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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: 1037234-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised without staff persons’ knowledge or supervision for approximately three to five minutes. Date of Incident(s): May 16, 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 for this investigation was obtained remotely, including documentation from the facility; and through five interviews conducted with a supervisory staff person (P1), facility staff persons (P2, SP1, and SP2), and the AV’s family member (FM). Attempts were made via telephone and mail to contact and interview another staff person (SP3), but attempts were unsuccessful. The facility shared a space with a church and occupied one floor. The church had multiple floors accessible by two sets of stairs and an elevator. On each side of the floor that the facility was located was an entryway, with doors leading outside, a set of stairs going up, a bathroom, and a door that led to a hallway were the facility as located. Inside the facility hallway at one end was a small room with an elevator. In the entryway closest to the elevator on the opposite side of the facility doors, was a set of doors that led to a lunchroom. This incident took place in the entryway nearest the elevator. Facility documentation showed the AV was five years old at the time of the incident. The FM stated that on May 16, 2023, the AV had a “bad day” before s/he arrived at the facility and after the incident another family member picked up the AV early. The AV ran off when s/he was “doing something bad.” SP1 was “good” at keeping the AV calm, and informing the FM of what was going on. The FM did not have concerns regarding the program. The facility Injury/Incident Reporting Form-Child, completed by SP1, showed that on May 16, 2023, at approximately 12:10 p.m., as the class transitioned to the lunchroom, the AV was missing for approximately one minute, and was found on the second floor in the elevator room. The facility provided video footage for May 16, 2023, from two cameras. One camera was in the entryway outside of and viewed the entryway, the bathroom, and the door to the facility hallway. The doorway to the lunchroom was not visible and the corner portion of the entryway nearest the lunchroom door was also not visible. The other was in the stairwell showing the top of the stairs and the entry to the small elevator room. The video footage provided the following information: · The entryway video was seven minutes, six seconds long. The first 4 minutes and 31 seconds of entryway video included multiple staff persons and children coming from the facility hallway door to use the bathroom and going to the lunchroom. At that time, two other children were visible on the video, but no other staff person were visible and SP3 walked through the hallway door with the AV and another child. At 4:43, SP3 was standing near the bathroom, the AV was standing against a wall, SP2 came out of the bathroom, another person walked out of the facility hallway door into the entry, and there were five additional children on video in various locations. At 4:51, SP2 and a group of children walked down the hallway to the lunchroom and off camera while SP3 stood just outside the bathroom area. The AV initially started to walk with that group of children but at 4:58, walked back to the bathroom/stairwell, past SP3, and off camera. At 5:13, a child ran out of the bathroom towards the lunchroom and off camera, followed by SP3. At 5:30, SP3 walked from the lunchroom doorway into the entryway and at 5:36, P1 came into the entryway, and it appeared as though SP3 and P1 talked. At 5:44, SP3 walked towards the lunchroom and off camera, and an unknown person walked from the lunchroom into the entryway and appeared to also have a conversation with P1. At 6:00, as P1 left the entryway, SP2 and a child walked from the lunchroom into the entryway and SP2 and the child left view of the camera near the bathroom/stairwell. At 6:35, the video skipped and resumed at 6:36 with SP2 and the AV in the entryway. The AV appeared to refuse to stand/walk and was picked up by SP2 and at 6:57, SP2, the AV, and the other child returned to the lunchroom and out of view of the camera. · The stairwell video was 2 minutes, 40 seconds long. At 0:17, the AV appeared in view walking up the stairs. At 0:24, the AV walked into the small elevator room as s/he turned and looked down the steps the AV walked off camera. At 0:48, the AV walked out of the elevator room and up the next flight of stairs out of view of the camera. At 1:15, the AV walked back down the stairs and ran to the small elevator room and out of view of the camera. At 1:44, SP2 appeared in view walking up the stairs with a child. SP2 and the child go into the small elevator room and out of view of the camera. At 2:26, the child, SP2, and the AV walk out of the elevator room and down the stairs. · The AV was without supervision for just over one minute. P1 provided information that was consistent with the video and the following additional information: · On May 16, 2023, SP1, SP2, and SP3 were working in the AV’s classroom. The number of children in attendance and their names were kept on an APP on an iPad. P1 did not know who was responsible for the iPad on May 16, 2023. No staff person conducted a head count or checked to see if all the children were there. · After children used the bathroom, they should have been lined up and sang a song as they waited for the other children to finish. After SP1 arrived outside the bathroom in the hallway, a head count should have been completed and there should have been communication between SP1, SP2, SP3 and P2. Another head count should have been completed once the class reached the lunchroom. · P1 stated hazards present to the AV were the stairs, accessibility to the street, and accessibility to the facility gym. SP2 provided information that was consistent with the video and stated that before walking to the lunchroom, SP2 was in the hallway and surrounded by children, including