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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: 1082346-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was inside a classroom without staff persons knowledge or supervision for 45 minutes. Date of Incident(s): July 1, 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 28, 2023; from documentation at the facility; and through three interviews conducted with one supervisory staff person (P), SP1, and SP2. This investigator interviewed the AV, but s/he was not able to provide pertinent details for this investigation. The AV’s family member (FM) was notified however, s/he did not provide any information to this investigator. The AV was four years old at the time of the incident and enrolled in the Preschool B classroom. On the day of the incident, the AV was visiting in the Preschool C classroom. The facility had three infant classrooms, three toddler classrooms, and four preschool classrooms. The Preschool C classroom had a door that led to the toddler and preschool playgrounds and two large windows facing the toddler playground. The preschool playground did not look into the Preschool C classroom. The Preschool C classroom had multiple shelves with manipulatives on them, a block area, a dramatic play area, a library area, tables, a counter with cupboards above and below it, and a bathroom. The P provided the following information: · On July 11, 2023, SP2 went to talk to the P around 3:30 p.m., but the P was on the telephone. Shortly after, another teacher told the P that the AV was “left inside” and to check video from surveillance cameras. Then, SP2 went back to the P and told his/her that the AV was left inside unsupervised. · When the P watched the video footage, the P noticed SP1 and SP2 got the children ready to go outside to eat snack, lined them up on a rope, and SP2 did a sweep of the classroom and saw a few children in the group area that s/he guided to the rope. At the time the AV was on the rope. The AV “snuck off” the rope while SP2 talked to other children and SP1 had his/her back turned checking the classroom. In the video the P could see SP2’s hand as s/he counted the children. · The AV was in the Preschool C classroom without staff person supervision for about 42-45 minutes. During that time the AV went to the door that led to the playground and stood there. The AV went to the bathroom, s/he stood on a chair to grab a stuffed animal off of the counter, and s/he went to a calming area. The AV got back up after about 30 minutes and went to the window, then went to the block area to play with blocks. The P saw SP2 notice the AV in the window and frantically try his/her key to enter the door. SP2 went to another classrooms outside door, came inside, and entered the Preschool C classroom through an interior door. SP2 hugged the AV. · The P said the policy to transition was to use the ropes, conduct name to face, and use the white boards that the P purchased that had each child’s name on it. The P said that they should have done another name to face once outside, but that was not done. · SP1 and SP2 were not the staff persons who usually worked in the classroom and some children had come back from an external program and they were “unaware” they had 21 children. The P said both SP1 and SP2 were “worried” about what was going to happen and “not having what it was going to take [to do the job].” · The P spoke with the FM and told him/her that the AV was “okay” and told him/her what had happened, how long the AV was in the classroom unsupervised, and what s/he did during that time. The AV returned to the facility the next day. SP1 provided the following information: · SP1 said the class woke up from nap earlier than normal and were excited to have a bounce house, so SP1 and SP2 took the children outside a little earlier than normal around 2:45 p.m. SP1 thought they had 19 children. SP1 said that s/he and SP2 lined the children up, SP1 scanned the classroom and the bathroom to make sure no child was in there, the children grabbed onto the rope, SP2 did a head count, and they left the classroom. · SP1 said around 3:30 p.m., SP2 approached SP1 and said that the AV was in the classroom the whole time they were outside. SP1 was “shocked” as they had been outside for about 45 minutes. SP1 was not sure what made SP2 go by the door to the classroom, but that was how s/he noticed the AV was in the classroom. · SP1 said s/he was trained to line the children up and make sure each child had a loop on the rope, do a headcount, scan the classroom or playground, and if there was more than one staff person, one should be in the front and the other in the back of the line. SP2 provided the following information: · When SP2 arrived at the Preschool C classroom, the children were awake on their cots, so SP2 thought the class should go outside and have a picnic for snack. SP2 was “under the impression” that there were 20 children in the class, but found out after the incident that there were 21 children. There were some children from the Preschool B classroom in the Preschool C classroom. · SP2 and SP1 had the children go to the bathroom, lined the children up to go outside, SP1 walked around and did a sweep of the bathrooms to make sure no children were in there, SP2 counted 20 children’s heads, and then the class went outside. · SP2 said the class ate snack outside and played on the bounce house. SP2 walked over by the windows