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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: 831012-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on a playground unsupervised for three to four minutes and found by a community person. Date of Incident(s): May 10, 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 23, 2023; from documentation at the facility; and through three interviews conducted with two facility staff persons (SP1, P), and the AV’s family member (FM). Due to the AV’s age s/he could not provide any information about the incident. This investigator made attempts through phone, email, and mail to interview another staff person (SP2), but attempts were unsuccessful. The facility was a large building with several classrooms. To right of the entrance was a large gym area. Past the gym towards the back of the building was a door that led out to a fenced in playground for the toddler class. The playground was a small area with both grass and concrete areas. The playground contained multiple riding toys, other small toys, and a child sized picnic table. The AV was 19 months at the time of the incident and enrolled in the toddler classroom.
The P provided the following information: · On the date of the incident, at approximately 4:30 p.m., a family member notified the P that there was a child alone on the playground. The P went out and saw the AV alone in the toddler playground riding a toy car. The AV did not appear upset. · The P brought the AV to the gym and found SP1 in the bathroom washing children’s hands and SP2 standing there with the rest of the children. SP1 and SP2 were not aware that the AV was not with the rest of the class. · Staff persons were to count the children when they left the playground and when they arrived at their destination. The P had no previous concerns with SP1 or SP2. SP1 provided the following information: · On the day of the incident, SP1 went outside to relieve another staff person. SP2 was outside and when SP1 asked, SP2 said they had ten children but SP1 did not count the children at that time. SP1 suggested that they take the children to the gym. · SP1 said s/he would take seven children to the gym and SP2 could take the other three children back to the classroom. SP1 took the older seven children and went into the gym. SP2 took the three remaining children and came inside after SP1. · SP1 took the seven children to the gym area and had them start washing their hands. SP2 came into the gym shortly after with three children so SP1 knew there were ten children there. Approximately two to three minutes after arriving in the gym, when SP2 started to help the second child wash his/her hands, a family member came in and said the AV was outside on the playground. · SP1 never counted the children when s/he arrived to the playground but s/he thought that there must have been eleven children at that time. SP2 did not respond to this investigator’s attempts to complete an interview. The FM had no previous concerns with the facility. The facility roster showed that on the date of the incident at the 4 p.m. count there were 11 children present. One child was picked up at 4:14 p.m., leaving 10 children in the classroom. Two additional children were picked up at 4:39 p.m. and 4:35 p.m., most likely after the children returned inside. The Risk Reduction Plan indicated that all classrooms used a name to face headcount sheet and conducted head-counts each hour. Staff persons conducted a head count when leaving an area and another head count when arriving at an area. One staff person led the class in front and another staff person was in back when walking down the hallway to made sure children were supervised at all times. According to www.wunderground.com, the outdoor condition at the facility, on May 10, 2023, at the time of the incident, was “partly cloudy” with a temperature of 79 degrees Fahrenheit (°F) and wind speed of 14 miles per hour (mph). 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, stated that a child must have supervision at all times and that supervision was 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 the day of the incident, SP1 and SP2 were outside on the playground and took the children back inside. SP1 was told that there were ten children outside but did not count when s/he arrived at the playground to relieve another staff person. SP1 took seven children and went inside to the gym. SP2 brought the remaining children inside and eventually to the gym. SP1 saw SP2 arrive to the gym with three children, so thought that since SP1 had seven children they had all the children. The attendance roster showed there were 11 children present until one was picked up at 4:14 p.m. It was unclear why the count of children was not correct. A family member informed the P that the AV was outside on the playground unsupervised. The P went to the playground and found the AV. SP1 thought the AV was unsupervised for two to three minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the playground was fenced, given the AV, who was 19 months old, had no staff person available to intervene if the AV attempted to do something dangerous, injured him/herself, or in the event of an emergency, that staff persons were unaware that the AV was not with the group, and that staff persons were unaware of how many children they should have had, there was a preponderance of the evidence that there was a failure to supply the AV with 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. 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 policies and the Reporting of Maltreatment of Minors Act prior to the incident. SP1 and SP2 both worked in the AV’s classroom and were supervising the children on the playground at the time of the incident and were responsible for knowing and correctly counting the number of children in the classroom. Both SP1 and SP2 were responsible for the neglect 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 SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident, and the AV did not sustain any 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. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed when staff persons did not count the children when returning inside. All staff persons were retrained on supervision. 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 August 23, 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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