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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: 1063111-CCC (Child Care Center) Investigator(s): Kimberly Huettl Anderson kimberly.huett.anderson@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) left an alleged victim (AV) on the facility’s playground without supervision or the SP’s knowledge for approximately three minutes. Date of Incident(s): April 11, 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 19, 2023; from documentation at the facility; and through three interviews conducted with facility staff persons. Attempts to contact the AV’s family member via telephone were unsuccessful. The facility was a standalone building located next to a bank and strip mall. The facility had a toddler age playground that was adjacent to the facility. The playground was surrounded by a metal fence that was approximately five feet high. There was a gate to the toddler playground that was secured and next to the facility’s entrance door. The playground was visible from the strip mall’s parking lot and from the facility’s infant room window. The toddler classroom was next to the infant classroom. There was an interior door that connected the infant and toddler classrooms. At the time of the incident, the AV was 18 months old and enrolled in the facility’s toddler classroom. A facility Incident Report Form, dated April 11, 2023, stated that the AV was unsupervised on a toddler playground from 5:28 p.m. to 5:31 p.m. The AV was uninjured. A facility management person (P1) was not at the facility at the time of the incident but was told about the incident later that day. The following day, P1 reviewed three video surveillance views from April 11, 2023. The view from the infant classroom showed that at 5:26:54 p.m., the SP was on the playground and handed three children to a facility staff person (P2) through the door leading to the infant classroom. The SP then shut the infant room door and was back on the playground. The toddler classroom’s video surveillance date stamped 5:27:54 p.m., showed the SP walking into the toddler classroom with a parent and grabbing diapers before walking through the interior door that connected the infant and toddler classrooms. The infant classroom video surveillance date stamped 5:29:10 p.m., showed the SP walk into the infant classroom and walked to the diaper changing table. At 5:30:33 p.m., the SP walked out of the infant classroom door to the playground and returned to the classroom with the AV at 5:30:47 p.m. The playground camera did not display the time of the day but showed the AV sitting on the top of an enclosed play structure that when s/he was on the playground without the SP’s supervision. According to P1, the AV was on the playground without the SP’s knowledge or supervision for approximately four minutes. P2 and the SP provided the following information: · On April 11, 2023, the SP was on the playground with six toddler children. Shortly before 5:30 p.m., two parents came to pick up their children and the SP started to combine his/her children with the infant children. The SP brought three children from the playground to the infant classroom door and handed the children to P2. The SP then went back to the playground. · The SP told P2 that s/he was going to clean the playground and then went back to the playground but shortly after came inside and grabbed diapers to change the children. When the SP entered the infant classroom s/he went to the changing table and started the process to change diapers. At that time, an infant parent was feeding his/her child a bottle and asked where the AV was because the AV’s siblings were in the infant room. P2 and the SP realized that the AV was on the playground and the SP “immediately” went outside and brought the AV into the classroom. · The SP stated the AV was sitting on top of a play structure that had a slide on it and the AV was sometimes afraid to slide down the slide when s/he got to the top. When the SP went onto the playground, the AV was crying but stopped when the SP picked him/her up. · When toddlers transitioned from inside to outside, or outside to inside, they used a rope to hold onto but toward the end of the night when there are less children, so the rope was usually not used. In addition, the SP typically conducted a name to face head count of the children before and after a transition. The SP stated that s/he did not conduct a name to face head count at the time of the incident. · The AV was unsupervised for approximately two minutes. The facility’s Child Care Risk Reduction Plan stated that the playground was surrounded by a fence and secured by a gate. Staff persons were to conduct a name to face count of all children prior to going outside as well as when they entered the playground and coming back inside. The facility’s Safety and Supervision policy stated that all children must be within sight and sound at all times. The facility’s personnel files showed that the SP was trained on the facility’s Safety and Supervision policy on April 5, 2022, on the facility’s Child Care Risk Reduction Plan on May 10, 2022, and on the Reporting of Maltreatment of Minors Act on November 30, 2022. P1 and P2 were trained on 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, state that “supervision” means 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; and that children are required to be supervised at all times. Conclusion: A. Maltreatment: Information showed that on April 11, 2023, the AV was on the playground without the SP’s supervision or knowledge between three and four minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The SP had four children on the playground and stated that s/he did not conduct a name to face count before taking the children inside. After giving three children to P2 who was in the infant room, the SP returned to the playground to clean and again did not notice the AV on the playground. It was not until after the SP was in the infant room changing diapers when an infant parent was feeding his/her child a bottle and asked where the AV was because the AV’s siblings were in the infant room, that the SP realized the AV was not present. The SP went to the playground and found the AV. Although the AV was unharmed, the conduct of leaving an 18-month-old child outside without staff person’s knowledge or supervision exposed him/her to community persons, other community hazards, and did not allow for staff person intervention in the event of an emergency. Therefore, there was 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 their 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; 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. At the time of the incident, the SP was responsible for the care and supervision of the children on the playground, including the AV. The SP was trained on the facility’s policies, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act prior to the incident. 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 of maltreatment 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. The facility has implemented a new policy that all staff must use their walkie talkie to request administrators when a transition is occurring. SP1 and SP2 are no longer employed. 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 July 19, 2023, the facility was issued a Correction Order for the violation outlined in this report. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but not followed at the time of the incident. All staff persons received additional training on the importance of following all procedures and focusing on the safety of all children. 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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