and noticed the AV inside the classroom seated on the floor holding a “stuffy” and the AV was not crying. SP2 tried to open the door from the outside but had trouble with his/her key. The AV also tried to open the door. SP2 went in through another door and got the AV. · SP2 went to tell the P what had happened, but the P was on the telephone, so SP2 went back into the classroom until some children left and s/he was able to leave the classroom to tell the P what had happened. SP2 did not know how long the AV was left in the classroom but was told by the P it was 45 minutes. · SP2 said the procedure for going outside was to hold the rope, do name to face, and double check the board the facility used as an “extra” name to face. SP2 said s/he did not do name to face but counted the children’s heads. This investigator reviewed the video footage and saw the following: · SP2 was standing by the doorway and the children were lining up. The AV was with the group. SP1 walked around the classroom and was out of view for some of the time. During this time the AV went into the block area. SP1 walked back into view and looked in the bathroom and then walked on the opposite side of the block area and the children headed outside. The AV looked out from the block area and saw the last few children and SP1 exit the door. · The AV got up from the block area, went and looked outside, and then went back to the block area to play. · The AV walked through the classroom and walked into the bathroom pulling down his/her pants. The AV came out after about 40 seconds and went to sit in the “calming area.” · The AV got up from the “calming area” and crossed the classroom. The AV grabbed a chair from a nearby table and dragged it close to the counter. The AV stood on the chair to get a stuffed animal, then got down, put the chair back at the table, and took the stuffed animal back to the “calming area” on the other side of the classroom. · The AV was sitting by the door when a staff person was visible on the outside of the door. The staff person tried to open the door and walked away. SP2 entered through an interior door, ran to the AV, held his/her hand, wiped the AV’s face, and then they exited the classroom out to the playground. The facility’s Safety and Supervision Policy stated, “Never leave the children unattended for any reason,” and “All children must be within sight and sound at all times.” The facility’s Risk Reduction Plan stated that, “When transition from one area to another, children will form a line using a walking rope. Staff [persons] will call the children by name to hold on to the walking rope. Staff [persons] will use face to name every time the rope is used. One staff [person] will be at the front of the line and one staff [person] will be at the back of the line. Staff [persons] will count the number of children transitioning to ensure all children are present.” Facility records showed the P, SP1, and SP2 were each trained on the facility’s Risk Reduction Plan, the facility Safety and Supervision Policy, 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 July 11, 2023, SP1 and SP2 took the Preschool C classroom outside to have a picnic with snack and to jump in the bounce house. SP2 lined the children up at the door and SP1 walked through the classroom to make sure no children were in the bathrooms. During this time, the AV “snuck off” and went to the block area. SP1 returned to the group and SP1 and SP2 took the children outside. During the time that the AV was left without supervision, s/he climbed up on a chair to get a stuffed animal off of a counter, went into the bathroom by him/herself, and wandered in the classroom and played in the areas. SP2 noticed the AV through the window and tried to enter the door, but had trouble with the key, so s/he went inside through another classroom and entered the Preschool C classroom from an interior door to get the AV and go back outside. Although the AV “snuck off,” SP2 said s/he counted 20 children, and SP1 did a sweep of the classroom to make sure no children were in the bathroom, given that the AV was inside a classroom without staff person supervision or knowledge for approximately 42-45 minutes in which time s/he went to the bathroom by him/herself, and climbed on a chair to obtain a stuff animal, that SP1 and SP2 each did not know how many children they had, that SP1 and SP2 did not count the children once they reached the outside playground so did not know the AV was not with them, and staff persons were not with the AV to intervene in the event of an injury or emergency, 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 and SP2 were responsible for the supervision of the AV at the time of the incident and were trained on the facility’s Safety and Supervision Policy, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. SP1 and SP2 were 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 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a one-time incident, and the AV sustained no 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 adequate, but not followed by SP1 and SP2. SP1 and SP2 received retraining 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 October 11, 2023, the facility was issued a Correction Order for the violation outlined in this report and for not maintaining required staff person to child ratio. 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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