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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: 1104621-CCC (Child Care Center) Investigator(s): Kim Anderson/Van Mulheron Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised on the playground for approximately three to four minutes and that staff persons (SP1 and SP2) were not aware that the AV was missing. Date of Incident(s): July 14, 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 27, 2023; from documentation at the facility, and through five interviews conducted with two facility supervisory staff persons (P2 and P3) and three staff persons (P1, SP1, and SP2). Attempts were made via phone to contact and interview the AV’s family member (FM), but the attempts were not successful. The facility consisted of five classrooms serving toddler through kindergarten. There was one toddler room, three preschool rooms, and one kindergarten classroom. The outdoor playground was accessible through a set of double doors at the east end of the building. There was a small vestibule between the doors prior to going outside to the playground. The outdoor playground was surrounded by an approximately four-foot-tall chain-link fence and the fence did not have any gates. The playground wrapped around to the front of the building and was visible from the front of the building. Staff persons at the facility used an application (app) on an iPad for attendance. The facility’s Child Care Risk Reduction Plan stated that the playground was surrounded by a fence and the only access to the playground was through the building. Staff persons were to conduct a count of all the children prior to going outside, when they entered the playground, and when coming back inside. The facility’s Supervision policy stated that all children must be within sight and sound at all times. The lead teacher/person at the beginning of the line was responsible for counting the children and the last staff person was to ensure that no students were left behind. The AV’s Enrollment Form stated that at the time of the incident, the AV was four years old and enrolled in the facility’s preschool program. Interviews with P1, P2, P3, SP1, and SP2 and facility documentation and provided the following information: · On July 14, 2023, around 5 p.m., P1 brought a child to the front door to meet his/her parent for pick up. As P1 said goodbye to the parent and child, s/he saw the AV outside on the playground. P1 then went outside via the front door and saw that the AV was “sobbing” and seemed scared. The AV told P1 that s/he could not get into the building, that the doors were locked, and that no one was outside. Because P1 could not access the playground via the front of the facility, P1 then ran into the building to the playground to get the AV. P1 then returned the AV to his/her classroom. When they got to the classroom, SP1 was cleaning the room and SP2 was in a nearby kitchen. SP1 and SP2 were not aware that the AV was on the playground. There were no injuries to the AV from being unsupervised. · SP1 stated that at the time of the incident, s/he worked with SP2 and had six children outside on the playground. This was the first time SP1 worked with SP2. When it was time to go inside, SP1 called the children to the door and counted six children (five children and the AV) by the door. SP1 then turned to go inside and when inside the vestibule, SP1 noticed two children (not the AV) with SP2 still outside by the door. SP1 waited for SP2 and the two children and then SP1 and SP2 and took the children to a closing classroom because SP1 and SP2 were done working for the day. SP1 said s/he did not complete a head count when s/he reached the closing classroom. SP1 did not realize the AV was missing until P1 brought the AV inside to SP1. SP1 thought the AV was outside for three to five minutes. · SP1 stated that the procedure for bringing children inside was to call the children to come inside and check the facility’s app to confirm attendance before transitioning. On the date of the incident, SP1 did not use the app and only completed a head count at the playground door. · SP2 stated that on the date of the incident, at 4:55 p.m., s/he was on the playground with SP1 and the preschool kids. SP1 called for the children to line up. SP2 then gathered all the children and SP1 counted six children. Around this time, SP2 was focused on two children “messing” with the water sensory table as SP1 then started walking inside. SP2 did not count the children and did not double check SP1’s count because s/he “trusted” SP1’s head count. SP2 dropped the children off to the closing classroom and did not complete a head count. SP2 then went to the kitchen and at 5:03 p.m., SP2 heard from P1 that the AV was found unsupervised on the playground. SP2 was “surprised” to hear that the AV had been unsupervised. The AV was unsupervised for approximately three to four minutes. Potential risks to the AV being unsupervised was from community persons in the area that could have accessed the AV through the fence. · SP2 stated that for transitions, staff persons were trained to count the children at the playground door and when they got inside the classroom. However, on the date of the incident, SP1 and SP2 did not count the children when they dropped the children off at the other classroom door. · P1 notified P2 and P3 after business hours on July 14, 2023. P2 reached out to the AV’s family on July 17, 2023. The AV’s family did not express any concerns. P2 and P3 did not have any prior concerns with SP1’s and SP2’s supervision of children. The facility’s personnel file showed that P1, P2, P3, SP1 and SP2 were trained on the facility’s Supervision policy, Child Care Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act 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 sign 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: On July 14, 2023, the AV was left on the playground for three to four minutes without the knowledge or supervision of staff persons, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 said s/he counted the children prior to coming inside. Neither SP1 nor SP2 completed the second head count when they reached the classroom and after dropping off the children, SP1 went to the classroom to clean and SP2 went to the kitchen. The AV was left on the playground unsupervised for approximately three to four minutes, which exposed the AV to community dangers and did not allow for a staff person’s intervention in event of an emergency. SP1 and SP2 did not count the children when they dropped them off in the closing classroom and each went about other duties, prior to P1 finding the AV on the playground. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with the 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. SP1 and SP2 were trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. At the time of the incident SP1 and SP2 were responsible for supervision of six children, including the AV, who were transitioning from the playground to the classroom. SP1 and SP2 did not complete a final head count when leaving the children in the closing classroom and moving onto other duties. 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 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the AV 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 policies and procedures were adequate. The facility revised the Child Care Risk Reduction Plan regarding supervision. Following the incident, staff persons were trained to count children at every doorway instead of “count frequently.” Additionally, SP1 and SP2 both completed four additional trainings on active supervision and safety. 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 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 SP1 and/or SP2. The determination that SP1 and SP2 were 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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