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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: 1089346-CCCC (Certified Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: Allegation One: It was reported that an alleged victim (AV1) was left in a classroom without staff persons’ (SP1 and SP2) supervision or knowledge for up to five minutes. Allegation Two: It was reported that on a separate occasion AV1 was left without staff persons’ (SP3 and SP4) supervision or knowledge for approximately two minutes. Allegation Three: During the course of this investigation, it was reported that another alleged victim (AV2) was left in a classroom without staff persons’ (SP5 and SP6) supervision or knowledge for approximately 15 minutes. Date of Incident(s): Allegation One: September 16, 2022 Allegation Two: April 26, 2023 Allegation Three: May 23, 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 10 and May 31, 2023; from documentation at the facility; and through 11 interviews conducted with two supervisory staff persons (P1 and P2), six facility staff persons (SP2-SP6 and P3), AV1, AV1’s family member (FM1), and AV2. This investigator reached out to SP1, but s/he declined the interview. AV2’s family member (FM2) was notified however, s/he did not provide any information to this investigator. The facility was located inside a school. The facility had five classroom (CE1-Grasshoppers, CE2-Crickets, CE5-Butterflies, CE6-Caterpillars, and CE7-Dragonflies). CE6 and CE7 were in one hallway that ran perpendicular to the hallway that CE1, CE2, and CE5 were in. There was approximately 47 feet between the entrances to CE2 and CE5. AV1 was almost four years old at the time of the first incident and four and one-half years old at the time of the second incident. AV2 was four years old at the time of the incident. Both AV1 and AV2 were enrolled in the pre-k CE5-Butterflies classroom. The facility used ProCare (a mobile app platform used to communicate with families and streamline administrative functions). The facility’s Supervision Procedure stated under transitions: · Head count all children in your care upon every transition to another location and every 15 mins thereafter. · Anticipate children’s behavior. · Count your kids upon arrival to the new location and initiate a “Name to Face” spot check. Facility records showed that SP1-SP6 and P1-P3 were trained on the facility’s Supervision Procedure and the Reporting of Maltreatment of Minors Act. Relevant Licensing Rules and Statutes Minnesota Statutes, section 245H.13, subdivision 10 states staff must supervise each child at all times. Staff are responsible for the ongoing activity of each child, appropriate visual or auditory awareness, physical proximity, and knowledge of activity requirements and each child’s needs. Staff must intervene when necessary to ensure a child’s safety. In determining the appropriate level of supervision of a child, staff must consider: (1) age of the child; (2) individual differences and abilities; (3) indoor and outdoor layout of the child care program; and (4) environmental circumstances, hazards, and risks. Allegation One: It was reported that AV1 was left in a classroom without SP1’s and SP2’s supervision or knowledge for up to five minutes. The following information was provided by FM1, AV1, and facility documentation: · On September 16, 2022, between 4:20-4:30 p.m., SP1 and SP2 lined the CE5 classroom up in their room to go down to CE6 for “a show.” At this time both SP1 and SP2 stated that a headcount was done, but not a name to face, and they had nine children. The group left CE5 and were stopped by a parent picking up who had questions so SP1 talked with that parent. While this happened, SP1 saw another child go back into the classroom to grab his/her blanket and held the door open for them to return to the group. Around 4:30-4:35 p.m. the group was in CE6 but were waiting on the class from CE7 to arrive to start the show. SP1 was preparing things to start the show and SP2 went down to the CE7 classroom to see where that group was. When SP2 returned, SP1 started a headcount (at this time there should have been eight children) and realized they did not have all eight children. SP1 conducted a name to face check and realized AV1 was not with the group. SP1 headed out of the CE6 classroom and ran into AV1’s family member (FM3) who was looking for a staff person to tell them that s/he had found AV1 alone in the classroom.
