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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: 1059365-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on a playground without staff persons knowledge or supervision for five to ten minutes and was found by a community person. Date of Incident(s): July 7, 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 20, 2023; from documentation at the facility, law enforcement records; and through five interviews conducted with one supervisory staff person (P), SP1, SP2, the AV’s family member (FM), and a community person (C). When this investigator conducted a site visit it was during naptime, so the AV was not interviewed. The AV was 34 months old at the time of the incident and enrolled in the preschool classroom. The facility shared a building with a school. There was a parking lot on the side of the building, and an alley that ran parallel to the parking lot and the back of the building. The playground was behind the parking lot across the alley and was enclosed in a chain link fence. The entrance to the playground was approximately 335 feet from the entrance to the facility. There was a house on either side of the playground with wooden privacy fences surrounding those. The playground had slides, climbing structures, and a merry go round. The playground was accessible to the public, and there was a sign posted on the side of the building that stated parents must be present when their children used the playground. The C said s/he went to the school to help a family member with some tables and chairs between 3 and 3:30 p.m. and parked in the parking lot. The C said the playground was adjacent to the parking lot and when the C pulled in s/he saw the AV sitting up against the fence and did not think anything of it, but when the C got out of his/her car the C heard the AV crying. The C approached the AV and asked if the AV was hurt, and the AV just said s/he wanted the FM. The C asked the AV where the FM was, and the AV said s/he did not know. The AV did not know where s/he lived or the FM’s name, so the C called 9-1-1. A law enforcement officer (LEO) arrived about three to four minutes later and recognized the AV from the facility and the LEO brought the AV back inside the facility. Law Enforcement Records provided the following information: · On July 7, 2023, at approximately 3:28 p.m., the law enforcement center was notified of a juvenile that was at the playground without any parents. · The LEO arrived a short time later and observed the AV on the playground with the C nearby. The C explained s/he heard the AV crying for the FM, approached the AV to ask if s/he was okay, and the AV said, “No.” At that time the C called emergency services. · The LEO recognized the AV as a child who attended the facility. The AV saw the LEO and stopped crying. The AV appeared to be in “good health.” · The LEO picked up the AV and brought him/her back to the facility. The LEO spoke with SP2 and SP2 was not aware that the AV was left outside and thought every child had been accounted for. The LEO asked SP2 for the P’s telephone number and the LEO called the P who estimated the AV was outside for five to ten minutes alone, but no more than 15 minutes. The LEO also spoke with SP1 who corroborated what SP2 told the LEO, that they believed all the children were accounted for. · The LEO called the FM who had already been made aware of the situation by the P and thanked the LEO for the call. SP1 provided the following information: · SP1 said that around 3 p.m., the class was outside at the playground. SP1 and SP2 had the children line up, scanned the playground, and did not see anyone still on the playground. SP2 was in the front of the line and SP1 was in the back of the line. · The class got back inside and about 15 minutes later the LEO came in with the AV saying the AV was left outside on the playground and s/he was crying. SP1 said that the AV “calmed down” quickly and played fine the rest of the afternoon. SP1 was not sure if the AV was hiding or if s/he ran back to the playground when the class went back inside but SP1 did not see anyone left on the playground when the class was going back inside. · SP1 said s/he was not trained to do a headcount of the children. SP1 said s/he was trained to call for the children to line up and then go inside. SP1 said it was “probably something obvious” to count the children. SP1 said now staff persons have been trained to use BrightWheel and conduct a name to face and a headcount. SP2 provided the following information: · SP2 said that around 3 p.m., s/he told the children to line up. SP2 started walking the group back to the facility and s/he faced backwards to scan the playground and did not see the AV on the playground but did not remember if s/he saw the AV in line either. SP2 said SP1 was at the back of the line. · When the group was inside, SP2 and SP1 had the children watch “a show” while they got the learning centers ready. Then SP2 went and started the laundry, and received a telephone call from the administrator stating that the LEO found the AV outside. · When the LEO brought the AV in, the AV was crying and upset and