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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: 1005378-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that five alleged victims (AV1, AV2, AV3, AV4, AV5) were left in a classroom unsupervised for “a couple of minutes” when two staff persons (SP1, SP2) left the classroom. Date of Incident(s): April 14, 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 28, 2023; from documentation at the facility; and through eight interviews conducted with three facility staff persons (SP1, SP2, P), AV1’s family member (FM1), AV2’s family member (FM2), AV3’s family member (FM3), AV4’s family member (FM4), and AV5’s family member (FM5). Due to their ages, AV1, AV2, AV3, AV4, and AV5 were not able to provide any information about the incident. The facility was a large building with five classrooms. The toddler classroom was a large room with a door that exited into the facility’s main hallway and another door that exited into the young preschool classroom. There was an additional door that exited into a fenced playground. In the middle of the classroom was a partial wall with a small window. The wall was in between the two exit doors so when someone stood at either of the doors the view of the other door was partially obstructed. There was a changing table area on one side of the wall and a sink and cupboards on the other side of the wall. AV1 was 20 months at the time of the incident and enrolled in the toddler classroom. AV2 was 30 months at the time of the incident and enrolled in the toddler classroom. AV3 was 30 months at the time of the incident and enrolled in the toddler classroom. AV4 was 20 months at the time of the incident and enrolled in the toddler classroom. AV5 was 18 months at the time of the incident and enrolled in the toddler classroom. SP1 and SP2 provided the following information: · On most days SP2 started the day in the toddler classroom with the children until around 8 a.m., when SP1 arrived for his/her shift and took over. Typically, SP2 then moved to another classroom at that time. · On the morning of the incident, SP2 was in the classroom with AV1, AV2, AV3, AV4, and AV5 starting to prepare breakfast when SP1 arrived. SP1 arrived 10-15 minutes early and came into the classroom and started doing a little prep work for the day. SP1 had not yet clocked in for his/her shift so right around 8 a.m., SP1 told SP2 that s/he was going to clock in and left out the door to the hallway. · SP2 said that most mornings, if SP1 had not clocked in yet, s/he said that s/he needed to clock in and went to do that. If SP1 had not clocked in s/he did not say that. On the date of the incident, SP2 was not aware that SP1 had not clocked in and did not hear SP1 say that s/he was leaving the classroom to clock in. SP2 thought SP1 was by the changing table supervising the children, so SP2 grabbed his/her things and walked out the preschool door to assist in another classroom. · The P who had also stopped in the classroom to talk, followed SP1 out the door and they talked for a few minutes about a concern with a child. SP1 then clocked in and returned to the classroom. When SP1 returned to the classroom, s/he saw three children sitting at a table in the classroom and two children standing by the door. SP1 could not locate SP2. SP1 had all the children sit down and served them breakfast. · SP1 was able to review the camera footage with his/her supervisor and it showed SP1 leaving the classroom at “around” 7:56 a.m., followed by the P. At the same time, SP2 grabbed his/her bag and left out of the other door. The children can be seen walking around the classroom until SP1 arrived back at the classroom at 8:05 a.m. The P provided the following information: · On the day of the incident, the P had come into the classroom and SP2 was in the classroom with the children. SP1 came into the classroom but still needed to clock in. The P went with SP1 towards the clock in area and had a discussion for approximately five minutes. The P then did a bus run and left for the day. Later that evening, SP1 called the P to let him/her know what happened. · The P did not have any previous concerns with SP1 or SP2. Time sheets showed that SP1 clocked in at 7:58 a.m. on the date of the incident. The Employee Handbook indicated that staff persons were to never leave a child unsupervised. Facility documentation showed that all staff persons were trained on the facility’s policies and the Reporting of Maltreatment of Minors Act 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, stated that a child must have supervision at all times and that supervision was defined as occurring 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: Information was consistent that on the date of the incident, SP1 and SP2 both went out of the classroom through different doors at approximately the same time thinking the other one was supervising the classroom. SP1 said s/he told SP2 that s/he needed to go clock in while SP2 said s/he did not hear SP1 say that SP1 needed to clock in and assumed SP1 was taking over. SP2 left to assist another classroom as was typical for his/her shift. There was a partial wall in the classroom so the whole classroom could not be viewed at either doorway. SP1 arrived back to the classroom several minutes later and found that AV1, AV2, AV3, AV4, and AV5 were unsupervised for approximately six to seven minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Given that AV1, AV2, AV3, AV4, and AV5 who were between 18 and 30 months old at the time of the incident, were without staff person supervision in the classroom for several minutes, with access to doors exiting to the facility hallway and playground, and other possible dangers in the classroom, there was a preponderance of the evidence that there was a failure to supply AV1, AV2, AV3, AV4, and AV5 with necessary care and supervision as well as failure to protect AV1, AV2, AV3, AV4, and AV5 from conditions or actions that seriously endangered AV1’s, AV2’s, AV3’s, AV4’s, and AV5’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 and SP2 were trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. SP2 worked in the classroom at the time of the incident and although SP1 was in the classroom, s/he had not yet clocked in. Given that SP2 left five children in the classroom whom s/he was supervising and went to another classroom without verifying that SP1 was in the classroom, and that SP1 said s/he told SP2 that SP1 was leaving the classroom to clock in; SP1’s responsibility was mitigated and SP2 was responsible for maltreatment of AV1, AV2, AV3, AV4, and AV5. 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 SP2 was responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and no serious injuries were sustained. 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 accurate and followed. Staff persons were retrained to make sure the classroom remained in correct staff person ratio until another staff person was present to take over supervision. Action Taken by Department of Human Services, Office of Inspector General: SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 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 SP2. The determination that SP2 was responsible for maltreatment is subject to appeal. On June 30, 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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