· SP1 and SP2 believed that AV1 went back into the CE5 classroom when they were in the hallway talking to a parent and that it was “less than” five minutes that AV1 was unsupervised. · On September 16, 2022, at 6:05 p.m., FM1 emailed the facility to say that when FM3 arrived at the facility at 4:35 p.m. to pick up AV1, FM3 found AV1 seated alone in the dark in the CE5 classroom. FM3 asked AV1 what s/he was doing and AV1 replied that s/he did not know where his/her friends were. FM3 went to the CE6 classroom and said that staff persons there did not have much to say about what happened. FM1 said that thankfully AV1 was not crying or upset about what had happened. SP2 and P1 provided the following information to this investigator: · SP2 stated that there was an incident with AV1 where s/he was found in a classroom unsupervised by FM3. SP2 said it was policy when transitioning to line the children up in the classroom, do a head count, and conduct a name to face using the ProCare App to make sure staff persons had the correct number of children. Once the classroom transitioned to the new location, staff persons were to conduct another name to face. SP2 remembered that SP1 was the other staff person in the classroom but was not able to remember if a name to face was done that day. · P1 was told by SP1 that s/he did a headcount and it matched and that AV1 was at the back of the line. · P1 stated that AV1 had a situation where s/he had a bathroom accident or needed to use the bathroom and left the group. The facility updated their Supervision Procedure on September 12, 2022, to include the name to face check requirement upon arrival to a new location and were “still getting used to it.” · P1 held a mandatory meeting on September 21, 2022, to go over the new requirement that stated once at the new location staff persons needed to conduct a name to face check. Conclusion for Allegation One: A. Maltreatment: Consistent information was provided that on September 16, 2022, AV1 was left unsupervised in the CE5 classroom and was found by FM3. After the incident, SP1 and SP2 provided information that a headcount was done prior to leaving the CE5 classroom. SP1 stated that the group was stopped in the hallway by a parent who was picking up his/her child and had questions. Upon entering a new classroom SP1 started to prepare for “a show” while SP2 went to find the other classroom who was also attending. When SP2 returned SP1 performed a headcount and a name to face and found AV1 was not with the group. SP1 went to look for AV1 and in the hallway ran into FM3 who was looking for a teacher to tell them that s/he had found AV1 alone in CE5. AV1 was without supervision for “less than” five minutes which was a violation of Minnesota Statutes, section 245H.13, subdivision 10. AV1 was not hurt or crying when FM3 found him/her. The facility had just updated their Supervision Procedure on September 12, 2022, to include performing a name to face check upon entering a new location. Although SP1 stated that s/he performed a name to face check and found AV1 was not with the group, given that this did not occur right away upon arrival at the new location, that AV1 was unsupervised for up to five minutes, and that FM3 stated that when s/he arrived to the CE6 classroom the teachers were unaware of AV1 being left behind, there was a preponderance of the evidence that there was a failure to supply AV1 with necessary care and a failure to protect AV1 from conditions or actions that seriously endangered his/her physical or mental health. 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. Given that both SP1 and SP2 were trained on the facility’s Supervision Procedure, the Reporting of Maltreatment of Minors, and were responsible for AV1’s supervision the day of the incident, SP1 and SP2 were each responsible for maltreatment of AV1. 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 one-time occurrence, and AV1 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. Allegation Two: It was reported that on a separate occasionAV1 was left without SP3’s and SP4’s supervision or knowledge for approximately two minutes. On April 26, 2023, when FM1 picked up AV1 s/he was told by a staff person that AV1 was left alone in a classroom when the group transitioned, and s/he was found by another family member. FM1 left with AV1. About 10 minutes later, FM1 received a telephone call from P1 who apologized and stated s/he was looking into what had happened. AV1 told FM1 that FM4 found him/her and brought AV1 to his/her friends. AV1 said s/he was in the bathroom and had a bathroom accident while s/he was alone. FM1 said AV1 was not bothered by what happened and that based on the ProCare app it looked like AV1 was alone for two to five minutes. AV1 said s/he was in the bathroom and his/her teacher left and