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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: 1065534-CCC (Child Care Center) Investigator(s): Anna Parkin/ Kyle Youker 651-431-6225 Suspected Maltreatment Reported: It was reported that two alleged victims (AV1 and AV2) were alone in the facility’s parking lot. Date of Incident(s): April 26, 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 May 15, 2023; from documentation at the facility; and through six interviews conducted with a supervisory staff person (P1), two facility staff persons (P2 and the SP), a community person (CP), and AV1’s and AV2’s family members (FM1 and FM2) respectively. According to the enrollment agreements, AV1 and AV2 were 33 months old and 31 months old respectively and enrolled in the toddler two room at the time of the incident. The facility had a toddler and a preschool room with doors that led outside to the respective playgrounds. The doors had push bars and were not locked when staff persons were on the playground. Both rooms were along a hallway that led to a front door and then a parking lot. The toddler playground was behind the facility and enclosed by a chain link fence. The preschool playground, which was separated from the toddler playground by a chain link fence, was along the back and side of the facility. There were roads next to and in front of the facility along with other businesses and woods. The front door of the facility had a front door that had a push bar to open from the inside, a vestibule, and then another door that had an electronic button on the push bar to unlock and open the door from the inside. Information from all sources was consistent that the incident occurred between 4 and 4:30 p.m. and that the SP was the only staff person on the playground when AV1 and AV2 left. In addition, all persons used the toddler playground door to enter/exit the building. The CP provide the following information: · On April 26, 2023, the CP was at the facility picking up his/her own child (C) who was also enrolled in the toddler two room. The C, the SP, and other children were outside on the playground. The CP and the C went inside to get items out of the toddler two room. On the way out of the facility, the CP and the C stopped in the toddler two room to grab a few items before leaving through the front door. The CP and the C walked “slowly” down the hallway and through the front doors. The CP did not hear or see other children near them. · While in the parking lot buckling the C into his/her car seat, the CP saw AV1 and AV2 run out of the front door. The CP looked around and did not see any staff persons in the parking lot. The CP saw P2 clocking out and waived P2 into the parking lot. P2 ran out to the parking lot and the CP told P2 that AV1 and AV2 were alone in the parking lot. P2 then brought AV1 and AV2 back inside through the facility to the playground. Prior to this incident, the front door of the facility did not close all the way and latch shut. · After the incident, the CP walked over to the preschool playground and told P1 that AV1 and AV2 were in the parking lot. S/he also told P1 about the front door not latching at times. P1 provided the following information: · On the day of the incident, P2 and the SP were on the toddler two playground with four children. P1 was on the preschool playground with other children. P2 left the playground to clock out so the SP was alone with four toddlers including AV1 and AV2 on the playground while P1 was on the preschool playground. · A few minutes later, the SP “shouted” to P1 that two of the children had left but AV1 and AV2 were already back by that time. The SP told P1 that s/he was trying to log the C out on the Ipad and had not realized that AV1 and AV2 left. · Later on, P1 spoke to P2 over the phone and asked what happened. P2 told P1 that the CP brought AV1 and AV2 to him/her. P1 then spoke with the CP who said s/he found AV1 and AV2 in the parking lot. The CP also told P1 that the front door did not always close all the way so P1 checked on the door the following day to ensure it closed properly. P1 was not aware of the door not closing prior to the incident. P2 provided the following information: · On the day of the incident, while outside on the playground the toddler two room was down children so P2 decided to leave early. The SP counted the four children including AV1 and AV2 out loud prior to P2 leaving the playground. On the way out, P2 stopped in the toddler two room to get his/her personal items. · When P2 was clocking out inside the facility, s/he saw the CP, AV1, and AV2 outside in the parking lot. P2 ran outside and met them at the curb of the parking lot. AV1 and AV2 were “giggling” and did not have injuries. The CP told P2 that s/he saw AV1 and AV2 run out of the front door and did not think the front door latched properly. · P2 then walked AV1 and AV2 back to the toddler playground. The SP “was just standing there” near the door that led into the toddler two room. P2 stated that the SP was not talking to anyone at the time, including P1. P2 told the SP about the CP finding AV1 and AV2 in the parking lot. The SP called P1 over and P1 asked P2 where AV1 and AV2 were and P2 told P1 they were in the parking lot. P1 asked if AV1 and AV2 followed P2 outside and P2 responded that they did not and were found by the CP. · P2 stated that prior to the incident, s/he was aware that children ran to the front door and pushed the unlock button. P2 was aware that the outside front door was a slow close door but was not aware it did not latch. The SP provided the following information: · On the date of the incident, P2 and the SP had four children including AV1 and AV2 on the toddler playground. P2 pointed and counted each child out loud and then left for the day. The facility Ipad was not working well and the SP was trying to use it. The SP was near the fence between the two playgrounds and P1 walked over toward the fence while on the preschool playground. The SP told P1 that the Ipad was not working. · After approximately two to three minutes, the SP turned and began walking back toward the children when s/he saw P2 walking with AV1 and AV2 out of the door from the toddler two room. P2 told the SP that the CP found AV1 and AV2 in the parking lot in front of the facility. The SP “yelled” for P1 and explained to P1 what happened. · Prior to the incident, on multiple occasions, the SP saw the front door slightly opened and not latched. The SP stated that “everyone” who worked at the facility was aware the front door did not latch including P1. If the SP had not had his/her back to the toddler playground talking to P1, then s/he would have prevented AV1 and AV2 from opening the door and going back into the facility. If the front door had been fixed and latched closed, it could have prevented AV1 and AV2 from leaving the facility and going into the parking lot. FM1 and FM2 each stated that they were aware of the incident but P1 had not told them that AV1 and AV2 were outside in the parking lot. FM1 and FM2 each did not have prior concerns with the facility. According to the facility employee handbook, staff persons “never” left a child unsupervised. Staff persons “never” had their backs towards the children and did not socialize with other staff persons while directly supervising the children. According to the facility’s risk reduction plan, staff persons spread out on the playground so they were in sight and sound of all children. Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0045, subpart 1, item A, stated that children are required to have supervision at all times. Minnesota Statute section 245A.02, subdivision 18, states that supervision means when 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.
Conclusion: A. Maltreatment: Consistent information was provided that on April 26, 2023, AV1 and AV2 left the toddler playground, went inside the facility, and out the front door where they were found by the CP in the parking lot unsupervised, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although it is not known how long AV1 and AV2 were gone, leaving the playground and the facility without the knowledge or supervision of a staff person, allowed AV1 and AV2, who were 33 and 31 months old, access to and exposure to dangers in the community and the facility, including traffic, community persons, and areas within the facility that were not designed for use by the children. Therefore, there was a preponderance of the evidence that there was a failure to supply AV1 and AV2 with necessary care and a failure protect AV1 and AV2 from conditions or actions that seriously endangered their 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 trained on the facility’s employee handbook, risk reduction plan, and the Reporting of Maltreatment of Minors Act. At the time of the incident, the SP was responsible for the care and supervision of four children on the playground including AV1 and AV2. Although the CP and the SP each provided information that the front door to the facility did not always latch close, this did not mitigate the SP’s responsibility to supervise and ensure that AV1 and AV2 did not leave the playground without supervision. The SP was responsible for maltreatment of AV1 and AV2. 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 AV1 and AV2 did not sustain an injury. 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 supervision. 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 23, 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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