroom. There was a fenced in playground area next to the front door. Next to the playground area there was a sidewalk and a parking lot with an entrance to a city street. The parking lot was shared with other building tenants. Information from all sources was consistent that SP1 and SP2 worked in the classroom with the AV at the time of the incident. The FM stated the AV tried to get outside of the facility “any chance” s/he got, and the FM told staff persons about this. The FM was told about the incident the date it occurred. The FM did not have any prior concerns about the facility. The facility had five cameras, two outside and three inside. The cameras were out of sync so while there was a running time at the bottom of all videos, it was not able to be determined exact times things occurred. The running time at the bottom of all videos when viewed together was 3:50:00 to 4:04:33 p.m. Each bullet time reference below will be based on a single camera view and the running time at the bottom of that video. · Camera A- (3:50:00 to 4:04:33 p.m.) was outside and viewed the playground, a portion of the parking lot driveway, and the sidewalk that led from the parking lot to the entrance. o From 3:55:14 to 3:55:28 p.m. a family member and their older child walk into view of the camera, across the parking lot driveway, and up the sidewalk to the main entrance. o At 3:56:58 p.m., the AV comes into view from the location of the main entrance. While outside, the AV on the sidewalk, overlooked the playground, moved near and into the parking lot, and played in the snow. o At 3:58:49 p.m. P1 comes running into view from the location of the main entrance and runs towards the AV who was standing next to the parking lot drive. As P1 runs towards the AV, the AV runs further into the parking lot and out of view of the camera at 3:48:56 p.m. followed immediately by P1. o At 3:59:01 p.m., P1 and the AV, holding hands, walk into view of the camera, across the parking lot, up the sidewalk to the main entrance. They are out of view of the camera at 3:59:17 p.m. o At 4:00:16 p.m. the family member and their older child and child who attended the facility walk out of the facility. · Camera B- (3:50:00 to 4:04:59 p.m.) was outside and viewed the parking lot and a corner portion of the fenced playground. o At 3:54:37 p.m. a car pulled into the parking lot from the driveway opposite the facility and parked. At 3:55:10 p.m. the family member and their older child get out of the car, walk across the parking lot driveway towards the entrance of the facility, leaving view of the camera at 3:55:17 p.m. o At 3:58:55 p.m. the AV comes into view of the camera and walked towards the family members car. Prior to the AV reaching the car, P1 comes into view and stops the AV. P1 takes the AV by the hand and they turn around and walk back towards the facility, leaving view of the camera at 3:59:03 p.m. o At 4:00:28 p.m. the family member and their older child and child who attended the facility come into view of the camera and get in their car. At 4:02:32 p.m., while they are still in their car, another car passed through the parking lot and at 4:03:30 p.m. they leave. · Camera C- (3:50:02 to 4:04:56 p.m.) was inside and viewed the front door, vestibule, and area immediately inside. o At 3:54:32 p.m. the family member and their older child walk into the facility. o At 3:55:34 p.m. the AV comes into view at the bottom of the camera, walks into the vestibule and at 3:55:56 p.m. the AV opens the door and leaves. o At 3:57:48 p.m. P1 holding a child comes into view at the bottom of the camera, runs into the vestibule and out the door. o At 3:58:25 p.m. P1, the child, and the AV return inside and as they are walking inside, P2 comes into view of the camera, walks directly to the AV, and picks up and hugs the AV. At this same time, the family member and their older child and child who attended the facility come into view of the camera. o At 3:58:52 p.m. P2 carries the AV out of view of the camera and at 3:59:30 p.m., P1 carries the child s/he was holding out of view of the camera. · Camera D- (3:54:48 to 4:04:52 p.m.) was inside and faced one direction in the long hallway. The classroom was on the left side of the camera. o At 3:54:52 p.m. the family member and their older child walk into view to the classroom and knock on the door. The door opens and at 3:55:00 p.m. the family member walks into the classroom. The older child follows but remains visible in the doorway. o At 3:55:17 p.m. the older child steps backwards into the hallway as the AV comes out of the classroom. The AV walks down the hall and at 3:55:21 p.m. out of view of the camera. o Between 3:57:34 and 3:57:40 p.m., as the older child remained in the hallway, the family member and child who attended the facility enter the hallway from the classroom. o At 3:57:51 p.m. the family member shuts the classroom door and the three of them walk down the hallway out of view of the camera as P2 walked into the hallway from a door further down past the classroom. o At 3:58:10 p.m. the classroom door opened and SP1 stood in the doorway, just as P2 past the classroom. They appear to have a conversation as P2 continued to walk down the hallway and out of view of the camera and SP1 remained standing in the classroom doorway. o At 3:58:23 p.m. SP1 walked into the hallway to a door across the hall as SP2 came to the classroom doorway. SP1 opened the door, went inside, then immediately came back out and walked down the hallway out of view of the camera. SP2 remained standing in the doorway of the classroom and looking down the hall. o At 3:59:18 p.m. P2 and the AV came walking into view of the camera and went directly to the classroom as SP1 entered the view of the camera and walked directly to the classroom. The AV walked into the classroom as P2 and SP1 stood in the doorway and appeared to have a conversation until 4:00:33 p.m. when they both walked into the classroom. · Camera E- (3:53:09 to 4:04:48 