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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: 803892-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: Allegation One: It was reported that an alleged victim (AV1) left his/her classroom and went into an adjoining classroom, that was not occupied at the time, without a staff person’s (SP1) knowledge or supervision for approximately three minutes. Allegation Two: It was reported that an alleged victim (AV2) was left on a playground without staff persons’ (SP2 and SP3) supervision or knowledge for approximately 10 minutes. Date of Incident(s): Allegation One: July 27, 2023 Allegation Two: August 1, 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 17, 2023; from documentation at the facility; and through seven interviews conducted with one supervisory staff person (P1), five facility staff persons (P2, P3, SP1, SP2, and SP3), and AV2’s family member (FM2). The facility had seven classrooms. The back of the Toddler A classroom had a bump-out space that had a door that led to the Toddler B classroom and another door that led to a preschool classroom. The bump-out space was a “blind spot” if a staff person was at the front of the Toddler A classroom. At the time of the incident there were no safety locks on the doors. The facility had two playgrounds with a variety of climbing structures. The two playgrounds were separated by an interior chain link fence and were used for different age groups. There was a five-foot high iron fence with vertical slots for the exterior fence surrounding both playgrounds. The exterior door from the Toddler B classroom exited onto the preschool playground and the exterior door from the preschool classroom exited onto the toddler playground. Next to the toddler playground was a parking lot for the facility and behind that was a parking lot for a neighboring business. There were trees and a grassy area beyond the facility’s fences. There was a nearby main road that ran along the back of the toddler playground. The posted speed limit for that road was 40 miles per hour. AV1 was 16 months at the time of the incident. AV2 was 19 months at the time of the incident. Both AV1 and AV2 were enrolled in the Toddler A classroom. The facility’s Risk Reduction Plan stated that, “When transitioning from one area to another, children will form a line using a walking rope. Staff [persons] will call the children by name to hold on to the walking rope. Staff [persons] will use face to name every time the rope is used. One staff [person] will be at the front of the line and one staff [person] will be at the back of the line.” The facility’s Safety and Supervision Policies stated, “All children must be within sight and sound at all times.” The facility’s Transition Policy stated, “Complete a name to face count prior to leaving your current location and when entering the transition location.” Facility records showed P1, P2, P3, SP1, SP2, and SP3 were each trained on the Reporting of Maltreatment of Minors Act, the facility’s Risk Reduction Plan, and the facility’s policies regarding supervision. 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. Allegation One: It was reported that AV1 left his/her classroom and went into an adjoining classroom, that was not occupied at the time, without SP1’s knowledge or supervision for approximately three minutes. P1 said that the Toddler A and B classrooms combined for naptime. SP1 was cleaning up after lunch and was getting his/her children lined up to go into SP2’s classroom and as SP1 counted the children, SP1 noticed that AV1 was not in the classroom with SP1 and the other children. AV1 had left the classroom through the door that adjoined to the preschool classroom and was found in the preschool classroom playing by a white board. P1 stated there was a “blind spot” where the door to the preschool classroom was. P1 reviewed video footage and saw SP1 sweeping and walking over to gather his/her things to take to the Toddler B classroom. P1 said AV1 was out of camera view for “maybe” four minutes and was in the preschool classroom as seen on camera for two minutes. P1 said safety locks were added three to four days after this incident. P1 said s/he heard AV1 tried to go into the preschool classroom only one other time, but P2 was right there. P1 said that P2 had taken AV1 over to his/her classroom in the past, so AV1 often tried to open the door to the preschool classroom because s/he had been “allowed” to go over there before. SP1 provided the following information to this investigator and during the internal review: · SP1 said that the classroom was transitioning from lunch to naptime and SP1 was changing a toddler’s diaper when AV1 got out. SP1 noticed AV1 was not in the classroom as s/he went to count the children to move into the Toddler B classroom for naptime. AV1 was found by SP2 in the preschool classroom. · SP1 stated there was not a safety lock on the door at that time and AV1 tried multiple times to open the door between the Toddler A classroom and the preschool classroom. SP1 said it was about a week after the incident that a safety lock was put in place on the door to the preschool classroom. · SP1 stated that “sometimes” P1 opened the door and let AV1 go into the preschool classroom and then P1 sent AV1 back into the Toddler A classroom. SP1 said there was a “blind spot” by the door because of the design of the classroom. AV1’s family member (FM1) heard that AV1 entered the preschool classroom by him/herself