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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: 1051311-CCC (Child Care Center) Investigator(s): Kyle Youker/Anna Parkin 651-431-4056 Suspected Maltreatment Reported: It was reported that a staff person (SP) left an alleged victim (AV) unsupervised in a restroom for approximately 15 to 20 minutes. Date of Incident(s): March 22, 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 April 12, 2023; from documentation at the facility; and through six interviews conducted with a community person who worked at another licensed facility (CP), a supervisory staff person (P1), two facility staff persons (P2 and P3), the AV’s family member (FM), and the SP. The AV was three years old and enrolled in a preschool classroom at the time of the incident. The facility was located in a community building. There was also another licensed facility (unrelated to the facility) located in the same building. Both facilities used a shared gym space. The gym had a single restroom that had a door that locked from the inside. There was a glass door with a push bar leading from the gym outside to a parking lot. The facility had a large open parking lot on the south and east side, a grassy field to the north, and an elementary school to the west. There was no alarm on the door leading outside and the facility did not have a video camera system. The facility entrance had a lobby area that had a door with a push bar lock leading to a main hallway. The facility had eight classrooms, including two preschool classrooms, connected via the main hallway. On the north side of the hallway there was a door leading outside with a push bar lock. There were two corridors located off of the main hallway. Each corridor had a door with a push bar lock that led to the exterior of the facility on the east and west sides. The CP stated that on March 22, 2023, at approximately 11 a.m., the CP and the children from the other facility went into the shared gym. At approximately 11:30 a.m., P2 came into the gym and tried opening the restroom door. It was locked so P2 began knocking on the door. After approximately 30 seconds of knocking, the AV opened the door and exited the restroom. The CP stated P2 told him/her that P2 did not recognize the AV and went to find a different staff person, leaving the AV with the CP. A few minutes later, the SP came to the gym and the SP took the AV to his/her classroom. The SP told the CP that the AV had been in the restroom for “about 15 minutes.” P2, P3, and the SP, and facility documentation provided the following information: · On March 22, 2023, the SP worked in one preschool classroom with eight children (facility documentation showed there were eight children, but the SP stated s/he had nine), including the AV, and P3 worked in the other preschool classroom with 11 children. At 10:30 a.m., P2, P3, and the SP went into the gym with the two respective preschool classrooms. P2 typically “floats” between classrooms but was assigned to P3’s classroom on the day of the incident. · At around 10:55 a.m., the SP saw the AV walk into the restroom in the gym. As the AV went into the restroom P2, P3, and the SP had the children clean up the gym equipment and then line-up in separate lines for their respective classrooms at the door leading to the hallway. · P2, P3, and the SP left the gym with their children to their respective classrooms sometime between 11:00 a.m. and 11:05 a.m. P2, P3 and the SP each stated that they were unsure which classroom left the gym first, but stated they left at around the same time. · P3 conducted a head count prior to leaving the gym and when s/he and P2 returned to the classroom they had all children accounted for. Then, P2 and P3 served lunch to the children. · The SP did not conduct a head count prior to leaving the gym or when arriving back in his/her classroom. The SP stated, “I don’t know,” when this investigator asked why a head count was not conducted. · When the SP got to his/her classroom s/he had the children wash their hands and sit down for lunch. Around 11:15 a.m., the SP served lunch to the children and noticed there was an extra lunch plate, so the SP counted the children and then realized that the AV was not in the classroom. · The SP immediately called P3 on the facility phone asking if s/he had the AV in his/her classroom. P3 told the SP that the AV was not in his/her classroom. The SP then remembered that s/he saw the AV go into the restroom in the gym and thought s/he might still be in there. · At approximately the same time that the SP called P3, P2 left his/her classroom and walked down the hallway towards the gym to use the gym restroom. P2 was not aware that the AV was missing at this time. When P2 got to gym and attempted to use the restroom the door was locked. P2 asked the CP if someone was in the restroom and the CP was unaware if there was a child in the restroom. P2 began walking out of the gym to check if the SP was missing a child when the AV opened the restroom door. The AV was crying and “upset” but otherwise unhurt. · P2 then brought the AV to the SP’s classroom at around 11:20 a.m. and the SP was already aware the AV was missing and was still talking