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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: 1088274-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on a playground unsupervised without staff person’s knowledge (SP1 and SP2). The AV was unsupervised for approximately five minutes. 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 12, 2023; from documentation at the facility; and through six interviews conducted with two facility staff persons (P1 and P2), SP1, SP2, the AV, and the AV’s family member (FM). Facility documentation showed the AV was three years old and enrolled in the facility’s preschool classroom. This investigator spoke with the AV but because of his/her age, s/he did not provide pertinent information regarding this incident. However, this investigator asked the AV to open the push bar door that led to the playground. The AV was just tall enough to reach the push bar with his/her arms raised above his/her head but was not able to push the bar and open the door. The facility was located in a community church that was on the corner of two residential streets. Speed limit signs were not posted. The surrounding area included residential homes, parks, and an apartment complex. Adjacent to the street on the side of the facility was a parking lot. A sidewalk led from that parking lot to the facility, past a playground for the preschool aged children. The playground was enclosed by a chain link fence and portions of the facility building. The chain link fence was approximately four feet high and had one gate that was secured with a child safe push latch at the top which was approximately four and a half feet high. The playground was set off the side road and was visible from that road. Off the sidewalk was a secure entrance with double push bar doors that led into the facility. This door was the one used to access the playground. A key card was needed for entry into the facility. Once inside the facility, there was a small hallway that then led to a larger perpendicular hallway that ran right and left. To the right were facility classrooms, a kitchen, and entrance into the church. To the left were facility classrooms, doors that led to P1’s office, a set of double push bar doors that led to another playground for younger children, and a gym. The classroom door had a child safety lock that had push buttons that needed to be pushed to engage the lock. The FM was notified by the facility that the AV had run out on his/her own and was found on the playground crying. The AV was “spirited” and strong and the door to the playground was heavy, but the AV “could have run out on [his/her] own.” The FM did not have concerns with the program. The facility’s Risk Reduction Plan stated that staff persons must supervise children by sight and sound, indoors and outdoors, at all times. Facility documentation and P1 provided the following consistent information: · On April 26, 2023, between 10 and 11 a.m., SP1 and SP2 transitioned the preschool children from the playground to the classroom. · When coming in from outside, SP1 and SP2 completed counts and had the correct number of children. SP1 started to get the children’s water bottles and SP2 was assisting children in the bathroom. SP1 then left the preschool classroom to find P1 to talk with him/her about the health of a child in the classroom. P1 and SP1 walked back to the preschool classroom and while P1 was in the classroom, s/he heard SP1 ask where the AV was. · P1 and SP1 both started to look for the AV. P1 went down one hallway and SP1 walked down the other hallway and toward the playground. SP1 found the AV on the playground by the gate, crying. SP1 told P1 that the AV told him/her that s/he had wanted to go back outside. P1 did not talk with the AV about the incident because the AV was crying and “looked sad.” · P1 stated that staff persons were to count the number of children present at the gate of the playground and at the door of the facility. Once they arrived back in the classroom, staff persons were to count again and take attendance using a name to face sheet. The name to face sheets were not retained. · The AV was unsupervised for approximately five minutes. · When this investigator asked the AV to open the push bar door, P1 watched and afterwards said the AV “had no idea how to really open the door.” The AV tried but did not know how to push and “barely” could reach the bar. After seeing this, P1 did not think the AV left the classroom to go to the playground. SP1 provided the following information: · On April 26, 2023, between 10 a.m. and 10:30 a.m., SP1 and SP2 were on the preschool playground. When it was time to go inside, the children were lined up on the sidewalk and SP2 counted the children. Then they all entered the building, walked to the classroom and shut the classroom door. SP2 took two children into the bathroom and SP1 had the other children sit at a table for water. SP1 and SP2 had the name to face count sheet but did not use the name to face sheet to count children once back in the classroom. · As the children sat at the tables and SP2 was in the bathroom, SP1 left the classroom, walked across the hallway, and notified P1 that a child was ill. As SP1 left the classroom, s/he closed the classroom door but did not engage the child safety lock. SP1 was out of the classroom for less than a minute before s/he returned. · Once back in the classroom, SP1 passed out water bottles and called the AV’s name. The AV did not answer. SP1 scanned the classroom and did not see the AV. At this time, P1 entered the classroom and SP1 told P1 that the AV was missing. Both P1 and SP1 left the classroom to look for the AV. P1 went right and looked in the facility large muscle room. SP1 went left towards the front doors and as s/he passed the doors, s/he saw the AV sitting in the playground at the gate, crying. · SP1 brought the AV back to the classroom and told P1 that