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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: 1112279-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised in a classroom for 20 minutes. 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 21, 2023; from documentation at the facility; and through six interviews conducted with four facility staff persons (SP1, SP2, SP3, P), the AV’s family member (FM), and the AV. The facility was a large building with classrooms along each side the building’s hallway. There was a playroom called the “house room” because it contained play structures that looked like house or store fronts. The house room was across the hall and down one room from the Preschool 1 classroom. The Preschool 1 classroom was a large open space with two different doors leading to the hallway. There was a bathroom in the classroom that was down a small hallway divided from the classroom by a half wall. There was a window that provided a view into the adjoining Infant classroom. The AV was four years old at the time of the incident and enrolled in the Preschool 1 classroom. The AV said s/he was going to the bathroom and his/her friends and staff persons did not know where the AV was. The classroom went to the house room and the AV was left in the classroom. The AV came out of the bathroom, looked around, and said, “Where is everyone?” The AV walked around in the classroom and played with instruments before the children and staff persons returned. The AV felt scared when s/he was alone in the classroom. This had not happened before, and the AV liked all the staff persons. SP1, SP2, and SP3 provided the following information: · On the day of the incident, 24 children were in the classroom and were very active. SP1 knew the children needed to play so s/he decided to take the classroom to the house room. The classroom could play in the house room for approximately 20-25 minutes before another class was scheduled to use the room, so SP1 decided to split up the class and let the children who were ready go first. · SP3 took the first 10 children that were ready and went across the hall to the house room. SP1 called the names of the children that SP3 was going to take. SP3 took the children out into the hallway and counted the children again. SP3 counted the 10 children when s/he arrived at the house room and then the children started to play. · SP1 and SP2 waited for the rest of the children to finish cleaning and getting in line. SP1 and SP2 did not know the AV was in the bathroom and did not do a final sweep of the classroom before they left. SP2 said s/he had a clipboard with the children’s names and did a “process of elimination” when initialing for each child as s/he did not know which children or how many SP3 took. SP2 continued to initial children as they walked down the hallway. SP1 did not think s/he counted when s/he left the classroom and went to the house room as s/he was in a hurry. · Once the classroom arrived at the house room SP2 put the clipboard down and went to supervise. The children played for approximately 20 minutes before cleaning up and heading back to the classroom. A count of the children was not done when the children arrived at the house room with SP1 and SP2. · SP1 said a count was not completed when the children were taken back to the classroom and SP2 did not remember if a count was completed before the classroom went back to the classroom. When SP1 opened the classroom door, s/he saw the AV sitting in the classroom’s reading corner. The AV started to cry and SP1 gave him/her a hug. The P said that there was a sheet on a clipboard that staff persons used to count the children. All children’s names were listed on the sheet with boxes for an in and out time. When the children left the classroom, they were counted and staff persons then initialed each child’s name when leaving the classroom and again when returning. Staff persons were also to do a final sweep of the classroom and a head count before leaving. The Internal Review indicated that at approximately 10:15-10:20 a.m., a staff person in the infant classroom looked through the window into the Preschool 1 classroom while changing a diaper and saw the AV playing. The AV was not crying and did not seem distressed. The staff person logged the diaper change and changed another child. At that time, the AV was standing by a sink. The staff person did not realize there was not a staff person in the classroom with the AV. The FM said that the AV said s/he heard the children leave the room but s/he was using the bathroom. The AV knew where the class had gone but did not leave the classroom as s/he knew the rules that children were not supposed to open the doors and leave the classroom. The FM had no previous concerns with the facility. The Supervision/Accounting For Children Policy indicated that children were supervised within sight and sound at all times. When the classroom moved from one room to another, a class list was taken and the children were counted and accounted for as they left the classroom and when they reentered the classroom. The Attendance/Outdoor Play Policy indicated that staff persons counted the children before leaving the classroom, when they reached their destination, and upon return to the classroom. Facility documentation showed that all staff persons interviewed were trained on the facility’s policies and the Reporting of Maltreatment of Minors Act 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 “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: A. Maltreatment: Information from all sources was consistent that on the morning of March 8, 2023, the AV was left in the facility’s preschool classroom without the knowledge or supervision of a staff person for approximately 20 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1, SP2, and SP3 were not aware that the AV was in the bathroom when they took the other children to another room, 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 20 minutes with no staff person available to intervene if the AV attempted to do something dangerous, 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. SP1, SP2 and SP3 were trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. Although SP1, SP2, and SP3 worked in the AV’s classroom and were supervising the children in the classroom at the time of the incident, given that SP3 counted and took 10 children from the classroom leaving the rest of the children, including the AV under the supervision of SP1 and SP2 who failed to accurately count the remainder of the children before they left the classroom and when they arrived at their destination, SP3’s responsibility was mitigated and both SP1 and SP2 were responsible for neglect 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 as it was a single incident and the AV was not injured. 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 policies were adequate but not followed when staff persons did not complete a name to face count of the children. Staff persons involved in the incident received corrective action and all staff persons were retrained on the Name-Face policy and doing final sweeps before leaving room. 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 May 12, 2023, the facility was issued a Correction Order for the violation outlined in this report and failing to report maltreatment as required. 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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