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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: 800466-CCC (Child Care Center) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that staff persons (SP1 and SP2) left an alleged victim (AV) unsupervised on the playground for ten minutes. The AV was discovered by another staff person and returned to the classroom, unharmed. Date of Incident(s): September 20, 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 September 29, 2023; from documentation at the facility; and through interviews conducted with the AV’s family member (FM), facility staff persons (SP1, SP2, and P1), and a supervisory staff person (P2). At the time of the incident, the AV was almost three years old and enrolled in the facility’s preschool classroom. The facility provided childcare services to children, infant to school age. The facility had a playground connected to the back of the building. The playground was fully enclosed by chain-link fencing and one side of the building, itself. There was a door near the center of the building connecting the playground to the school age classroom. Once inside, there was a pass-through bathroom to the right, which led into the preschool classroom. The facility was located on a road with speed limits around 30 miles per hour. There were single and multi-family residences, various businesses, and a wooded area surrounding the facility. P1 provided the following information: · On the day of the incident, at 11:15 a.m., P1 was delivering lunch trays to the toddler classroom and in doing so, heard “crying” coming from the school age classroom exterior door. P1 looked out the window and saw the AV standing outside. P1 immediately opened the door and brought the AV inside. The AV was crying but not physically injured. [Note: Immediately following the incident, P1 told P2 that s/he discovered the AV outside at 11:45 a.m. Some of the times provided to this investigator did not match those provided to P2 immediately following the incident. However, despite this, all information showed the AV was outside for around ten minutes, regardless of if it was closer to 11:15 a.m. or closer to 11:45 a.m.] · P1 brought the AV to the preschool classroom where SP1 and SP2 were not aware the AV was left outside. The facility’s Incident/Accident Report stated that on September 20, 2023, at 11:35 a.m., “[The AV] was left unattended on the playground. Brought [the AV] in [and] checked for safety concerns[.] [The AV] appeared fine and sat down to eat.” SP1 and SP2 provided the following information: · On the day of the incident, SP1 and SP2 worked together in the preschool classroom with 13 children, including the AV. SP1 and SP2 did not typically work together. According to SP1, this was the first-time s/he had ever worked in the preschool classroom. · At 11 a.m., SP1 and SP2 brought the children outside onto the playground. SP1 and SP2 each said that they counted 13 children, using a name to face count, as they transitioned outside. [Note: Immediately following the incident, SP1 and SP2 each told P2 that the classroom went outside at 10:30 a.m.] · SP1 said that around 11:27 a.m., the children formed a line by the door to head back inside. SP1 was in front of the line holding a clipboard with a Child Supervision Record (class roster). SP2 was in the back of the line. SP1 told SP2, “Sweep the playground and make sure no kids were left behind.” SP2 did this while SP1 completed a name to face count of the children in line and counted 13. SP1 then led the children inside. SP1 planned to do a second name to face count once they were settled in the preschool classroom. · SP2 said that s/he checked the playground and did not see the AV, or any other child, remaining outside. There was no one else, including other staff persons, on the playground at that time. · Once inside, the children stopped at the bathroom sinks to wash their hands. Lunch was typically delivered to the classroom around 11:30 a.m. SP1 said s/he saw the AV washing his/her hands. · However, then things got “kind of chaotic” and children were no longer standing in a line. A child, not the AV, tried to run back outside but was stopped by SP2, and another child began throwing school age toys. An administrator entered the room and was asking SP1 where s/he should put the pizzas that were ordered for lunch. · SP2 believed that during this time, when everyone was facing the sinks and shuffling into the preschool classroom, the AV ran back outside without anyone noticing. SP2 said that SP1 started counting the children inside but put that count on “pause” as they transitioned from the sinks to the preschool classroom lunch tables. SP2 had also not yet counted the children. · SP1 said that after everyone washed their hands, they walked into the preschool classroom where the children started sitting at various tables to await lunch. At this point, SP1 said that s/he asked SP2, “We have 13 kids?” and SP2 responded, “Yes. We do.” SP2 later that s/he thought SP1 had already counted the children. · SP1 then started serving lunch trays. While doing so, s/he heard “knocking on a door” but was immediately called away out of the classroom to get another milk container. · It was around this same time, according to SP2, that s/he noticed an empty chair at one of the lunch