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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: 1053996-CCC (Child Care Center) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised on the facility’s playground and was found sleeping on the playground five to twenty minutes later. Date of Incident(s): April 24, 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 24, 2023; from documentation at the facility; and through four interviews conducted with a facility administrative staff person (P1), and three staff persons (P2, SP1, and SP2). Attempts were made by telephone and letter to contact two staff persons (SP3 and SP4), but neither SP3 nor SP4 responded to the requests for interviews. Attempts were also made by telephone and letter to contact the AV’s family member (FM), but the FM did not respond to the requests. The AV was 29 months old and enrolled in the transitional preschool classroom at the facility. The facility was located in a rural area next to a street with a posted speed limit of 55 miles per hour. The facility was a large building located on the far side of a large parking lot from the street. There were no other buildings near the facility and there were woods along three sides of the facility. Two playgrounds were located on one side of the facility. A sidewalk ran from the parking lot along the side of the facility between the building and the playgrounds. Each playground was enclosed by a chain link fence and were each accessed by gates which opened on to a grassy area next to the sidewalk. The gates were not locked, but each included a latch that had to be pulled upward by a handle in order for the gate to open. The playground used by the transitional preschool children contained a large climbing structure near the middle, as well as smaller climbing structures and toys spread around the area. In the back corner was a plastic climbing structure that had several openings that allowed access to various platforms within the structure, as well as a slide from the upper level. Consistent information was provided that the AV was found in the plastic climbing structure. SP1, SP2, P1, and P2, and the facility’s documentation provided the following information: · On April 24, 2023, SP1, SP2, SP3, and P2 worked in the transitional preschool classroom with 18 children, including the AV, and SP4 worked in the preschool classroom. At approximately 10:30 a.m., SP1, SP2, SP3, and P2 took the children outside to the playground. At approximately 11:30 a.m., the staff persons prepared to take the children back to their classroom. SP1 stated that since there was snow on the ground and all of the children were wearing coats and boots, it was “chaotic” to take all of the children into the facility at the same time. SP3 suggested that they take the children inside the facility in groups of six, rather than take all of the children in at one time, which they did. · SP2 and SP3 brought the first group of six children into the building and SP3 took off their outerwear and changed their diapers. SP1 stated that at that same time, another staff person (P3) was working with a separate group of children in the transitional preschool classroom, and they did not want to disrupt their work time, so SP2 then took the first group of children to the facility’s foyer to wait for the rest of the children. SP1 then brought the second group of six children in and assisted them with removing their outerwear and took them to the group in the facility’s foyer. P2 was still on the playground and supposed to bring the remaining group of children into the facility. However, because P2 had to feed his/her infant child in another classroom prior to bringing the last group of children into the facility, P2 asked SP4, who was on another playground, to come to the playground to get the last group of children into the facility when the other staff persons said they were ready for them. SP4 agreed. P2 stated that s/he told SP4 that there were six children on the playground and P2 then entered the facility, leaving SP4 on the playground with the last group of six children, including the AV.
· A short time later, SP4 walked the children from the playground to the facility’s door, where SP1 met them. SP1 then walked them to the classroom and assisted them with taking off their outerwear and SP4 returned to his/her group of children on the other playground. SP1 did not count the children at that time. SP2 and SP3 brought the first two groups from the foyer back to the classroom, where they joined the third group. SP1, SP2, and SP3 had the children sit at the tables as they prepared to serve lunch to the children. · SP1 stated that as s/he was giving drinks to all the children, one of the other staff persons who s/he could not recall, asked if the AV’s milk was there. SP1 then looked around the tables, asked where the AV was, and called the AV’s name, but got no response. SP1 then ran outside to the playground and called the AV’s name but again did not get a response. P3 told P1 that the AV was missing and P1 went outside to help look for the AV. SP1 ran to the facility’s front entrance to look for the AV in the parking lot and then returned to the playground, where s/he checked inside the climbers and found the AV sleeping in the small plastic climber in the corner of the playground. SP1 told P1 that s/he found the AV and picked up the AV and took him/her back to the classroom to eat lunch. P2 stated that the AV was already back in the classroom when s/he returned to the classroom after feeding his/her child. SP1 telephoned the FM and told him/her that the AV was left unsupervised on the playground. Consistent information was provided that the AV was not upset or crying when s/he was brought back to the classroom. P1 stated that they checked the AV for injuries and did not see any injury to the AV. · SP1 stated that s/he knew s/he had six children that s/he brought into the facility, but was not sure if the other staff persons counted subsequent groups of children. SP1 was not in the facility’s foyer as the children were taken there, so was uncertain if anyone counted children there. SP1 