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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: 1078336-CCC (Child Care Center) Investigator(s): Alice Percy 651-431-6569 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left outside the facility unsupervised. The AV was found by a community person (CP) outside of the facility’s back door. Date of Incident(s): May 22, 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 June 8, 2023; from documentation at the facility; and through six interviews conducted with three facility staff persons (SP1, SP2, and P1), an administrative staff person (P2), the CP, and the AV’s family member (FM). The AV was 33 months old and enrolled in the toddler classroom at the time of the incident. The facility was located in a strip mall along with several other businesses, including a Dominos Pizza. A large parking lot was located in front of the facility and neighboring businesses. Additional businesses were located on the far side of the parking lot. Various streets ran from the parking lot to a main street that had a posted speed limit of 30 miles per hour. A street ran from the parking lot around the back of the strip mall to additional parking at the back of the building. The facility’s playground was located behind the building on the far side of the street running around the back of the building. A residential area was located on the far side of the playground. The AV’s classroom was located immediately adjacent to another toddler classroom. The two classrooms were separated by a half wall. At the back of each classroom was a door leading to the back of the building. The staff persons used those doors to take each group of children outside to the playground. The CP, who worked at one of the businesses in the strip mall, stated that on the day of the incident, as the CP walked to his/her car, which was parked behind the building, a truck driver, who had turned his/her truck around in the parking lot behind the strip mall where the facility was located, stopped next to the CP. The truck driver told the CP that there was a child unsupervised behind the building. The CP walked to the facility’s back door and saw the AV leaning against the door of the facility. The CP knocked on one of the facility’s doors and told the staff person who answered the door that s/he found the AV unsupervised outside the door. The staff person took the AV into the facility. Later, P2 asked the CP to come to the facility and talk to him/her and the FM about what occurred. The CP did not believe the AV was outside for more than 15 to 30 minutes because the CP did not see the AV outside when s/he arrived at the strip mall a short time before s/he found the AV unsupervised. Consistent information was provided that when the staff persons took the children to and from the playground, they used a nylon rope that had belts that buckled around each child’s waist. The children were unable to unbuckle the belts on their own. Although the facility had a video camera in the classrooms, P2 was unable to save a copy of the video after viewing it after the incident. P1, P2, SP1, SP2, and the facility’s documentation provided the following information: · On May 22, 2023, at approximately 9:30 a.m., SP1 and SP2 took nine children, including the AV, to the facility’s playground. While they were on the playground, another child arrived, which meant they had ten children in the group. At approximately 10:30 a.m., SP1 and SP2 lined the children up, placed a belt that was attached to the nylon rope around each child’s waist, and walked to their classroom’s back door. SP1 was at the front of the line and SP2 was at the back of the line. When they reached the back door, SP1 counted the children and assisted the two children at the head of the line off the rope and helped them step over the threshold so that they did not fall. At the same time, SP2 assisted children at the back of the line off the rope and sent them toward the door. SP1 stated that the AV was in the second row on the rope and tripped as SP1 unhooked him/her from the rope. SP1 helped steady the AV and then they unbuckled the other children and sent them into the facility. · Once the children were inside, SP1 and SP2 entered the facility and SP2 closed the door. SP2 stated that prior to entering the facility, s/he turned and looked back toward the playground, but did not see anyone. SP1 stated that both staff persons typically counted the children once they were inside the facility, but on that day SP1 did not count the children. SP2 stated that s/he counted the children when they left the playground, but was distracted when they got to the facility’s door because one of the children, not the AV, tried to go back outside. Once SP1 and SP2 brought the children into the classroom, SP1 went to the bathroom, leaving SP2 with the children. SP2 stated that while SP1 was gone, a child was upset so SP2 attempted to calm the child. Neither SP1 nor SP2 counted the children once they were back in the classroom. · At approximately 10:40 a.m., P1 heard a knock on his/her classroom’s back door. When s/he opened the door, s/he saw the CP and the AV. The CP told P1 that the staff persons “left one outside unattended.” As SP1 returned from the bathroom, s/he saw the CP at the facility’s back door with the AV. P1 then brought the AV into the facility and told SP1 and SP2 that the CP found the AV outside the facility. P1 stated that the AV was not crying but was a “little anxious and scared.” SP1 told an administrative staff person (P3) about the incident. P3 then telephoned P2 and told him/her about the incident. P2 went to the facility and talked to the staff persons and telephoned the FM to tell him/her about the incident. P2 stated that s/he watched a video recording taken in the classroom at the time of the incident. At 10:30 a.m., the video showed SP1, SP2, and the children, not including the AV, entering the classroom from the back door. At 10:41 a.m., P1 opened the back classroom door and the AV entered the facility. · SP1 believed that after s/he unhooked the AV from the rope, the AV went behind SP1 without being seen by SP1 or SP2, as SP1 held the door open with his/her back. SP2 stated that the AV might have “sneaked” past him/her as s/he was unbuckling one of the children from the rope. SP1 did not believe the AV was outside for more than 15 minutes. Neither SP1 nor SP2 knew the AV was not with the children in the classroom until the CP brought the AV to the facility’s back door. The AV did not sustain any injury while unsupervised. The FM stated that the facility did a “good job” of informing the FM about the incident, but the FM was disappointed that the AV was left unsupervised in an area where s/he could have been hit by a car or taken by an unknown community person. After the incident, the AV was moved to another classroom. According to the facility’s Risk Reduction Plan, when the staff persons took the children to and from the toddler playground, the children were to form a line, with one staff person at the front of the line and another staff person at the back of the line. All children were to be under a staff person’s supervision at all times. The staff persons were to remain within sight and sound of the children. Facility documentation showed that P1, P2, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies 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: On May 22, 2023, approximately 10:30 a.m., the AV was left outside the facility unsupervised for 11 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Eleven minutes after SP1, SP2, and the children entered their classroom, the CP knocked on P1’s classroom door and told P1 that the AV was left unsupervised at the back of the building. P1 then brought the AV into the facility and told SP1 and SP2 that the AV was found by the CP. The AV was not crying and did not sustain any injury during the incident. Neither SP1 nor SP2 were aware that the AV remained outside when they took the other children into the facility, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Given that SP1 and SP2 failed to count when they returned into the classroom, and that the AV, who was 33 months old, was unsupervised for 11 minutes in an unfenced area outside the facility, where the AV was found by a community person and had access to community dangers such as cars and trucks, 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 and/or 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. Facility documentation showed that SP1 and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. SP1 and SP2 were each responsible for the care and supervision of the AV at the time of the incident. SP1 and SP2 were responsible for the 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 SP1 and SP were each 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 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 the facility’s polices were adequate, but were not followed by the staff persons. After the incident, SP1 and SP2 were retrained on the facility’s supervision policies. 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 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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