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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: 1046049-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left his/her class while on a fieldtrip to the Minnesota Zoo so was unsupervised and then joined another facility’s class who was also at the zoo. Date of Incident(s): June 8, 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 27, 2023, and July 6, 2023; from documentation at the facility; and through seven interviews conducted with one supervisory staff person (P1), four staff persons (SP1, SP2, SP3, and SP4), the AV, and a staff person from the other facility (P2). The AV’s family members (FM1 and FM2) were notified however, they did not provide any information to this investigator. The AV was four years old at the time of the incident and enrolled in the PreK B classroom. There was a walkway at the Minnesota Zoo that led from the Upper Plaza to some indoor trails. The walkway had an open area with cafeteria tables set up for groups to eat at. On one side of the walkway was the Tropics Trail and on the other side was the Minnesota Trail. There were three automatic sliding doors from the open area of the hallway to a Learning Center lobby that had bathrooms and benches to sit on. From the lobby there was an archway on one end that led to a gathering area to the Minnesota Trail and on the other end of the lobby there was an automatic sliding door that led to the outside trails. In the gathering area there were places to sit, an alcove with turtles in an aquarium that could also be seen from the hallway, an information desk, and an entrance and exit to the Minnesota Trail. The entrance had an automatic sliding door that led to a vestibule which had another automatic sliding door on the other side, and through that door was the start of the Minnesota Trail exhibit. The exit door had a bar to push/pull it open or was able to open automatically with a push button located on either the outside or inside of the door. The facility had the children and staff persons on the fieldtrip wear a purple shirt to identify them as part of a group. There were other facilities from the same organization at the zoo that day also wearing purple shirts. The AV said that after lunch, s/he got lost at the zoo. The AV said s/he was not looking, and everyone had the same shirts. The AV said someone found him/her and then another child’s (C) family member (SP2) found him/her and brought the AV back to his/her class. The AV said the C was with SP2 when they found the AV. The AV did not remember SP2’s name. The AV said s/he was a “little bit sad” and cried a “little bit.” The AV said when s/he got back to the class s/he saw some more animals. P2 and another staff person (from the facility location P2 worked at) had finished lunch and were taking their class to the bathroom before doing more site seeing and heading to the bus. When the class was almost done going to the bathroom, P2 saw the AV running in a circle yelling for his/her family member. P2 said it was near the Tropics Trail. P2 knew that the AV was not one of their children but went to another facility location based on his/her shirt. P2 approached the AV and asked him/her some questions. P2 said the AV was crying and it was hard to understand the AV. P2 did not see any other class in purple shirts around so s/he kept the AV with him/her while P2’s class looked at more exhibits nearby. About five minutes later, P2 saw a staff person and a child (SP2 and the C) coming from the direction of the bathrooms and P2 asked SP2 if the AV was part of their class. SP2 nodded his/her head, held out his/her hand, the AV took it, and they walked away. P2 recognized SP2 from previous trainings. SP1 said the AV had only been in his/her class for a few days when the incident occurred. SP1 said the class finished lunch about 12:30 p.m. and then went to the Tropics Trail by where they sat for lunch and that only took about 30 minutes. The class was getting tired, so they went to where the Minnesota Trail started. They walked through sliding doors, counted kids, looked at the turtles, walked through another set of sliding doors, and counted the children again. The class started walking down the trail and a couple of minutes later, SP2 went to the bathroom and saw the AV standing with another facility’s class. SP1 said the AV did not seem “phased.” SP1 thought the AV was not with the class for two to three minutes. The AV was not aware he wandered from the class. SP1 said supervision on fieldtrips included being in ratio, staff persons spreading out, using name to face on Tadpole (an application used to track attendance), and counting. SP1 said s/he did name to face when they left the facility and when they got back, otherwise, s/he just counted at the beginning and end of each trail. The last count before the AV was found was at the beginning of the Minnesota Trail. SP1 said s/he was leading the class, SP4 was “a little ways” behind, and then SP2 and SP3 were in the back. SP1 said there were also three chaperones who were not facility staff persons on the fieldtrip. SP2 said that the day of the incident, the class went to the bathroom and washed hands and around noon the class had lunch and then planned on going to some exhibits. After lunch was finished the class went to see more animals. SP2 was not familiar with the Minnesota Zoo, so s/he was not sure of what area they were in. The C had to use the bathroom, so SP2 took the C and on the way back, SP2 saw the AV with another staff person wearing a purple shirt (P2). P2 asked SP2 if the AV belonged with SP2. SP2 took the C and the AV back to the class and the AV ran up to SP1 and said, “I was lost,” and that SP2 found the AV after leaving the bathroom. SP2 looked at his/her