on the phone to P3. P2 stated that the SP told P2 that the AV needed a lunch and did not have further conversation. P2 went back to his/her classroom. The SP stated the AV had been crying when s/he came back to the classroom but was “fine” after eating lunch. At an unknown time on the same date, after the AV ate lunch, the SP informed P1 that s/he “forgot” the AV in the gym restroom. · P2, P3, and the SP each stated it had been approximately 15 to 20 minutes from when they left the gym to when the SP realized the AV was missing. · P2, P3 and the SP provided consistent information that the SP was responsible for counting the children in his/her classroom and P2 and P3 were responsible for counting the children in their classroom. P2, P3, and the SP all provided consistent information that a head count should be conducted before and after transitioning from room to room. P1 stated that the SP told P1 about the incident approximately one hour after it happened. The SP told P1 that s/he did not conduct a head count before leaving the gym or when arriving at the classroom. P1 stated the SP was responsible for the supervision of the AV while in the gym and when transitioning from the gym to the classroom. The FM stated s/he was informed about the incident by P1 on the same date it occurred. Prior to the incident, the FM had no concerns about the care the AV received at the facility. The facility provided a Risk Reduction Plan that stated staff persons should conduct a head count before leaving one area to go to another and once again when the destination was reached. Staff persons were not allowed to leave children unsupervised for any amount of time. Facility documentation showed P1-P3 and the SP each received training on the reporting of Maltreatment of Minors Act and on the facility’s Risk Reduction Plan 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: Consistent information was provided that on March 22, 2023, the SP was in the shared gym beginning at 10:30 a.m. with the children from his/her classroom, including the AV, as well as P2’s and P3’s preschool classroom. At approximately 10:55 a.m. the SP saw the AV go into the restroom in the gym. While the AV was in the restroom P2, P3, and the SP had children clean up the gym equipment and line up at the door to go back to their respective classrooms. P2, P3, and the SP were unsure which class left the gym first but provided consistent information that both left around the same time between 11:00 and 11:05 a.m. P3 counted the children from his/her classroom when leaving the gym. The SP did not conduct a head count prior to leaving the gym and/or after arriving in his/her classroom. Immediately following P2, P3, and the SP leaving the gym, the CP brought his/her classroom into the gym. Around 11:15 a.m. the SP noticed the AV was not in his/her classroom and at approximately the same time the CP and P2 found the AV in the restroom in the gym. P2 then took the AV to the SP’s preschool classroom. The CP provided information that it was 11:30 a.m. when the AV was located but P2, P3, and the SP provided consistent information that the AV was located around 11:15 a.m. and brought back to the SP’s classroom at 11:20 a.m. The AV was unsupervised for at least 15 to 20 minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A.
Although the restroom was in the gym and the CP’s class was in the gym after the SP’s classroom left, the CP did not know the AV was in the restroom. Given that the AV was unsupervised in the restroom for at least 15 to 20 minutes with no staff person available to intervene if the AV had attempted to do something dangerous, had injured himself/herself, or in the event of an emergency, there was a preponderance of the evidence that there was a failure to supply the AV with 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. The SP was trained on the reporting of Maltreatment of Minors Act and on the facility’s Risk Reduction Plan prior to the incident. At the time of the incident, the SP was responsible for the supervision and headcounts of his/her classroom, which included the AV, while P2 and P3 were responsible for the supervision and headcounts for their classroom. Even though both classrooms were in the gym together and left the gym around the same time, the SP was responsible for the AV’s supervision and did not count his/her classroom children before leaving the gym or after arriving back to the classroom. Therefore, the SP was 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 the SP was responsible did not meet statutory criteria to be determined as recurring because it was a single incident or serious because the AV was uninjured. 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 that the policies and procedures were adequate, but were not properly followed by the SP. The SP was re-trained on the transition procedures in the facility’s Risk Reduction Plan. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP 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 SP. The determination that the SP was responsible for maltreatment is subject to appeal. On June 2, 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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