|
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: 1002184-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised on the facility playground and found by the AV's family member (FM). Date of Incident(s): June 12, 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 26, 2023; from documentation at the facility; and through three interviews conducted with a supervisory staff person (P), a staff person (SP) and the AV. Attempts were made via telephone and mail to contact the AV’s family member (FM), but those attempts were unsuccessful.
The facility was located at one end of a strip mall which had other services and stores. To the front and side of the mall was a parking lot. Behind the facility was an alley. On one outside wall of the facility and adjacent to the parking lot were two facility playgrounds. The perimeter of the playgrounds were surrounded by a five-foot, vinyl fence with slats and a gate that led to the alley, with a gravity latch. There was a playground for younger children and a playground for older children that were separated by a chain link fence and a gate with a U-shaped latch. To go from the facility to the playground, doors on the back side of the facility that entered onto the alley were used. On the other side of the alley was a large apartment complex and at the end of the alley and behind the apartment complex was a pond. Across one side of the parking lot was another apartment complex and across the front of the parking lot was a public bus transit hub. Facility documentation showed the AV was three and a half years old and enrolled in one of the facility’s preschool classrooms. The AV stated that when the SP was at the gate, s/he hid by the slide. When s/he was on the playground alone, s/he ran back and forth between the two playgrounds and played with balls. The FM found him/her on the playground. The P provided the following information: · Staff persons used a form to write a list of each child’s name and a check mark indicating the child checked in and out for the day. Staff persons counted the number of children at each transition threshold and compared it to the number of children on the list. If and when classrooms combined, staff persons had either the lists for all of the rooms or combined the children onto one list. The facility also used an iPad with an APP to track the children in attendance. On June 12, 2023, the staff persons in the preschool rooms did not use the form to create a list of students in their care. That afternoon between 3:45 and 4 p.m., three preschool classrooms went out to the playground. When the SP started at 4:30 p.m., the other staff person’s shifts ended, and the SP was the only staff person on the playground with ten preschooler children. · On June 13, 2023, at approximately 11 a.m., the AV and the FM walked into the P’s office and told the P that the night before, the AV had been left on the playground alone. The P then viewed video footage from the previous evening and at approximately 4 p.m., the P talked with the SP about the incident. · The SP told P that when they were leaving the playground, s/he lined the preschooler children up by the facility wall and put on the classroom backpack. The SP thought that was when the AV must have run away. The class went inside and ate snack. The SP did not realize the AV was missing until the FM arrived. · The AV was unsupervised on the playground for approximately eleven minutes. The SP provided the following information: · On June 12, 2023, the SP began his/her shift at 4:30 p.m. After the two staff persons left and there were 10 children remaining, at approximately 5:10 p.m., the SP lined the preschoolers up on the sidewalk near the facility, placed the rings from a rope in each child’s hand, counted the children and noticed s/he was missing “one” child. · The SP walked out onto the playground and saw a child, not the AV, in a piece of play equipment. The SP got the child and they walked back to the line where the SP put the rope ring on the child’s hand, told the oldest child that s/he was to close the gate, grabbed a backpack, and walked out of the gate followed by the children. · The SP walked to the corner of the facility, turned around, and saw the last child in line walk through the gate. Then they all walked forward with the SP at the front of the line as the SP instructed the children to touch the wall of the facility in the alley. At that point, the AV ran into the alley and the SP told the AV not to run away and put the AV back in the line and gave him/her the rope to hold. The group walked to the facility door and the SP opened the door, and held it open for “all” the children to enter the facility. The SP then entered the facility and shut the door. The group was in the hallway of the facility and walked to the kitchen door where the SP had the group stop. The SP opened the kitchen door and grabbed snack items. The SP did not count the children at that point but saw all the children’s faces, including the AV’s face. The group walked to the prekindergarten classroom and when at the door, the SP had the children hand him/her the rope but did not count the children as they entered the classroom. The AV was in the back of the line. · Once everyone was in the room, the SP shut the door and instructed the children to wash their hands and sit down at a table for snack. A child’s family member came into the room to pick up their child. As they were leaving, the SP told the child and family member goodbye and then washed his/her hands. The SP did not check to see if the family member had shut the classroom door as they left. · As the SP passed out crackers and water s/he realized there was a child missing and said out loud that s/he was