p.m.) was inside and faced the other direction in the long hallway. The classroom was on the right side of the camera but was not visible to the camera’s view. o At 3:54:49 p.m. the family member and their older child walk into view of the camera and down the hallway to the classroom and then were out of view. o At 3:55:30 p.m. the AV comes into view from the classroom and walks/runs down the hallway and around the corner leaving view of the camera at 3:57:45 p.m. o At 3:57:53 p.m. P1 came out of a classroom nearest the corner and walked around the corner and out of view. o At 3:58:03 p.m. the family member and their older child and child who attended the facility come into view of the camera from the classroom and walk down the hall. As they reach the corner, they turn around as the same time as P2 comes into view of the camera. P2 then runs down the hallway and all four of them go around the corner out of view of the camera. Simultaneously, SP1 comes into view and goes to the door across the hallway, enters the room, exits the room, and then runs down the hall looking into P2’s classroom prior to going around the corner out of view of the camera. SP1 is out of view for three seconds prior to coming back into view at the end of the hallway at the corner and then remains in view of the camera. o At 3:59:03 p.m. P2, holding the AV, comes into view of the camera at the corner. The video then skips to 3:29:22 p.m. where P2 and the AV now walking were in the middle of the hall between the corner and the classroom, while SP1 remained at the corner. As the video resumes all three are walking towards the classroom. o At 3:59:30 p.m. the AV and P2 walk out of view of the camera and at 3:59:36 p.m. SP1 walked out of view of the camera. P1 provided the following information: · P1 worked in the toddler room that had a window that overlooked the playground and part of the parking lot. P1 worked with the AV in the past and stated the AV was non-verbal but occasionally made “little noises.” · On the date of the incident, P1 was in the toddler room with one other child, the AV’s sibling. P1 heard the AV making noises and looked up and saw him/her running down the hallway towards the front door. P1 thought the FM was there to pick him/her up for the day, but the FM did not come in to pick up the AV’s sibling after the AV went by the door. P1 stated “something didn’t feel right” and a few minutes later s/he looked outside the window and saw the AV alone on the sidewalk next to the playground. · P1 picked up the AV’s sibling and ran outside through the front door to get the AV. By the time P1 got outside, the AV was not where s/he last saw him/her. P1 “panicked” at first, but then saw the AV in the parking lot by a parked car. P1 walked to the AV, took him/her by the hand, and walked him/her back into the facility. The AV did not appear upset and did not know what was going on. · When they came inside the facility, P2 and SP1 were looking for the AV. P2 “quickly” grabbed the AV and gave him/her a hug. P1 then returned to his/her classroom until the AV’s sibling was picked up and reported the incident to P3 about 30 minutes later. P1 stated it was common for vehicles to “cut through” the parking lot at that time of day. P2 provided the following information that was different information than the video showed: · On the day of the incident around 3:45 pm, P2 and another staff person were in another classroom with children, when SP1 came in and asked if the AV had come into P2’s classroom. P2 told SP1 s/he had not seen the AV and then P2 and SP1 began looking for the AV, checking the hallway, the other classrooms, and the kitchen. · P2 then started running down the hallway towards the family member and older child and asked if they had seen the AV. One pointed towards the facility entrance, so P2 continued running towards the entrance. As P2 turned the corner of the L-Shape, s/he saw P1 and the AV walking into the facility. · P2 stated the AV was “oblivious” to the incident and seemed happy. After finding the AV, SP1 told P2 s/he was “scared” and did not recall if SP2 said anything. SP1 and SP2 provided the following consistent information: · On March 8, 2023, at around 3:50 pm, SP1 and SP2 were in the classroom with 11 children including the AV. SP1 stated that s/he did not normally work with the AV, but classrooms were combined later in the afternoon as children were picked up by parents. · SP1 stated a child’s family member came to the classroom to pick up them up at approximately 3:50 p.m. SP1 stated s/he was standing in the doorway to the classroom speaking to the family member. The child being picked up was “struggling” and not listening to the family member to leave, so SP1 alternated between talking to the family member and helping the child, but never left the doorway. SP1 stated s/he did not see the AV walk past him/her while s/he was standing in the doorway. · SP2 was on the carpeted area of the classroom interacting with the other children while the AV was on the tiled area playing and SP1 was in the doorway talking to the family member. SP2 last remembered the AV being about a “table length” away from SP2 when SP2 then turned away from the AV and interacted with the other children. About one minute later, SP2 conducted a head count of the children in the room and discovered that the AV was missing and immediately told SP1, who was still in the doorway talking to the family member. · SP1 immediately stopped talking to the family member and started looking for the AV in the classroom. SP1 and SP2 checked the entire classroom and then SP1 went into the hallway to check for the AV while SP2 remained in the room with the other children. While in the hallway, SP1 saw P2 and told him/her the AV was missing. SP1 and P2 ran towards the entrance of the facility where they saw P1 and the AV re-entering the facility. · SP1 and SP2 were aware of the AV’s diagnosis and his/her history of trying to leave the facility. SP1 