|
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: 1099497-CCC (Child Care Center) Investigator(s): Lindsay Arth/ Anna Parkin 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised in a gym for approximately 17 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 5, 2023; from video and documentation at the facility; and through three interviews conducted with a supervisory staff person (P1), the SP, and the AV’s family member (FM). This investigator contacted another staff person (P2) via telephone for an interview but P2 did not respond. According to the AV’s enrollment information, the AV was 22 months old and in the toddler C room. On the date of the incident, the SP and seven toddlers, including the AV, were in the toddler C room. The facility had two levels. The basement level had the toddler C room and a gym that were next to each other. The gym had two doors each with windows in the top portion. One door led to the toddler C room and the other door led to a main hallway. The basement also had another empty classroom, a laundry room, and a bathroom. The upper level of the facility had additional classrooms and an exit to a playground. Video footage dated March 22, 2023, provided the following for three locations: · Video from inside the facility’s gym showed the following: o St 10:23 a.m., the door to the hallway was open and the light in the gym was turned off. The SP and some children were visible in the hallway wearing coats and snowpants. At 10:24:10 a.m., a child (C1) closed the door. At 10:24:22 a.m., the door opened, and the AV walked into the gym. C1 stood in the doorway with the door open while the AV ran toward a back corner of the gym. Another child (C2) walked over to where C1 stood in the doorway. The SP walked over, took C2 by the hand, and walked C2 out of sight of the camera into the hallway. At 10:24:55 a.m., the SP escorted C1 out of the doorway as C2 initially closed but then partially opened the door. At 10:25:10 a.m. the SP returns to the door and the door closes. The AV was in the far back corner of the gym. o There was no video provided between 10:25:38 and 10:41:34 a.m. so it was unknown what the AV did during those approximately sixteen minutes. o On March 22, 2023, at 10:41 a.m., the AV was still inside the gym and stood in front of the door to the toddler C room (the door was still closed.) At 10:42:11 a.m., P2 opened the door from the hallway and looked to the left and saw the AV so P2 ran and picked up the AV. P2 then carried the AV out of the gym. · Video footage from the hallway outside the gym and room showed the following: o At 10:24:14, the SP assisted seven children including the AV with taking off their boots, coats, and snowpants. The door to the gym was closed. At 10:24:17 a.m., the SP opened the door to the toddler C room and then walked over to a child to assist a child (Note: the SP’s back was to the camera and blocking the child so it is not known what s/he was doing.) At 10:24:22 a.m., a few of the children went inside the toddler C room and the AV walked out of the view of the camera by the location of the gym door. o At 10:24:42 a.m., the SP took the C by the hand and guided him/her to the toddler C room. At 10:24:54: a.m., the SP walked over and closed to door to the gym. The SP then walked into the toddler C room with the remaining children and closed the door. · Video footage from inside the toddler C room showed at 10:32 a.m., there were five toddlers and the SP inside the toddler C room. The SP went into the bathroom attached to the room and escorted another child out of the bathroom, making it six toddlers inside the room. The SP closed the bathroom door and placed an item on top of shelves. At 10:33:28 a.m., the SP began prepping the diaper changing table. At 10:33:40 a.m., the SP looked around the room as s/he was putting gloves on and then quickly walked out of the room. The video then ended. The SP provided the following information: · On the morning of the incident, at approximately 10:30 or 11 a.m., the SP brought the toddler C children including the AV out to the playground. There were two other staff persons and their children outside on the playground. It was windy and cold outside, so the SP and other staff persons decided to bring the children back inside. The SP did not count the toddler C children prior to leaving the playground. · Once inside the hallway, the SP assisted the children with taking their boots and winter coats off. The SP saw “out of the corner of [his/her] eye” the door to the gym open and C1 trying to go inside the gym. The SP walked over, closed the door to the gym, took C1 by the hand, and walked C1 back by the rest of the children. · As the children finished taking off their coats and boots, the SP counted the children and realized that the AV was missing. The SP thought the AV might have gone to another room since they were just outside with other classes so the SP called P3 on a radio and asked P3 to come to the room. A couple of minutes later, P3 came to the toddler C room. The SP told P3 that the AV possibly went with another class to their room when coming inside from the playground. · The SP went to toddler A and B rooms while P3 stayed in the toddler C room with the other children and asked the staff persons if they had seen the AV and they responded that they had not. The SP ran outside to the playground and looked for the AV but did not see him/her. P2 and another staff person (P4) were on the playground with another room and went inside the facility with the SP and they searched for the AV. · After a few minutes, the SP returned to the toddler C room and P2 was already inside there with the AV. P2 told the SP s/he found the AV inside the gym. The AV was “calm,” not crying, and did not have any injuries. Later on, the SP spoke to P1 about the incident. P1 said s/he reviewed video footage and the AV was alone for ten minutes. P1 stated that on the day of the incident, while s/he assisted in a classroom, s/he saw a staff person “looking around for something.” P1 asked what was going on and the staff person responded that the AV was missing from the toddler C room. P1 went outside and then into the toddler C room and saw P2 with the AV. The AV was “very calm” and did not have any injuries. P2 told P1 that s/he found the AV in the gym alone. The FM did not have any concerns with the facility. The facility was “prompt” when notifying the FM about the incident. According to the facility’s Risk Reduction Plan: · All staff persons created a “safety zone” around doors and were trained awareness during activities within close proximity to doors. It is the staff person’s responsibility to increase his/her level of supervision at those times. In addition, children were discouraged from opening doors. · Staff persons conducted head counts of the children when leaving a room and arriving at a play area and “vice versa.” Facility documentation showed that staff persons, including the SP, received training on the facility’s risk reduction plan and Maltreatment of Minor’s 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, 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, at 10:24 a.m., the AV went into the gym alone without the SP’s knowledge. The SP saw C1 standing in the gym door so s/he went and got C1 and closed the door. The AV was alone inside the gym for approximately 17 minutes 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. The SP stated that as the children finished taking off their coats and boots, the SP counted the children and realized that the AV was missing. However, the video showed that the children were done taking off their winter gear, and already in the classroom for a period of time because the children were playing, one child went into the bathroom, and the SP was preparing the change diapers when s/he appeared to count and then run out of the room. Although the AV was in a gym within the facility and there was no information that the AV was injured, the SP was not in a position to intervene to protect the AV in the event of an injury or emergency. Given this and that the AV, who was 22 month old, was in the gym without the knowledge or supervision of a staff persons for approximately 17 minutes, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health when reasonable 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. 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 responsible for the care and supervision of the AV and trained on the facility’s risk reduction plan and the Reporting of Maltreatment of Minors Act. 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 or serious because it was a single incident for which 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 policies and procedures were adequate but not followed. All staff persons received additional training on security policies and procedures and name to face list. 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 16, 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.
|