then FM4 found him/her. AV1 said FM4 brought him/her to another teacher’s room (CE2 classroom). AV1 said s/he felt “sad” when s/he was by him/herself. SP4 stated that on the day of the incident, SP3 wanted to bring the CE5 classroom to the CE2 classroom around 4:30 p.m. SP4 and SP3 lined up the eight children in their classroom and SP4 started cleaning the classroom. A child (C) ran out of the classroom because s/he saw his/her family member (FM4). SP3 went after the C and the class followed SP3 out of the CE5 classroom. At this time SP4 went to the back door to make sure it was locked and then knocked on the bathroom door to make sure no children were in there. There was no answer and SP4 did not open the bathroom door. SP4 then left the classroom and went to the CE2 classroom. Upon arriving at the CE2 classroom, SP4 realized s/he forgot to put a sign on the CE5 classroom door letting family members know where they had gone to for the end of the day. SP4 left the CE2 classroom and saw AV1 with the C and FM4. FM4 stated s/he found AV1 in the classroom (SP4 thought s/he had said the bathroom) and that the AV1 smelled like s/he had a bowel movement accident. SP4 thought AV1 was unsupervised for “two [minutes] at most.” SP4 relayed the information to SP2 who spoke with FM1 when s/he picked up AV1 as SP4 was helping another child at that time. SP4 stated that when s/he does a transition s/he lined the children up and counted them and then once the group arrived to the new location SP4 conducted a name to face check. SP4 stated that SP3 brought the group to the other classroom that day so SP4 did not do the procedure. SP3 stated s/he had been in another classroom from 3-4:30 p.m. and then went to the CE5 classroom from 4:30-5 p.m. so another teacher was able to go home for the day. SP3 stated that when s/he arrived at the CE5 classroom the teacher who was going home already had the kids lining up to go to the CE2 classroom. SP3 counted ten children and touched their heads. SP3 remembered AV1 because s/he stuck his/her tongue out. SP3 told AV1 not to stick his/her tongue out. At that time the C ran out of the CE5 classroom because s/he saw FM4, SP3 thought the C was running out of the classroom, so SP3 went after the C. The other children in line followed SP3 out of the classroom. SP3 said that SP4 was cleaning up. SP3 talked with FM4 to sign the C out for the day. SP3 stated that SP4 came out of the classroom, and they walked the group to the CE2 classroom. SP3 said that FM4 came down “about a minute” later with AV1 and said AV1 needed to be changed. SP3 cleaned AV1 up and then left for the day. SP3 stated that s/he did not do a name to face check with this group. The following information was provided by P1, P2, and facility documentation: · P1 stated that s/he spoke with SP3, SP4, and FM4. SP3 told P1 that AV1 was lined up and s/he remembered AV1’s face and SP3 counted the children when they were in line to move to the CE2 classroom. The C ran to FM4, SP3 followed, and so did the rest of the group. SP4 told P1 that s/he checked the back doors and bathroom and there were no children left to SP4’s knowledge. SP4 stated that s/he was on his/her way back to the CE5 classroom when s/he saw FM4 with AV1. FM4 said s/he was going into the CE5 classroom and AV1 was right in front by the tables. FM4 said that AV1 was not crying, but s/he had had a bowel movement accident. P1 said AV1 was unsupervised for, “No more than one to two minutes.” · P2 received information from SP3, SP4, and FM4. SP3 told P2 that s/he remembered AV1 was lined up when SP3 performed a head count because AV1 stuck out his/her tongue and SP3 told AV1 not to stick out his/her tongue. The C ran out into the hallway when s/he saw FM4. SP3 brought the group to the CE2 classroom and SP4 was still cleaning the CE5 classroom. SP4 knocked on the CE5 bathroom door but did not open it before s/he left the CE5 classroom to join the group in CE2. FM4 saw AV1 by the tables when s/he and the C went into the CE5 classroom. FM4 brought AV1 to CE2 because AV1 needed assistance in the bathroom. P2 said a transfer was done on the ProCare app but not a name to face check. P2 said AV1 was unsupervised one to two minutes. P2 said that SP2 spoke with FM1 when s/he picked up AV1. · Facility records showed that the C was signed out at 4:43 p.m. and the CE5 classroom, including AV1, was checked into CE2 at 4:44 p.m. P1, P3, and SP4 provided consistent information on the policy for how to transition: by counting the children prior to leaving a classroom and then doing a name to face check upon arrival at the new location. Conclusion for Allegation