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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: 1026207-CCC (Child Care Center) Investigator(s): Kim Anderson/Alice Percy kimberly.huett.anderson@state.mn.us Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) left eight alleged victims (AV1 – AV8) unsupervised on the facility’s playground for approximately eight minutes. Date of Incident(s): July 13, 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 August 3, 2023; from documentation at the facility; and through five interviews conducted with a facility staff person (P1), a supervisory staff person (P2), the SP, AV1’s family member (FM1), and AV2’s family member (FM2). Verbal notification was made by telephone to AV3’s, AV4’s, AV5’s, AV6’s, AV7’s, and AV8’s family members. At the time of the incident, the eight AVs were enrolled in the PreK classroom. AV1, AV2, AV3, AV4, and AV8 were four years old, AV5 and AV6 were three years old, and AV7 was five years old. The facility was located in a residential area and small business area off of a two-lane street that had a posted speed limit of 30 miles per hour (M.P.H.). The facility’s parking lot ran along the front of the building and extended to an adjacent strip mall. The preschool playground was located at one the end of the facility and along the side of the parking lot, on the opposite end from the strip mall. The playground was enclosed by a chain link fence and had a gate that was located on the side next to the parking lot. The gate had a latch but did not have a lock. The staff persons used a carabiner clip to keep the children from opening the latch. A large plastic climbing structure was located in the playground near the end of the building and several smaller plastic toys were placed around the playground. Information was provided that on the day of the incident, a “bouncy house” was located in the parking lot near the gate to the playground. The preschool playground was visible to persons driving or walking by the facility and those parking at the strip mall. P1, P2, the SP, and the facility’s documentation provided the following information: · On the morning of July 13, 2023, P1 and another staff person (P3) supervised eighteen children on the playground. P1 was responsible for eight children and P3 was responsible for ten children. The SP came outside to assist P3 with supervising the “bouncy house.” P3 and the SP took his/her group of ten children to the “bouncy house” to play, leaving P1 on the playground with eight children. P1 stated that while s/he was on the playground, P2 came outside to talk to the SP and P1 asked P2 to watch P1’s group of children while s/he entered the facility to use the bathroom. P2 entered the playground and P1 went into the facility. · P2 stated that s/he was with P1’s children for approximately five minutes before s/he asked the SP to take over the supervision of the eight children so P1 could finish getting lunch ready. The SP came into the playground and P2 went into the facility.
· The SP stated that s/he remained near the gate to the playground and watched both the children on the playground and the children in the bouncy house. The SP then assisted P3 with taking P3’s group of children from the bouncy house to the facility’s main entrance. The SP stated that when s/he helped P3 bring the P3’s children inside s/he did not remember that s/he told P2 that s/he would supervise the children or that P1 went into the facility. The SP stated that s/he “forgot” that s/he was supposed to be supervising the children on the playground. · P1 estimated that s/he was in the bathroom approximately five minutes. As s/he left the bathroom, s/he saw P3 and the SP bringing P3’s group of ten children into the facility. The SP stated that s/he saw P1 in the hallway and could also see the children on the playground. P1 checked on what was being served for lunch and approximately 10 minutes after entering the facility, P1 went back outside to the playground where s/he found his/her eight children unsupervised. · P1 stated that when s/he got to the playground, AV3 was “upset” and was having a “meltdown.” The children told P1 that there were no staff persons on the playground with them. P1 took the eight children into the facility and P2 asked P1 what occurred. P1 told P2 that the children were on the playground unsupervised. P2 told P1 that s/he had to leave the playground, so s/he asked the SP to supervise the children. P1 believed the SP was busy helping P3 supervise the children in the bouncy house and did not go into the playground and was not within “sight and sound” of the eight children on the playground. · P2 stated that the SP told P2 that s/he became “flustered” and “forgot” s/he was supervising P1’s group of children and began to assist P3 with moving his/her ten children from the bouncy house to the facility. P2 did not believe that P3, the SP, and the ten children were “technically” inside the facility when P1 left the bathroom because they were by the main entrance of the facility. The SP believed the children were unsupervised on the playground for approximately two minutes because s/he was watching them from outside the playground fence as s/he also helped P3 with the group of children in the bouncy house. FM1 stated that s/he heard about the incident but was not told the details of what happened. FM2 stated that s/he moved AV2 to a different child care center because s/he was “not comfortable” at the facility. According to the facility’s Employee Handbook, the staff persons were to keep the children within sight and sound at all times and were to “pay special attention” to areas that were difficult to supervise, such as the large outdoor playground structure. When the staff persons took the children to the playground, they were to count the children as they left the building and as they entered the building to ensure that all children were accounted for. According to Weather Underground, (“Weather history for Fort Snelling, MN”), on July 13, 2023, at 10:53 a.m., the temperature was 77 degrees Fahrenheit. Facility documentation showed that P1, P2, and the SP each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies 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: A. Maltreatment: On July 13, 2023, P1 asked P2 to supervise P1’s group of eight children on the playground while P1 went into the facility to use the bathroom. P2 then asked the SP to watch the eight children and went inside to start preparing lunch for the children. The SP stated that s/he stood by the gate of the playground and supervised the children on the playground and also helped P3 supervise the children in the nearby bouncy house. When P3 took the children into the facility, the SP assisted P3 with taking the children into the facility. The SP stated that s/he believed either P1 or P2 was supervising the children on the playground and did not remember that s/he was responsible for supervising the children on the playground when s/he went into the facility with P3 and his/her group of children. P1 then returned to the playground and found the eight children unsupervised, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart1, item A. AV1-AV8 were left outside on the facility’s playground unsupervised by the SP for approximately two to five minutes, which exposed them to community dangers and did not allow for a staff person’s intervention in event of an emergency. Therefore, there was a preponderance of the evidence that there was a failure to supply the Avs with the necessary care and a failure to protect the AVs from conditions or actions that seriously endangered their 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 policies and the Reporting of Maltreatment of Minors Act prior to the incident. At the time of the incident, the SP was responsible for the supervision of all of AV1-AV8 who were on the playground. The SP told P2 that s/he forgot s/he was supervising the playground when s/he went inside. The SP was responsible for maltreatment of AV1-AV8. 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 because this was a single incident that impacted AV1-AV8 and was not serious because AV1-AV8 did not sustain an injury. 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 the facility’s policies were not adequate and that the policies in place at the time of the incident were not followed by the staff persons. The facility planned to develop a more thorough supervision policy and then retrain all of the staff persons on the updated policy. 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 or not 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 October 20, 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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