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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: 1093049-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that six alleged victims (AV1-AV6) were unsupervised for approximately three minutes when a supervisory staff person (SP) left them alone in a classroom. Date of Incident(s): April 24, 2023 (The Department of Human Services received the report on 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 May 31, 2023; from documentation at the facility; and through nine interviews conducted with facility staff persons (P1, P2, P3, and P4), the SP, and AV1’s-AV4’s family members (FM1, FM2, FM3, and FM4 respectively). Attempts to contact AV5’s and AV6’s family member were unsuccessful. The facility was a stand-alone building located at a “T” intersection of two roads approximately two blocks from a river. Surrounding the facility were single family homes, churches, school bus parking, open fields, and wooded areas. The facility was “L” shaped and had a preschool classroom, a toddler classroom, and an infant classroom. The main entry of the facility was located in approximately the bottom middle of the “L,” and opened into a small vestibule that had two half doors. A half door to the left that led to the toddler classroom. Through the toddler classroom was another half door that led to the infant classroom and through the infant classroom to the back was a kitchen located at the top of the “L.” The preschool classroom was to the front of the vestibule. The half doors were secured with slide bolt locks. The preschool classroom had an attached bathroom and two additional doors that opened directly outside. There was a window in the wall between the preschool classroom and toddler classroom. The facility had video cameras in classrooms and this investigator asked the SP for video footage from April 24, 2023, (the date of the incident). The SP told this investigator that s/he was not able obtain the video footage from that day because s/he could not get the video to work on his/her cell phone. The facility’s enrollment documentation for AV1-AV6 showed that at the time of the incident AV1, AV4, and AV5 were four years old and AV2, AV3, and AV6 were three years old, and each were enrolled in the preschool classroom. FM1 stated that on April 24, 2023, at approximately 3:15 p.m., s/he arrived at the facility and went into the preschool classroom. FM1 did not see a staff person in the preschool classroom but saw two children standing and the other children lying on cots. FM1 talked with some of the children and after “several” minutes, FM1 saw the SP walked from the toddler classroom to the preschool classroom with snack items in his/her hands. FM1 asked the SP how long AV1 had been asleep and then FM1 got AV1, and they left the facility and did not return the next day. On April 26, 2023, FM1 talked with the SP regarding this incident and the SP apologized to FM1 and told him/her that s/he left the classroom because s/he needed to get snack. Neither FM2, FM3, nor FM4 had seen the preschool classroom unsupervised in the past and had no immediate concerns regarding the facility. P1 provided the following information: · P1 could not recall the exact date but on the day of the incident, s/he was in the toddler bathroom changing diapers when s/he heard the half door between the infant classroom and the toddler classroom shut. P1 looked up, saw the SP lock the half door from inside the infant room and walk away towards the kitchen. Then heard the facility main door open. P1 exited the bathroom and looked through a window between the toddler classroom and the preschool classroom. P1 saw FM1 in the preschool classroom near AV1, who was on a cot and did not see a staff person in the preschool room. P1 then walked to the infant classroom half door and asked P4 and another staff person to tell the SP to go back to the classroom because there was someone in the preschool room. P1 then saw the SP “running” to the front. P1 saw the SP and FM1 talk briefly near the facility entrance and as FM1 and AV1 left the facility his/her voice sounded “angry.” P1 stated the SP was out of the preschool classroom for approximately three minutes. · When P1 arrived at the facility the next day, all the other staff persons looked at him/her “weird,” and P4 told P1 that the SP told the other staff persons that s/he had told P1 to watch the preschool classroom when s/he left to get snack. P1 stated the SP did not ask him/her to watch the preschool classroom and that the SP could have asked to have one of the infant staff persons to get the snack from the kitchen and pass it to the toddler room and then to the preschool classroom. · P1 said that she did not review video footage for April 24, 2023, but the SP told P1 that s/he had pulled up the video and watched it. · P1 said that when the preschool children were unsupervised, they could have left the facility through the front door or one of the other two doors in the preschool classroom. P1 did not think s/he had been trained on supervision, but a staff person should be in a room, watching and interacting with children. · On May 31, 2023, P1 asked P4 if s/he was going to be truthful when talking with this investigator. P4 responded that s/he would be truthful “to a degree” and would respond with yes or no and not expand on his/her answers because s/he wanted to keep his/her job and did not want the facility “shut down.” P2 stated s/he did not work on April 24, 2023, but on April 25, 2023, P2 overheard P3 and the SP talking about the incident and that FM1 “freaked out” because the SP walked out of the preschool room to get snack and when the SP returned to the classroom FM1 was in the room. P2 said s/he discussed the incident with P1, P3, P4, and the SP. P2 told the SP leaving the classroom was not “ok,” and the SP told P2 that “it was just a mistake,” and that s/he “felt bad.” According to P2, supervision meant being in a room at all times with the ability to see and hear the children. P3 stated the SP worked in the preschool classroom from 7 a.m. until 6 p.m. P3’s shift usually ended at 2 p.m. Afternoon snack was usually brought to the preschool classroom by either P2 or P4 between 3 and 3:30 p.m. P3 was not at the center at the time of the incident but heard from other staff persons about a time in late April or early May when the preschool classroom had been unsupervised. The SP told P3 that s/he ran back to get snack for “a second,” because no one brought snack to the preschool room. P3 received training on supervision and children needed to be within sight and sound of a staff person at all times. P4 stated that on April 24, 2023, s/he was working in the infant room and s/he did not see the incident. On May 31, 2023, the SP told P4 that the SP had left a child unsupervised and that was why this investigator wanted to talk to P3. P4 stated s/he did not hear other staff persons discussing the incident and his/her only knowledge was what the SP told her on May 31, 2023, at the time of the site visit. P4 had been trained to not leave a classroom and that a staff person had to see and hear children at all times. The SP stated that everyday s/he was a preschool teacher from 6:45 a.m. to 5:00 p.m. On most days, either P2 or another staff