watch and it was around 1 p.m. SP2 said the AV seemed “shaken up” but was not crying at the time. The AV did not say why s/he wandered off. P2 did not tell SP2 how long the AV was with P2, but SP2 did not think s/he and the C were in the bathroom more than three minutes. SP2 stated that s/he saw other classes in purple shirts but did not recognize the people. SP2 stated that supervision on fieldtrips was “sight and sound at all times.” SP2 said to ensure that, staff persons were supposed to count and do name to face every 15 minutes using Tadpole. SP2 said that SP1 had the iPad and SP2 said they were all counting, but SP2 did not see SP1 do a name to face. SP2 said SP1 was in the front of the line and either SP2 or SP3 were in the back on the line. There were also three chaperones who were not facility staff persons. SP2 did not say that SP4 was at the fieldtrip. SP4 was not aware of the incident until the class returned to the facility and heard from SP1. SP4 said the class had lunch and then went to one or two more trails before going to the Minnesota Trail. SP4 heard that the AV was not with the class for “like five minutes.” SP4 said at every exhibit, “We counted going into and coming out of it.” SP4 thought the AV got confused and wandered off with another group. SP4 said SP1 was in the front of the class, SP4 was in the middle, and SP2 and SP3 were in the back. SP4 said there were three chaperones as well. SP3 said that SP1 told him/her after they returned to the facility that the AV had wandered off. SP3 thought the incident occurred in the morning before lunch. SP3 said one staff person was in front, one was in the middle, and SP3 was in the back. SP3 said SP1, SP2, and SP4 were the other staff persons on the fieldtrip. SP3 said the supervision policy on fieldtrips was to line the children up and make sure the staff persons had everyone by counting them. SP3 said there were other classes with the same shirt on. SP3 thought the AV was gone “maybe a few seconds.” P1 was made aware of the incident when the class returned to the facility. P1 spoke with SP1, SP2, SP3, and SP4 and found out that SP2 took the C to the bathroom and when s/he came out there was another staff person from a different facility who had the AV. The AV rejoined the class with SP2 and SP2 informed SP1 what had happened. P1 said it was “not more than ten minutes” that the AV was not with the class. P1 said the policy was to have an attendance roster with the class on the fieldtrip, conduct a name to face when leaving the building, getting off the bus, and continuing the checks while at the zoo. The chaperones were not in the ratio count. There was a staff person in the front, two in the middle, and one in the back. The facility’s Program Plan and Supervision stated that, “Children will be supervised at all times.” The facility Risk Reduction Plan stated, “Name to face head counts are implemented at every transition and constantly on field trips.” The facility’s Fieldtrip Manifest stated, “Roll call is taken…before and after each transition.” P1 and SP1-SP4 were trained on the facility’s Program Plan and Supervision, Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute 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. Conclusion: A. Maltreatment: Consistent information was provided that on June 8, 2023, SP1, SP2, SP3, and SP4 were at the Minnesota Zoo with a class of preschoolers. There were classes from other facilities within the organization also at the Minnesota Zoo that day and all were wearing purple shirts. Sometime after lunch, the AV was found by P2, a staff person from a different facility within the organization. The AV was crying and yelling for a family member. P2 did not see another class nearby, so s/he kept the AV with him/her. After about five minutes, SP2 and the C walked by from the direction of the bathrooms and P2 asked if the AV belonged with SP2’s class. SP2 nodded and s/he, the C, and the AV returned to the class. At that time the AV looked “shaken up,” but was no longer crying. The AV was unsupervised for an unknown amount of time which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, prior to being found by P2. It was estimated that the AV was with P2 for about five minutes without SP1’s, SP2’s, SP3’s, and SP4’s knowledge. Although SP1 stated that s/he counted the children prior to entering the Minnesota Trail exhibit and the AV was found by P2, given that SP1-SP4 were not aware that the AV was no longer with the class, SP1-SP4 were not present to intervene if the AV was injured or in an emergency, and that the AV was unsupervised in the community for more than five minutes, 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 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. SP1-SP4 were responsible for the AV’s supervision at the time of the incident and were trained on the facility’s Program Plan and Supervision, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. SP1-SP4 were each responsible for 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-SP4 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV did not sustain any injuries. 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 found their policies and procedures were adequate, but not followed by SP1-SP4. The facility retrained all staff persons on supervision on June 20, 2023, and SP1-S4 had a documented conference write-up in regard to the incident. Action Taken by Department of Human Services, Office of Inspector General: SP1-SP4 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1-SP4 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-SP4 were each responsible for maltreatment is subject to appeal. On August 30, 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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