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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: 1092878-CCC (Child Care Center) Investigator(s): Alice Percy 651.431.6569 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) left an alleged victim (AV) unsupervised in the facility’s gym for approximately 13 minutes. Date of Incident(s): January 18, 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 for this investigation was obtained remotely, including documentation from the facility; and through five interviews conducted with a facility administrative staff person (P), SP1, SP2, a community person (CP1), and the AV’s family member (FM). An attempt to contact another community person (CP2) by telephone was unsuccessful. The AV was four years old and enrolled in the preschool classroom at the time of the incident. The facility was located in a large building near an elementary school. The facility shared the building with an Early Childhood Family Education program and a Head Start preschool program. The main entrance doors were heavy glass doors with push bars that opened to a small entry way and another set of heavy glass doors with push bars that opened onto a large muscle room and reception desk. The large muscle room was shared by all of the child education programs in the building, including the facility. The large muscle room was a large space with several riding toys available for the children’s use. A short hallway ran from the gym to the AV’s classroom. There were no doors separating the hallway and the large muscle room. A carpeted area was near the main entrance doors. CP1 stated that s/he worked for a preschool program that was located in the same building as the facility. At 10 a.m., CP1 and CP2 took their children into the building’s large muscle room, which was approximately three minutes after SP1 and SP2 left the large muscle room with their group of children. Approximately ten minutes after CP1 entered the large muscle room, s/he saw the AV “popping up” from behind a desk in one corner of the room. The AV also attended CP1’s program three times each week, so CP1 knew the AV. CP1 stated that s/he and CP2 would have seen the AV if s/he ran into the large muscle room from his/her classroom because there was “only one way in and out.” CP1 believed that the AV had been hiding in the large muscle room since SP1 and SP2 took their group of children back to their classroom. CP1 said that CP2 told SP1 and SP2 that the AV was in the large muscle room and at 10:10 a.m., one of the SPs came to the large muscle room and took the AV back to their classroom. SP1, SP2, the P, and the facility’s documentation provided the following information: · On January 18, 2023, SP1 and SP2 worked in the preschool classroom with 20 children. SP1 stated that at 9:30 a.m., s/he and SP2 took the children to the facility’s gym. At approximately 10 a.m., SP1 and SP2 had the children sit on a rug near the entrance to the facility, where “we counted” them. They then took the group to the classroom, where SP1 counted them again. SP1 stated that when they returned to the classroom, s/he “counted heads” and had the correct number of children. SP1 did not recall the exact number of children that were in the classroom that day, but believed it was 19 or 20 children. SP1 believed his/her count was accurate, but was “not 100% sure” s/he did not count one child twice. SP1 typically used name-to-face counting when they left the gym and when they returned to the classroom, but shortly after returning to the classroom, a child pushed another child who hit his/her head on a bookcase, so the staff persons were distracted and did not do a final name-to-face count of the children. SP2 did not believe that s/he counted the children when they returned to the classroom even though s/he typically counted the children after every transition. SP2 was not aware that the AV was not in the classroom. · The P stated that at approximately 10 a.m., CP2 told the P that the AV was in the large muscle room. The P and SP1 provided conflicting information: o The P stated that as s/he entered the large muscle room, SP1 also entered the large muscle room to look for the AV. The P then went to the classroom with SP1 and the AV to ensure that the staff persons counted the children when they left the large muscle room and when they returned to the classroom. The P stated s/he was told by SP1 and SP2 that the staff persons were in the process of doing a head count when they returned to the classroom and the AV ran back to the large muscle room. The P believed the AV was unsupervised in the large muscle room for “less than a minute.” The P stated that the AV was upset because s/he wanted to talk to CP1 and CP2 instead of returning to his/her classroom. o SP1 stated that approximately five minutes after they entered the classroom, the P brought the AV to the classroom and told SP1 and SP2 that the AV was found in the gym area by CP1. SP1 stated that neither s/he nor SP2 knew that the AV was not in the classroom until the P returned the AV to the classroom. · In the past, the AV attempted to run away from his/her group on several occasions. The P stated that s/he often worked in the classroom and followed the AV when s/he left the classroom and then returned the AV to the classroom. SP1 believed that the AV ran out of the classroom and back to the gym while SP1 and SP2 were busy with the child who hit his/her head. The AV frequently attempted to leave the classroom and a gate had previously been installed on the classroom gate to prevent any child from leaving the classroom. However, the AV was able to open and close the gate. SP1 believed the AV closed the gate when s/he left the classroom, because it was closed when the P brought the AV back to the classroom. · The staff persons were trained to do a name-to-face count of the children each time they transitioned from one area of the building to another The FM stated that the staff persons told him/her about the incident immediately after it happened. The AV was “known to sneak out.” The FM had no previous concerns about the care the AV received at the facility. All the AV told the FM about the incident was that it was “too loud” with the other children. The AV no longer attended the facility, but that was not a result of the incident. According to the facility’s Risk Reduction Plan, the staff persons were “never to leave the children unsupervised.” The staff persons were trained to supervise the children whenever they were in the hallways or common areas. The staff persons were to do a head count and name-to-face counting of the children before leaving the classroom and upon arrival at their destination. The staff persons were also trained to do head counts of the children throughout the day and during “any and all transitions.” Children were to stay within sight and sound of the staff persons at all times. Facility documentation showed that SP1, SP2, and the P each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. Relevant Rules and 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 was provided by SP1 and CP1 that on the morning of January 18, 2023, the AV was left in the facility’s large muscle room without the knowledge or supervision of a staff person which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although SP1 stated that it was about five minutes, CP1 stated his/her classroom was in the gym for ten minutes after SP1 and SP2 returned to their classroom and so the AV was unsupervised for approximately thirteen minutes. Neither SP1 nor SP2 were aware that the AV remained in the large muscle room when they took the other children into their 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 SP1 and SP2 may have initially had to care for another child who hit their head, neither was aware the AV was missing until the AV was returned to the classroom and CP1 stated that s/he believed the AV was in the gym the entire time. The AV was unsupervised for 13 minutes in the facility’s large muscle room which had a door that provided access to the outside of the building and that was used by other programs that were housed in the same building gave the AV access to community dangers including unknown community persons. 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. Facility documentation showed that SP1 and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. SP1 and SP2 were each responsible for the care and supervision of the AV at the time of the incident. SP1 and SP2 were 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 SP1 and SP2 were each 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 completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. After the incident, the staff persons were retrained on counting procedures. 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 24, 2023, the facility was issued a Correction Order for the violation 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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