person were also in the preschool classroom and one of them went to the kitchen to get afternoon snack, so usually there is a staff person in the room “all the time.” The SP said that there “could have been one time” when the SP left the classroom unsupervised to get afternoon snack, but the SP did not recall the date this happened. One day when SP1 was working in the preschool classroom and FM1 came to the facility angry, but the SP did not know why. The SP did not “think” s/he ever failed to supervise children. The SP trained staff persons on supervision and ensured children in every room were supervised at all times. According to the facility’s Risk Reduction Plan, supervision was very important to the facility and that no staff person should ever leave a group of children unsupervised. On June 8, 2022, (prior to the incident in this investigation) the facility was placed on a conditional license for citations that included failing to supervise children. On June 17, 2022, the facility appealed the conditional license and denied all portions of the supervision citations. On January 11, 2023, the conditional license was upheld and the response stated, “There is sufficient information to support the cited violations.” The facility was ordered to: · Develop a detailed supervision plan to ensure that children will be supervised by program staff persons at all times, consistent with the definition of supervision under Minnesota Statutes, section 245A.02, subdivision 18, and in compliance with the risk reduction plan requirements under Minnesota Statutes, section 245A.66, subdivision 2, paragraph (f), (1) through (5); and within 30 days from receipt of this order, you must submit the supervision plan to your licensor for approval. · Within 30 days after the supervision plan is approved by your licensor, you must provide training to all staff on the supervision plan and maintain documentation of the training in each staff person’s personnel record. You must also ensure new hires receive the same training and document the training in each new hire’s personnel record. The facility’s Supervision of Children (indoor and outdoor) was received by the DHS via email from the SP on February 20, 2023, and was verbally approved by DHS on March 13, 2023, and stated the following: To ensure that children are supervised through the day, Little Sandbox Childcare and Learning Center is in accordance with the Minnesota Department of Human Services (DHS), the following policies and procedures are implemented in our program. . . . Children of any age are not allowed out of the classroom without adult supervision. Infants, toddlers and preschool children are supervised by sight and sound at all times . . . “By sight” means the child is being actively observed. “By sound” means the child can be heard from where the caregiver is positioned. While supervising children in these age groups, staff should position themselves so that they can see and hear all of the children and re-position themselves as children move around the room. When children are sleeping or resting, staff should position themselves so that all children are continuously supervised by sight and sound. The room should not be completely dark and should be bright enough for: . . . staff to maintain full sight supervision for all age groups. Cots should be fully visible to staff during naptime. However, if the environment prevents full visible, then teachers need to circulate to provide full supervision. . . . Facility documentation showed that the SP and P1-P4 each received training on the Reporting of Maltreatment of Minors Act, the facility’s Risk Reduction Plan, and on Supervision of Children (indoor and outdoor) Plan. Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0045, subpart 1, item A, stated that children are required to have supervision at all times. Minnesota Statute section 245A.02, subdivision 18, states that supervision means 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: FM1 and P1 provided consistent information that on April 24, 2023, at approximately 3:15 p.m., the SP left the preschool classroom to go into the kitchen, leaving AV1, AV2, AV3, AV4, AV5, and AV6 unsupervised for an unknown amount of time or approximately 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 SP stated s/he did not “think” there was a time when s/he failed to supervise the preschool classroom and “did not think” s/he failed to provide supervision, FM1 and P1 each saw the preschool classroom without the supervision of the SP and P2, P3, and P4 also had knowledge of the incident. In addition, on June 8, 2022, the facility was placed on a conditional license for citations that included failing to supervise children. On January 11, 2023, the conditional license was upheld and on February 20, 2023, the SP submitted a Supervision of Children (indoor and outdoor) Plan that stated in part: “Children of any age are not allowed out of the classroom without adult supervision. Infants, toddlers, and preschool children are supervised by sight and sound at all times . . . ‘By sight’ means the child is being actively observed. ‘By sound’ means the child can be heard from where the caregiver is positioned;” and “When children are sleeping or resting, staff should position themselves so that all children are continuously supervised by sight and sound.” The SP, a supervisory staff person, signed the Supervision of Children (indoor and outdoor) Plan on April 3, 2023. Yet on April 24, 2023, the SP left AV1-AV6 unsupervised while s/he left the classroom, went through the toddler classroom and through the infant classroom into the kitchen. Only returning when s/he was notified that FM1 was in the classroom. Leaving AV1-AV6 unsupervised in the classroom exposed them to dangers including staff persons inability to intervene in the event of an emergency and allowed AV1-AV6 unsupervised access to leave the classroom to go into the community. Therefore, there was a preponderance of the evidence that there was a failure to supply AV1, AV2, AV3, AV4, AV5, and AV6 with necessary care and a failure to protect each from conditions or actions that seriously endangered their 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. The SP was trained on the facility’s Risk Reduction Plan, Supervision of Children (indoor and outdoor) Plan, and the Reporting of Maltreatment of Minors Act. At the time of the incident, the SP was responsible for the care and supervision of AV1-AV6. The SP was responsible for the maltreatment of AV1-AV6. 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. The Office of Inspector General is also required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 the SP and the facility was responsible did not meet statutory criteria to be determined as serious because there was no information that any child sustained an injury. In addition, the neglect was not recurring because it was a single incident that impacted AV1-AV6. 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 their policies and procedures were adequate and followed. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On September 22, 2023, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal. 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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