the AV and it looked like the AV was going to be at the end of the line as the group walked to the lunchroom. Once the group was in the lunchroom, SP1 noticed that the AV was not there. SP2 left the lunchroom to look for the AV and walked to the bathroom area, and called out the AV’s name. When SP2 heard the AV giggle, s/he walked up the stairs and found the AV in the elevator room, under a bench. The AV was not injured. SP2 and the AV walked back to the lunchroom. SP2 stated s/he did not count when the children entered the lunchroom because they were not all there, some children were still in the hallway. Attendance was kept on and iPad. Typically, SP2 had the iPad but s/he could not recall who had the iPad on May 16, 2023. SP2 believed s/he should have communicated about the AV and stopped SP1 and counted the children. SP2 stated s/he failed to provide supervision for the AV on May 16, 2023. SP1 provided information that was consistent with the video and stated on May 16, 2023, the class finished an activity and SP2, SP3, and P2 took most children out of the room to wash hands and use the bathroom before lunch. SP1 stayed in the room with three children, including the AV, who did not want to transition yet to the lunchroom. When the two other children were ready for lunch, the AV left the classroom and ran down the hallway away from SP1. SP1 watched the AV go to the other end of the hallway and used the walkie talkie to communicate to SP2 that the AV was in the hallway. SP3 heard that communication and went to the hallway to get the AV. SP1 and the two children left the classroom and walked to the bathroom area. At that time, P2 blocked the hallway to the lunchroom, SP2 monitored the bathroom, and SP3 blocked the stairway access. SP1 took “all the kids” as s/he walked to the lunchroom. SP1 stated that the last staff person in the bathroom area was responsible to ensure everyone was out of the bathroom and SP3 was the last one in the area. Once in the lunchroom, SP1 realized that the AV was missing and SP2 went to look for him/her. SP2 used the walkie talkie and communicated to SP1 that s/he had found the AV in the elevator room and then SP2 brought the AV to the lunchroom. SP1 called the FM and told the FM that the AV had been missing. SP1 said s/he did not fail to supervise the AV because s/he provided supervision to other students and trusted SP3 to provide supervision to the AV. P2 stated that on May 16, 2023, as everyone used bathrooms before lunch, P2 stopped in the hallway to prevent children from going to the lunchroom. Some children ran into the lunchroom and P2 went with them. P2 was unaware that the AV was missing and learned about the incident on May23, 2023. P2 knew that staff persons should count children and that a staff person should be at the front and end of a line of children. After this incident, staff persons counted children every “few minutes,” and staff persons communicated the number of children present more with other staff persons. The facility’s Procedures & Responsibilities documentation showed that children must be within sight and hearing of a staff person at all times. Staff persons used “active supervision” strategies that included positioning themselves to see all the children, watching, counting, and listening at all times. When children transitioned from one location to another, staff persons counted children frequently. The facility’s Risk Reduction Plan stated that when groups walked in hallways, there was a staff person in the front, middle, and end of the line, and head counts were done “constantly.” 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, 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. Minnesota Rules part 9503.0155, subpart 15, states that kitchen, stairs and other hazardous areas must be inaccessible to children except during periods of supervised use. Conclusion: Information was consistent that on May 16, 2023, the AV was in the elevator room without the knowledge or supervision of a staff person for approximately one and a half minutes as the AV’s class transitioned from the classroom to the bathroom and then to the lunchroom, which was a violation of Minnesota Statutes, section 245.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV went up the stairs to an elevator room and was found by SP2, which was a violation of Minnesota Rules part 9503.0155, subpart 15. 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. At the time of the incident, SP1, SP2, and SP3 were still in the process of transitioning from the classroom to the bathroom, and then the lunchroom. Although SP3 did not see the AV walk past him/her, within 17 seconds of SP3 entering the lunchroom, staff persons were aware that the AV was not there, and they immediately began looking for the AV. SP1’s-SP3’s actions or conduct was determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, SP1-SP3 were performing job related duties, as required by the facility’s policies, by supervising children as they transitioned. (2) SP1-SP3 had not been determined responsible for any previous incident that resulted in a finding of maltreatment. (3) SP1-SP3 had not been determined to have committed a nonmaltreatment mistake under this paragraph. (4) The AV was uninjured and did not require medical care after the incident; and (5) Except for the period when the incident occurred, the facility and SP1-SP3 were each in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake to the AV by SP1, SP2, and SP3 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 policies and procedures were adequate but not followed. SP1 and SP3 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which each was responsible met the criteria to be determined a nonmaltreatment mistake. SP1, SP2, and SP3 were notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which each is responsible might not be considered a nonmaltreatment mistake. On August 18, 2023, the facility was issued a Correction Order for the violations 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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