missing someone and the children looked at each other. The SP then looked out a window in the classroom that looked into the facility and saw the FM walking towards the classroom, realized it was the AV who was missing, and thought to his/herself, “Now I am in big trouble” Then the FM came into the classroom and the SP told him/her that s/he did not have the AV and the AV had been in the classroom but must have opened the door and left the room. The SP apologized to the FM. The FM looked at the SP but did not say anything. · There was another staff person in the entryway who directed the AV to the classroom. When the AV came back to the classroom the AV said to the SP, “Why did you forget me?” The SP replied “I [did not] forget you, you ran from me.” Then the FM and the AV left the classroom and the facility. · The SP said that s/he brought the AV inside and denied that the AV was left on the playground. The AV could not open the gate on the fence surrounding the playground because the latch was above his/her head. · The SP stated s/he failed to supervise the AV on June 12, 2023. The facility provided two videos of the incident that showed the following: · At 22:37 the SP and children were on the playground. The SP looked around the playground and moved his/her finger in a counting motion as the AV walked toward the back of the playground out of camera view. At this time, there nine children were visible in the video. · At 24:44, the SP and some of the children were partially out of camera view but the rope with handles could be seen and the SP handed the rope to a child. The SP walked off the sidewalk to the playground, turned around and pointed to the sidewalk. The SP then turned back and walked away from the sidewalk. · At 25:04 the SP saw a child in a piece of play equipment. The SP walked over to that equipment, bent down, opened the door of the equipment, and pulled the child out. Then the SP took the child by the hand and walked him/her to the sidewalk out of camera view. · At 25:23, the SP put on a backpack, and walked out of camera view. The playground gate opened and a child holding an iPad walked through the gate and then the gate shut. · At 26:51 the AV walked from the play structure on the playground. For approximately ten minutes the AV was in and out of camera view. When the AV was in camera view s/he was between both playgrounds and threw balls back and forth between them. · At 36:21 the AV walked to the playground gate and at 36:41 the playground gate opened and shut, and the video ended. · Another video provided by the facility showed the AV and the FM walk in the hallway just inside the exterior door from the alley. The AV and the FM then walked down the hallway. The AV turned to the left, toward the facility front door and out of camera view and the FM turned right, toward the prekindergarten classroom and out of sight. The facility document COUNT showed that typically when a group came in from outside a staff person counted the number of children and then once again inside a staff person counted the number of children. Every child held onto the rope and a staff person took time to make sure all children were accounted for and conducted a name to face attendance. The facility’s Employee Handbook stated that “all staff must focus their entire attention on the supervision of the children.” The facility’s Risk Reduction Plan stated that staff persons were required to supervise children at all times. Facility documentation showed that the P and the SP each received training on the Reporting of Maltreatment of Minors Act, the facility’s supervision policy, and the facility’s Risk Reduction Plan prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, state 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: On June 12, 2023, the AV was unsupervised on the playground for approximately 11 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18. The SP said that s/he brought the AV in with the group, that s/he saw the AV in line at the kitchen, and at the end of the line when they walked into the classroom. However, the video of the playground shows that the AV did not go inside with the group and remained on the playground when the group went inside. After the group returned to the classroom, the children and the SP washed hands, and sat down for snack, and as the SP passed out snack, s/he realized a child was missing from the group but did not know who the missing child was until s/he saw the FM walking toward the classroom. The conduct of leaving a three-year-old child outside for eleven minutes without staff persons’ knowledge or supervision exposed the AV to community dangers including unknown persons and community hazards and did not allow for staff persons’ intervention 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 his/her 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 responsible for the supervision of the AV at the time of the incident. The SP was trained on the facility’s Risk Reduction Plan, the facility’s supervision policies and procedures, and the Reporting of Maltreatment of Minors Act prior to the incident. The SP was 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 the SP was responsible did not meet statutory criteria to be determined as recurring or serious because this 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 policies and procedures were adequate but not followed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP 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 or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in disqualification. The determination that the SP was 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. 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.
|