did not count the children when they all returned to the classroom for lunch. SP2 stated that the staff persons “should have counted” the children when they all returned to the classroom, but s/he did not count until all of the children were seated at the tables. P1 stated that after the incident, SP4 told him/her that s/he was not told how many children were left on the playground when s/he was asked to “take over” from P2 and that after the last group of children entered the facility, SP4 looked around the playground, but did not see the AV. · SP1 believed the AV was unsupervised on the playground for approximately five minutes, from the time SP4 and the other preschool staff persons took their group of children into the facility until when SP1 found the AV sleeping on the playground. SP2 believed the AV was unsupervised on the playground for approximately 10 minutes and that it took approximately 15 to 20 minutes from when the first group went inside to when the children were sitting at the tables. P2 believed the AV was unsupervised on the playground “about three minutes.” P2 stated that the playground gates had locks that required pushing down on a large lever at the top of the latch in order to unlock the gates and the children were unable to open the locks. According to the facility’s Risk Reduction Plan, the children must always be within sight and sound of the staff persons. No staff person was to leave children without supervision. According to Weather Underground, (“Weather history for Duluth, MN”), on April 24, 2023, at 10:55 a.m., the temperature was 36 degrees Fahrenheit. Facility documentation showed that P1, P2, P3, SP1, SP2, SP3, and SP4 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. It was reported that on a previous occasion another child (C) left the facility and was left unsupervised for several minutes. P1 stated that on one occasion, the C followed his/her family member out of the facility, but a staff person saw him/her leave the facility, immediately followed the C, and brought the C back to his/her classroom. SP2 stated that s/he was not present when the C left the facility, but “heard” that the C went out the door and was followed by a staff person. P2 and SP2 were not able to provide any information about 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: Consistent information was provided that on April 24, 2023, P1, SP1, SP2, and SP3 took 18 children to the playground. When it was time to return to the facility, the staff persons split the children into three groups and took the groups into the facility at staggered times in order to make it less “chaotic.” P1 was the last staff person on the playground with six children, when s/he asked SP4 to supervise the children until they went inside the facility with the other children. P2 stated that s/he told SP4 how many children were present. SP4 did not provided information for this report but told P1 that s/he was not told how many children were present when P2 left the playground. A short time later, SP4 walked the children to the facility’s door, where they were met by SP1, who took them to the classroom. A few minutes later, the staff persons noticed that the AV was not with the group and searched for the AV. SP1 found the AV outside sleeping in a climber on the playground. The AV was unsupervised from three to ten minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart1, item A. The AV did not sustain any injury when s/he was unsupervised. Minnesota Statutes, section 260E. 30, subdivision 3 states that rather than making a determination of substantiated maltreatment by an individual, the commissioner of human services shall determine that a nonmaltreatment mistake was made by the individual. A nonmaltreatment mistake occurs when: (1) at the time of the incident, the individual was performing duties identified in the center's child care program plan; (2) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; (4) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; and (5) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing requirements relevant to the incident. Although the AV was left outside on the facility’s playground unsupervised by SP1, SP2, SP3, and SP4 for approximately three to ten minutes, the AV remained in the climber, was not visible to passersby, and was unable to open the playground gate. SP1’s, SP2’s, SP3’s, and SP4’s actions or conduct were determined to be a nonmaltreatment mistake for the following reasons: · At the time of the incident, SP1, SP2, SP3, and SP4 were performing job-related duties as required by the child care program plan including assisting the children with removing their outerwear and changing diapers and then counted the children once they had returned to the classroom and were sitting at the table; · SP1, SP2, SP3, and SP4 had not been determined responsible for any incident that resulted in a finding of maltreatment. · SP1, SP2, SP3, and SP4 had not been determined to have committed a nonmaltreatment mistake under this paragraph; · The AV sustained no injury during the incident; and · Except for the period when the incident occurred, the facility and SP1, SP2, SP3, and SP4 were all in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake regarding the AV by SP1, SP2, SP3, and SP4 was not maltreatment. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. After the incident, the staff persons received additional training on supervision and a transition sheet was created for the staff persons to use during transitions to accurately count the children. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, SP3, and SP4 were not determined as perpetrators of maltreatment of the AV because the Department of Human Services found that the incident for which SP1, SP2, SP3, and SP4 were responsible met the criteria to be determined a nonmaltreatment mistake. SP1, SP2, SP3, and SP4 were notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP1, SP2, SP3, or SP4 is responsible might not be considered a nonmaltreatment mistake. On August 9, 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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