and SP2 stated that there is normally a third staff person in the classroom to assist in supervising the AV, but there was not one on the date of the incident, due to that staff person not working. SP1 stated s/he requested an additional staff person for the classroom from P3 to assist in the supervision of the AV. SP2 stated that even without the third staff person, they were within the appropriate ratio of children to staff persons. SP1 stated that on the date of the incident, s/he and SP2 created a verbal plan regarding supervising the AV which entailed SP2 supervising the AV, while SP1 supervised all the other children in the classroom. SP2 stated that on the date of the incident, s/he and SP1 did not create a verbal plan regarding supervision of the AV. SP1 stated s/he conducted head counts of the children every five minutes. · SP1 did not know how the AV was able to walk past him/her in the doorway without being noticed. SP1 and SP2 told another supervisory staff person of the incident, who also told P3. P3 talked to SP1, SP2, P1, and P2 after the incident and each provided information to P3 that was consistent with the information each provided to this investigator. There were not past incidents where SP1 and SP2 left a child unsupervised. P3 stated the AV was a known “flight risk” and that on the date of the incident, SP1 did not request an additional staff person to assist in the supervision of the AV. P3 did not know what additional training was provided to staff persons for the AV other than what was written in the IEP. The Active Supervision policy that stated staff persons should position themselves to see and hear all the children in their care and to stay close to children who may need additional support. The Risk Reduction Plan that stated staff persons were to ensure children were always within sight and hearing. According to Weather.com, the temperature on the date of the incident was a high of 35 degrees Fahrenheit and a low of 27 degrees Fahrenheit. Facility documentation showed SP1, SP2, P1, P2, and P3 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, stated that a child must have supervision at all times and that supervision is defined as occurring when a program staff person is within sight or hearing of a child at all times so that the program staff person can intervene to protect the health and safety of the child. Conclusion: A. Maltreatment: Information from all sources was consistent that on March 8, 2023, the AV left the classroom without the knowledge or supervision of SP1 and SP2, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, Part 9503.0045, subpart 1, item A. P1 saw the AV walk past his/her classroom and shortly after saw the AV outside. P1 then ran outside and brought the AV back to the facility. The AV was not harmed. SP1 and SP2 were not aware that the AV left the classroom or the facility which is inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a facility policies and procedures. Given that the AV, who was nonverbal and had autism, was able to leave the classroom and facility without the knowledge of staff persons; that the AV was outside on the sidewalk, next to a parking lot drive and parking lot, which exposed the AV to community dangers; and the AV was outside without winter clothing, 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 engendered his/her 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 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 Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. Although the facility failed to have an Individual Childcare Program Plan for the AV, it did not mitigate SP1’s or SP2’s responsibility to supervise the children in accordance with Minnesota Rules and Statutes. SP1 and SP2 were each responsible for the care and supervision of the AV at the time of the incident. SP1 and SP2 were each aware the AV had a history of trying to leave the classroom. SP1 stated that on the date of the incident, s/he and SP2 created a verbal plan regarding supervising the AV which entailed SP2 supervising the AV, while SP1 supervised all the other children in the classroom. SP2 stated that on the date of the incident, s/he and SP1 did not create a verbal plan regarding supervision of the AV. Regardless, information from SP1 and SP2 was consistent that at the time the AV left the classroom, SP1 was standing in the doorway working with a family member and a child who was leaving and SP2 was on the carpeted area working with the remainder of the children, and it would have been reasonable for SP2 to believe that SP1 would ensure that no child left through the door while SP1 was standing there. SP1 said that s/he never left the doorway and did not see the AV walk past him/her while s/he was standing in the doorway. SP2 said the AV was standing on the tile area about a “table length” away from SP2 when SP2 then turned away from the AV and interacted with the other children for about one minute. When SP2 looked up, s/he counted the children and discovered the AV was no longer there. Given that SP1 was standing in the doorway and that SP2 was in the classroom actively engaged with other children and took regular counts of the children discovering that the AV was missing, SP2’s responsibility was mitigated and SP1 was responsible for the 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 the SP 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 conducted an internal review and determined that policies were adequate but not followed by SP1 and SP2. The facility retrained all staff persons on the Active Supervision policy and the Maltreatment of Minors Act. The facility placed a sign prohibiting the front entrance door from being propped open. 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 of the SP1. The determination that the SP1 was responsible for maltreatment is subject to appeal. On May 10, 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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