Two: A. Maltreatment: Consistent information was provided that on April 26, 2023, SP3 and SP4 were getting ready to leave the CE5 classroom. SP3 lined the group up in the classroom and remembered AV1 was in line because s/he stuck his/her tongue out. SP4 was cleaning up the classroom. The C ran out of the CE5 classroom when s/he saw FM4 in the hallway so SP3 ran out after the C. The rest of the group followed out into the hallway. SP4 locked up the back door, knocked on the bathroom door but did not open it and did not hear anyone, and then left to join the group. FM4 and the C walked into the CE5 classroom and saw AV1 standing by the tables. AV1 needed bathroom assistance so FM4 walked him/her to the CE2 classroom. P1, P2, SP3, and SP4 stated that AV1 was unsupervised anywhere between one to two minutes which was a violation of Minnesota Statutes, section 245H.13, subdivision 10. Neither SP3 nor SP4 conducted a name to face check once the group arrived at the new location. Although AV1 was found by FM4 within one to two minutes of SP3 and SP4 leaving the classroom, given that SP3 did not do another head count of the children once they ran out into the hallway, that SP4 did not open the bathroom door to ensure no one was in there, that neither SP3 nor SP4 conducted a name to face check upon arrival at the new location, that AV1 was unsupervised for one to two minutes, and that AV1 needed bathroom assistance, there was a preponderance of the evidence that there was a failure to supply AV1 with necessary care and a failure to protect AV1 from conditions or actions that seriously endangered his/her physical or mental health. 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: (2) 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; (3) 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 (4) whether the facility or individual followed professional standards in exercising professional judgment. Given that both SP3 and SP4 were trained on the facility’s Supervision Procedure, the Reporting of Maltreatment of Minors, and were responsible for AV1’s supervision the day of the incident, SP3 and SP4 were each responsible for maltreatment of AV1. 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 SP3 and SP4 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a one-time occurrence, and AV1 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. Allegation Three: During the course of this investigation, it was reported that AV2 was left in a classroom without SP5’s and SP6’s supervision or knowledge for approximately 15 minutes. On May 23, 2023, P2 said that SP5 and SP6 took the children outside from the CE5 classroom around 9:05 a.m. Around 9:20 a.m. P3 walked into the CE5 classroom and noticed AV2 was lying in the calming cube (a large wooden cube with large circle openings on each side). AV2 was not feeling well. P2 spoke with SP5 and SP6 and was told a head count was performed prior to leaving the classroom and it matched the ProCare app count of children. While getting the children ready to go outside there was another child who had a bloody nose, and then when in the line there was an altercation between two other children so SP5 and SP6 said they “felt overwhelmed.” A name to face check was not completed when the group arrived at the playground. AV2 said s/he went to the calming cube because s/he was tired, and s/he snuggles with the “stuffies.” AV2 did not go outside with the group and did not realize s/he was left in the classroom because s/he was sleeping. SP5 said around 9 a.m. s/he and SP6 lined the children up to go outside. SP6 had just finished assisting a child who had a bloody nose. There were two other children in line who were fighting. SP5 said s/he thought they had 18 kids that day and when they group arrived outside SP5 thought s/he counted 18 children. Once outside SP6 was relieved by another teacher so SP5 could take a break. About 10-15 minutes after the group got outside, P3 and SP6 brought AV2 outside and stated s/he was asleep in the calming cube. SP5 said AV2 looked very tired and did not want to play when s/he rejoined the group outside. AV2 also complained of being cold even though it was a warm day. SP5 stated that FM2 was proud of AV2 for going to the calming cube by him/herself. SP5 said name to face meant pulling up the ProCare app and using the list of children icons with pictures, look at the names and pictures, and then look at the children in line. SP5 stated that this was new at the beginning of school year (September 2022) and prior to that staff persons just needed to do a head count. SP5 stated that s/he did not do a name to face check. SP6 said