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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: 801268-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left outside unsupervised for 15 minutes. Date of Incident(s): July 5, 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 July 26, 2023; from documentation at the facility; and through four interviews conducted with four facility staff persons (P1, P2, SP1, SP2). This investigator made multiple attempts through phone calls and mail to interview the AV’s family member (FM), but attempts were unsuccessful. Due to the AV’s age s/he was unable to provide any information about the incident. The facility was a building with a fenced in play area along the side and back. The two year old classroom was the first door to the left of the entrance. The classroom had a door that exited into the fenced in area. Straight out the door was the preschool playground. Around the corner to the right was a fenced in area within the playground that was the toddler playground. The playground had a large play structure and several smaller structures and tables. The playground faced the back of the building. There was a door and window in the infant room that looked out to the playground. The AV was 23 months at the time of the incident and enrolled in the two year old classroom. P2 said that at approximately 11:15 a.m., on the day of the incident, P2 was working in his/her classroom. P2 looked out the window and saw the AV standing in the toddler playground by the gate. There was no one else on the playground, so P2 went outside and grabbed the AV. The AV was crying and trying to get out. P1 provided the following information: · On the date of the incident at approximately 11:15 a.m., P2 came into the office with the AV. P2 said that the AV was on the playground. Another staff person took the AV back to the classroom. · When transitioning to the playground, staff persons completed a name to face count of the children at the door and then when they reached the playground. On the way inside, staff persons counted the children at the gate and counted at the door to the classroom. Staff persons did a name to face once they got inside the classroom. P1 had no previous concerns with SP1 or SP2. SP2 provided the following information through a written statement and an interview with this investigator: · On the date of the incident, SP1 completed a count of the children before going outside. When they got to the playground gate, SP1 counted the children again at the gate and let them into the toddler playground. · The classroom was outside for approximately an hour. When leaving the playground, SP1 and SP2 called the children to the gate and SP1 counted the children as they were exiting the gate. SP2 was “rallying” the children who were not wanting to leave the playground. SP2 did a sweep of the playground before s/he left but did not see any children. · SP2 walked at the end of the line to the classroom door. There was a child that tried to leave the group and go to an area where another classroom was playing so SP2 had to go get the child. SP2 remembered hearing SP1 counting children as SP2 approached the door. SP1 and SP2 did not realize the AV was not in the classroom. SP1 and SP2 were unsure how the AV was missed as SP1 said that the AV was one of the first names on the child supervision record. · SP1 began changing children’s diapers and SP2 was getting the children to sit down when a staff person came to the classroom with the AV 10-15 minutes later. SP1 provided the following information: · On the date of the incident, SP1 and SP2 were outside on the toddler playground. When it was time to go back inside, it was a “messy” transition. SP1 completed a name to face check with the child supervision record before they left the toddler playground, and they did have the AV. · SP1 walked in the front of the line, while SP2 walked at the back. SP1 ran ahead a bit to block the other playground so the children did not try to stop and play on the preschool playground which was adjacent to the two year old classroom door. · SP1 thought they did the second name to face count right outside of the classroom door with the children standing in a “bunch.” SP1 was not sure why s/he had checked off the AV when the AV would have been back in the toddler playground and not with the group by the door. The Child Supervision Record showed that on the date of the incident, the classroom went outside at 10:10 a.m. A name to face transition was completed at that time and there were 9 children present. Two additional children arrived at 10:24 and 10:49 a.m. At 11 a.m. another name to face transition occurred when the classroom came inside. All 11 children including the AV were marked as in attendance. The Supervision of Children policy stated that children were supervised at all times. Staff persons completed name to face attendance at least every 30 minutes and during any large class transitions including going outside to the playground. According to www.wunderground.com, the outdoor condition at the facility, on July 5, 2023, at the time of the incident, was “partly cloudy” with a temperature of 73 degrees Fahrenheit (°F) and wind speed of 13 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 from all sources was consistent that on the morning of July 5, 2023, the AV was left on the facility’s toddler playground without the knowledge or supervision of a staff person for approximately 15 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 and SP2 were each not aware that the AV was still on the playground when they took the other children back to the classroom, 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. Another staff person noticed the AV on the playground and brought him/her inside the facility. Although the playground was fenced, the AV, who was 23 months old, was unsupervised for approximately 15 minutes with no staff person available to intervene if the AV attempted to do something dangerous, injured him/herself, or in the event of an emergency. Therefore, 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. 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. Both SP1 and SP2 were responsible for 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 SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident and the AV was not injured. 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 that policies and procedures were adequate but not followed. All staff were retrained on child supervision and transitions. Staff persons involved received correction action. 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 September 8, 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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