said s/he wanted water. The AV snuggled with SP1 and a couple of minutes later the AV seemed “fine.” SP2 said it was 10 to 15 minutes from when they went inside from the playground to when the administrator called him/her. · SP2 said that when s/he was trained, the staff person training SP2 just showed SP2 what to do and did not tell SP2 what s/he was doing. SP2 said s/he was told to, “Yell to have them line up, line up, and then walk in.” SP2 said now s/he counts the children. SP2 stated that the facility had the BrightWheel app with the name to face, but s/he was not trained to utilize it and it was not used that day. The P stated that s/he received a telephone call from an administrator at the school that law enforcement brought a child in from the playground. The P called SP2’s phone and the LEO answered and explained the situation. The P then called the FM right away. On Monday, July 10, 2023, the P spoke with SP1 and SP2. SP2 said s/he was at the front of the line leading the class back to the facility and SP1 was in the back of the line. SP2 thought s/he remembered seeing the AV in the line and thought everyone was there. SP2 felt “terrible” about what had happened. The P found out that another family member had reached out to SP2 through BrightWheel to ask what time the class was going inside on the day of the incident. SP2 responded that they were just lining up at 3 p.m. and the LEO said the call came in at 3:28 p.m. so it was possible the AV was unsupervised for 20 to 25 minutes depending on how long it took the class to walk inside. The P said they used an application called BrightWheel to track the number of children present. The P said that the policy was to line the children up on the gate and have one staff person lead and the other staff person was to be at the back of the line. The P said that it was not in the policy to count, s/he just thought the staff persons were doing that. Since the incident staff persons do a “head check count called name to face.” The FM said the AV seemed “fine” and s/he “bounced back pretty quick” from the situation. P1 called the FM about ten minutes after finding out what happened. The FM had no prior concerns. The FM stated it could have been upwards of 15-20 minutes that the AV was unsupervised. The facility’s Risk Reduction Plan stated that, “Students walk in a line, following a [staff person], across the parking lot to access the playground,” and “[A staff person] is in eyes view of students at all times.” The facility’s Child Care Program Plan stated, “All students must be supervised at all times. Children are not to be unsupervised on the playground.” Facility records showed that the P, SP1, and SP2 were each trained on the facility’s Risk Reduction Plan, the facility’s Child Care Program 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: On July 7, 2023, SP1 and SP2 lined the children up to go back inside the facility from the playground around 3 p.m. Both SP1 and SP2 did a scan of the playground and did not see the AV. SP1 said s/he was not trained to count the children and SP2 stated that although the center used the BrightWheel app, staff persons were not trained to use the name to face aspect of it to ensure they had all of the children present in their care. The C pulled into the parking lot between 3 p.m. and 3:30 p.m. and saw the AV by the fence and when the C exited his/her car s/he heard the AV crying. The AV was not able to provide information to the C, so the C called 9-1-1. When the LEO arrived, s/he recognized the AV as a child from the facility and the LEO brought the AV back inside the facility where the LEO spoke with SP1 and SP2 who both were unaware the AV was still outside, and they thought all the children were accounted for. The AV was not injured. Initially the P thought the AV was alone for five to ten minutes, but after further review of what happened, it was likely the AV was unsupervised for 20 to 25 minutes based on when the class came back inside and when the call came into 9-1-1, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was not injured and was found inside the chain link fence of the playground, given that neither SP1 nor SP2 were aware the AV was not in their care and that community persons had access to the playground, and that staff persons were not available to assist the AV in the event of an emergency or injury, 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 and 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. SP1 and SP2 each stated they were not trained to count the children but each was trained on the facility’s Risk Reduction Plan and Child Care Program Plan which stated that children needed to be supervised at all times. 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 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 their policies followed by SP1 and SP2, but that they were not adequate. The facility updated their policies to start using the head count feature on BrightWheel. SP1 and SP2 received written warnings. 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 18, 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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