that about 30 minutes prior to going outside the group had been playing a game and a child fell resulting in a bloody nose. SP6 stated it took a long time for the bleeding to stop but when it did SP6 helped the child get cleaned up and then messaged the office that maintenance was needed because blood got on the floor. During this time SP6 saw AV2 in the calming cube. SP6 went down to the office to make sure someone was coming to clean up the blood, when SP6 returned to the CE5 classroom, SP5 had the children lined up so SP6 joined the back of the line, and the group went outside. SP6 said s/he did not notice any movement from the calming cube when s/he returned to the classroom. Once the group was outside, SP6 went inside for a 15-minute break. SP6 and P3 walked into the CE5 classroom for their break and there was another child being dropped off. SP6 said AV2 “woke up by the commotion.” SP6 said AV2 looked tired and like s/he had no idea of what happened. SP6 and P3 brought AV2 outside to rejoin the group. SP6 told P2 what had happened. SP6 thought AV2 was unsupervised for ten minutes. SP6 said that the facility had not used name to face in the past when s/he worked there, and it was not done that day. SP6 stated name to face meant using the ProCare app to see who was signed into the classroom and looking at the children’s name icon and then looking at their face to make sure they are there. This was to be done before going anywhere and then once arrived at location. P3 said s/he and SP6 were walking in the hallway when a child was being dropped off by a family member. P3 said that child had a younger sibling, so P3 and SP6 walked the older child into the CE5 classroom to put his/her stuff away. P3 said AV2 “popped” his/her head up out of the calming cube and said s/he was tired and cold. P3 said s/he and SP6 brought AV2 and the other child outside. Conclusion for Allegation Three: A. Maltreatment: Consistent information was provided that on the day of the incident, SP5 and SP6 left the CE5 classroom to go outside and left AV2 without supervision asleep in the calming cube for 10-15 minutes until s/he was found by P3 and SP6 when they entered the classroom with another child. AV2 appeared tired and like s/he did not feel well. SP5 and SP6 stated that a name to face check was not completed when the group arrived on the playground as per the facility’s policy. It was estimated that AV2 was without supervision for 10-15 minutes which was a violation of Minnesota Statutes, section 245H.13, subdivision 10. Although AV2 was asleep, given that SP5 and SP6 did not conduct a name to face check upon arrival to the playground to ensure they had all of the children, the length of time AV2 was unsupervised, and SP5 and SP6 were not present to intervene or assist AV2 in an emergency, there was a preponderance of the evidence that there was a failure to supply AV2 with necessary care and a failure to protect AV2 from conditions or actions that seriously endangered his/her physical or mental health. 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: (3) 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; (4) 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 (5) whether the facility or individual followed professional standards in exercising professional judgment. Given that both SP5 and SP6 were trained on the facility’s Supervision Procedure, the Reporting of Maltreatment of Minors, and were responsible for AV2’s supervision the day of the incident, SP5 and SP6 were each responsible for maltreatment of 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 SP5 and SP6 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a one-time occurrence, and AV2 did not sustain an injury. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph © 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: On May 26, 2023, the facility held a mandatory meeting to review their Supervision Procedure and updated it to: · Count your kids and initiate a “Name to Face” spot check before leaving and upon arrival to the new location. · Head count all children in your care every 15 mins thereafter. · Anticipate children’s behavior. Action Taken by Department of Human Services, Office of Inspector General: SP1-SP6 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1-SP6 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-SP6 were each responsible for maltreatment is subject to appeal. On July 19, 2023, the facility was issued a Correction Order for the violations outlined in this report and for failure to 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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