the AV had been found. SP1 then asked the AV if s/he left the classroom by him/herself and the AV replied, “Yes,” and also stated that s/he had wanted to play at the playground. The AV cried for a few more minutes. · The AV was unsupervised for approximately five minutes. · SP1 did not think there were hazards on the playground but if the AV did leave the building, s/he could have gone to the street. · SP1 had not seen the AV open the push bar door previous to this incident and thought there was a “small” possibility that the AV could have been left on the playground. If the facility door that led to the playground was not latched, the AV could open the door without pushing the push bar. · SP1 stated P2 saw the AV come in the facility. (P2 said that s/he saw the AV on April 26, 2023, but s/he did not see the AV exit or enter the facility with the class and SP1 and SP2. P2 had no additional information regarding the incident.) SP2 provided the following information: · On April 25th, 2023, before leaving the playground, the children were gathered at the gate and counted and all the children, including the AV, were at the gate. SP1 walked to the facility door. SP2 was the last to leave the playground and left the gate to the playground open because s/he was holding two children’s hands. · As the class went into the building SP1 and SP2 counted the children and all children were present, including the AV. SP1 and SP2 had the children sit on a pew to “make sure they had everyone.” Then SP1, SP2 and the children walked to the classroom and as the children entered the classroom, they were counted again. SP2 did not recall if s/he closed the classroom door after entering the classroom. SP2 could not recall if the child safety lock on the classroom door was engaged. · SP2 took the two children, whose hands s/he was previously holding, into the bathroom and SP1 had the other children sit at the tables in the classroom. · SP2 told SP1 that a parent needed to be notified of a child’s illness so SP1 left the room to talk with P1. A few minutes later, SP1 returned to the room with P1. P1 assisted SP2 in the bathroom and SP1 passed out water bottles. When SP1 tried to hand out the AV’s water bottle, s/he noticed the AV was not in the room. P1 and SP1 left the room to look for the AV while SP2 stayed in the classroom and stood in the doorway of the bathroom to supervise both the classroom and the bathroom. SP1, P1 and the AV came back into the classroom and SP1 asked the AV if s/he went back onto the playground the AV replied, “Yes.” · SP1 told SP2 that when SP1 found the AV on the playground, the gate to the playground was shut. The gate was easy to shut but difficult for the AV to open. To open the gate a rod needed to be pushed down. · On April 26, 2023, the name to face sheet was kept in a backpack and not used during the playground transition. · Hazards to the AV being on the playground alone were accessing the street or being taken by someone coming off the street. · The AV “incredibly strong” and could have opened the push bar door, especially if it was not shut all the way. SP2 could not recall if the push bar door was closed completely. Facility documentation showed that staff persons interviewed for this investigation received training on the facility’s Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. Relevant Minnesota Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states that a child must have supervision at all times and that supervision is 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 April 26, 2023, the AV was on the facility playground without the knowledge or supervision of a staff person for approximately five minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 and SP2 stated that they believed the AV left the classroom and returned to the playground which then made SP1 and SP2 unaware that the AV had left the preschool classroom, walked through the facility hallway and exited the facility doors and went onto the playground. However, when asked by this investigator to open the door, the AV was unable to open the facility exterior door that the AV would have open and left through. In addition, P1 watched the AV attempt to open the push bar door and afterwards said the AV “had no idea how to really open the door.” The AV tried but did not know how to push and “barely” could reach the bar. After seeing this, P1 did not think the AV left the classroom to go to the playground. Regardless of whether the AV left the classroom or was left on the playground, given that the AV was unsupervised, alone, and found on the facility playground with the gate shut and latched, that the location of the playground was near a street and was visible to passersby, that the AV was without a staff person’s supervision or knowledge and staff persons were unable to intervene if the AV injured him/herself or in the event of an emergency and other hazards, there is a preponderance of the evidence that there was a failure to supply the AV with the 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. SP1 and SP2 were trained on the facility’s Risk Reduction Plan the Reporting of Maltreatment of Minors Act. SP1 and SP2 were each responsible for the care and supervision of the AV at the time of the incident and were each 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 responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident and the AV was not injured so did not require 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 their policies and procedures were not adequate. The facility did not require classroom doors to be closed and secured with the child safety lock. The facility updated that policy and now required that the doors be shut and child safety locks engaged. 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 July 12, 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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