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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: 1102873-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised by staff persons (SP1 and SP2) on a facility playground between five to fifteen minutes. 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 31, 2023; from documentation at the facility; and through four interviews conducted with a supervisory staff person (SP1), facility staff persons (P1 and SP2) and the AV’s family member (FM). Facility documentation showed that the AV was 21 months old and enrolled in the facility’s toddler classroom at the time of the incident. The facility was a former church that had been repurposed and occupied space in the upper level of an “L” shaped building that was located in a residential neighborhood at the corner of two, two lane streets. At the back and side of the facility were two additional community programs with their own separate entrances. The playground was located in the inside “L” on the side of the building and was a large space with two play areas. One area had a large wooden play structure with small rocks as the fall zone. The other area had a large shoe structure for play, a patio table and chairs, and a large wooden bench between the play areas. The playground was surrounded by a chain link fence that was approximately six feet high. There was one gate on the playground located by the doors to the two other community programs. The gate had a u-shaped latch that was not secured. Adjacent to the playground was a parking lot. The playground was visible from the street and passers-by. The FM stated that on July 10, 2023, SP1 told him/her that when the AV’s class transitioned into the facility from the playground, the AV had been missed and left on the playground unsupervised for approximately 15 minutes before being found by P1. The AV was fine after the incident. Prior to the incident the FM requested the AV not be allowed on the playground playset because s/he felt it was too large for the AV’s age and the FM was concerned the AV might swallow the tiny rocks under the playset. After the incident the FM told SP1 that counting the children was not enough and the staff persons should have a list of the children present and SP1 agreed with the FM. The FM stated there had been times when s/he dropped off the AV and children were unsupervised but could not recall exact dates. P1, SP1, and SP2 provided the following information: · On July 7, 2023, at approximately 12:45 p.m., SP1 and SP2 were on the playground and P1 stated there were nine toddler children, including the AV. It was SP2’s first day working in ratio in a classroom at the facility. When it was time to go into the classroom SP1 told SP2 that when they got back into the classroom, they would change the children’s diapers and get them ready for nap. · SP1 and SP2 gathered the children at the door that led into the facility from the playground. At the door SP1 counted the eight children and thought there were eight children in attendance that day. SP2 held the door open and SP1 went in first and started to walk up the stairs to the upper floor of the facility. SP1 did not count the children when they entered the building. SP2 told SP1 that three children went down the stairs instead of up. SP1 told SP2 that s/he would go get those children so as SP1 went down the stairs, SP2 closed the door and went into the facility, up the stairs and to the front of the line. SP1 and the children who went down the stairs, then rejoined the group. The group of children, with SP2 at the front of the line and SP1 at the back of the line, walked to the classroom. · SP2 entered the classroom first and thought s/he counted eight children before they entered the classroom doorway. Then SP1 entered the classroom without counting the number of children and set out cots for naptime. SP2 changed diapers and SP1 supervised children as they played. SP2 did not know how many diapers s/he changed before it was time to change the AV’s diaper. It was at that point that SP1 and SP2 realized the AV was not in the classroom. SP1 and SP2 looked for the AV in the classroom but did not find him/her so SP2 left the classroom to go back to the playground to look for the AV. Both SP1 and SP2 did not know how long they had been in the classroom at this point but estimated they were in the classroom between five to fifteen minutes before discovering the AV was not with them. · In the meantime, P1 stated that at sometime after 12:30 p.m., a parent was dropping off a child in his/her classroom and told him/her there was a child alone on the playground. P1 then went to the playground and found the AV on the playground standing by the door that led to the facility from the playground. P1 picked up the AV and as s/he opened the door s/he saw SP2 at the top of the stairs coming toward P1. P1 handed the AV to SP2. SP2 told P1 that both s/he and SP1 had counted the number of children before they went inside. · SP2 stated the AV seemed “unbothered” and when SP2 asked the AV if s/he was okay, the AV responded s/he was. Then SP2 and the AV went to the toddler classroom. SP1 hugged the AV when he returned to the classroom and SP2 told SP1 that the AV was found on the playground by P1. The facility’s Risk Reduction Plan showed that the facility shared the building with two other community programs and had its own entry to and from the playground. All children were supervised closely when entering and exiting the playground. During transitions, staff persons counted how many children were present before they left an area, while they moved to the new area, and once they arrived at their destination. The facility’s General Safety Rules stated that children are supervised at all times. Facility documentation showed that P1, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A, state that “supervision” means 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; and that children are required to be supervised at all times. Conclusion: A. Maltreatment Information was consistent that on July 7, 2023, between 12:30 p.m. and 1 p.m., the AV’s class transitioned from the playground to the toddler classroom. When entering the facility, SP2 counted the number of children present but the AV was left on the playground unsupervised which was a violation of Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A. Another parent at the facility saw the AV on the playground when s/he dropped off his/her child and told P1 that the AV was alone on the playground. P1 then went to the playground at the same time SP1 and SP2 noticed the AV was missing from the classroom. SP2 met P1 just after P1 picked up the AV from the playground and entered the facility. SP2 and the AV returned to the classroom. The AV was unharmed. SP1 and SP2 estimated the AV was unsupervised on the playground between five to fifteen minutes. Although the AV was unharmed, the conduct of leaving a toddler outside for five to fifteen minutes without staff persons’ knowledge or supervision, exposed to community persons and hazards, and did not allow for staff persons’ intervention in the event of an emergency. SP1 and SP2 had completed the transition into the classroom and began new activities when it was time for the AV’s diaper to be changed and they realized the AV was missing. Therefore, there was 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 endangered 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 trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. SP1 and SP2 were each responsible for the supervision of AV2 at the time of the incident. However, it was SP2’s first day in ratio in a classroom at the facility and SP1 had significant administrative and supervisory authority over the operation of the facility and maintaining compliance with Minnesota Rules and/or Statutes and trained all staff on supervision during orientation. Therefore, SP2’s responsibility was mitigated and SP1 was responsible for the 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 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 found their policies and procedures adequate but not followed by SP1 and SP2. Since the incident the facility created and trained staff persons on a new procedure when transitioning from the outdoor play area to the building. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1 was responsible for maltreatment is subject to appeal. On October 31, 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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