tables and started to determine who was missing. · SP1 returned to the preschool classroom with the milk container. P1 then entered the preschool classroom with the AV. According to SP1, P1 was “yelling" at staff that the AV was left outside. The AV was “crying” but “okay” and not physically injured. SP1 was “very emotional” about what happened. · SP1 believed the AV was outside for around five minutes. SP2 believed it was around four to seven minutes. [Note: For the facility’s internal review following this incident, P2 estimated the time to be around ten minutes. P2 explained that lunch was typically served to the preschool classroom at 11:30 a.m. SP1 said that they brought the classroom inside at 11:27 a.m. to get washed up before lunch. P2 estimated it would take “five minutes” for the children to get washed up. SP1 said that s/he saw the AV washing his/her hands during this time. P1 told P2 that s/he discovered the AV outside at 11:45 a.m.] · SP1 and SP2 were each trained to complete a name to face count every time they transitioned from one area to another. At the time the AV was discovered outside, they were “halfway” done with the count but waiting until everyone was settled at the lunch tables. P2 said that SP1 and SP2 each received training on name to face counts. When transitioning inside from the playground, staff were supposed to complete a name to face count before leaving the playground and then again once in the classroom. This included calling each child’s name from the Child Supervision Record and ensuring that child was in line with the class. P2 did not have prior or related concerns with SP1’s and/or SP2’ conduct. The FM did not have concerns with the facility’s overall care or supervision prior to this incident. Following the incident and later that same day, the FM asked the AV if s/he was left outside and the AV responded, “Yes. Left outside.” The AV did not make any other statements about the incident. The facility’s Child Supervision Record procedure stated the following: Several times throughout the day, there are segments of time between activities when children are moving from one routine to another. During these transitional times, children may be less directed, confused, or stray from the group. Transitions between locations, such as classrooms and outside areas, are the most vulnerable times for teachers to leave a child unattended. Using the Child Supervision Record as a tool to promote safe transitions, decreases the chance of an adverse incident. When transitioning from one location to another, teachers will use the Name-to-Face Transitions section of the Child Supervision Record to confirm all children are accounted for during transitions, whether that be a transition within the classroom or across thresholds. Perform name-to-face checks as children cross the threshold from the space they’re in to the new location. For example, when leaving the classroom to go to the playground, complete name-to-face before crossing the threshold out of the classroom and again after crossing the threshold into the playground. Make sure you actually look at each child’s face and verify they’re with you instead of just counting children. The facility’s Risk Reduction Plan stated, “Children are always in sight and sound” of a staff person. Facility documentation stated that SP1, SP2, P1, and P2 received training on the facility’s Risk Reduction Plan and Child Supervision Record and on the Reporting of Maltreatment of Minors Act.
Relevant Minnesota Statutes and Rules: 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 September 20, 2023, the AV was left outside on the playground for around ten minutes without the knowledge or supervision of SP1 and/or SP2, or any other staff person which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. P1 discovered the AV crying outside and brought him/her inside. The AV was not physically injured. Given the AV’s age at the time of the incident and that s/he was left outside for around ten minutes without staff knowing; that staff did not complete a name-to-face count upon entering the classroom; and that the surrounding area included environmental hazards and community persons, which placed the AV at an increased risk of harm, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care required for his/her physical or mental health and a failure to protect the AV from conditions that seriously endangered his/her physical or 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. 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. 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 working together in the AV’s classroom and responsible for the AV’s care and supervision. SP1 and SP2 received training on the facility’s Risk Reduction Plan and Child Supervision Record and on the Reporting of Maltreatment of Minors Act. 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. SP1’s and SP2’s actions were considered a single incident of maltreatment for which there was no information the AV sustained a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility retrained all staff persons on supervision and the Child Supervision Record procedure. 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 November 29, 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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