and was in there about two minutes without supervision. FM1 did not blame SP1 as s/he did not design the Toddler A classroom and there were “blind spots.” P2 said that AV1 was “pretty strong” and able to open the door between the Toddler A classroom and the preschool classroom and walk over. P2 would tell the staff persons working in the Toddler A classroom that AV1 was in the preschool classroom. P2 said the longest AV1 was over in the preschool classroom without someone noticing AV1 had walked over was five to ten minutes. P2 said staff persons complained about the toddlers being able to open the doors so P1 finally got a safety lock to put on the door. The facility did not provide video footage however, P1 viewed it at the time of the incident and that information was included above. Conclusion for Allegation One: On July 27, 2023, AV1 opened the door that joined the Toddler A classroom to the preschool classroom while SP1 was cleaning the classroom after lunch time to transition to the Toddler B classroom for naptime. As SP1 lined up and counted the children to bring them to the Toddler B classroom, s/he noticed AV1 was not there. AV1 was found in the preschool classroom playing by the white board. SP1 along with other staff persons asked P1 to install a safety lock on the door because the toddlers kept trying to open the door and either hurt their fingers or tried to leave the classroom. Although video showed that AV1 was in the preschool classroom without staff person knowledge or supervision for approximately two minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, given that AV1 opened the door by him/herself, that SP1 was engaged in cleaning up the classroom to transition to another classroom for naptime, and that before moving to the other classroom SP1 completed a headcount and noticed AV1 was not in the classroom anymore, there was not a preponderance of the evidence that SP1 failed to supervise AV1 when reasonably able to do so. It was not 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 (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Allegation Two: It was reported that AV2 was left on a playground without SP2’s and SP3’s supervision or knowledge for approximately 11 minutes. FM2 said P1 pulled FM2 aside when FM2 picked up AV2 and told FM2 that AV2 was left outside and P1 was still determining what happened. AV2 seemed “fine” when FM2 picked him/her up. The next day, P1 told FM2 that AV2 was outside for about ten minutes. SP2 and SP3 did not realize that AV2 was not in the classroom with them and P3 was outside on the preschool playground and saw AV2 on the toddler playground and brought him/her inside. Prior to this FM2’s only concern was which classroom AV2 was going to be in the afternoon at pick up time. FM2 said P1 handled the situation in a professional and compassionate manner. P3 was outside on the preschool playground on the day of the incident. About ten minutes after the toddler classrooms went inside, P3 noticed AV2 standing by the fence watching the preschool children. AV2 was not crying and did not seem to be overheated. P3 picked AV2 up and brought him/her to the Toddler B classroom to SP2 and SP3. P3 said s/he did not see if SP2 and SP3 used a rope to bring the classroom in as they cut through the preschool classroom instead of going on the preschool playground. P3 said the policy was for children to grab the rope, for staff persons to conduct a name to face, and then for staff persons to do name to face again once inside. SP2 stated that s/he and SP3 were outside, and it was getting close to 5 p.m. diaper changes. SP2 said s/he grabbed a water jug and other items from outside and SP3 was putting the children inside the door to the classroom. SP2 asked SP3 if all of the children were inside and SP3 responded, “Yes,” so SP2 and SP3 brought the toddler children inside from the toddler playground and entered through the exterior preschool door and walked the children through the preschool classroom, and the shared bathroom into the Toddler B classroom. SP2 stated that there were family members picking up other children so s/he and SP3 talked to those family members. About ten minutes later P3 brought AV2 into the room through the exterior door and told SP2 and SP3 that AV2 was outside on the playground. SP2 said AV2 was “okay” and not crying when s/he came inside. SP2 felt “ashamed” that s/he left AV2 outside. SP2 stated that s/he and SP3 did not use the rope that day to bring the children inside. SP2 said they used a different way to get inside that day and s/he did not remember if it was because the children were needing to be changed or if children were upset and wanted to go inside. SP2 stated s/he did not count but thought SP3 had so SP2 did not double check. SP2 said the policy was to have the children grab the rope, go around the “older kids” playground, and count face to face naming. SP3 stated that s/he went onto the toddler playground with SP2 and SP2 already had the children lining up to go inside. SP3 stated that they went in through the exterior preschool door, instead of going out the gate. SP3 said that SP2 started doing diaper changes when they came inside and then the group sat down. About seven to ten minutes later P3 brought AV2 to the door and stated s/he was left outside. SP3 said AV2 did not seem in “distress” but sat down and SP3 wiped off AV2’s face. SP3 said both s/he and SP2 were in “shock.” SP3 stated that no rope was used, and s/he did not think that SP2 counted the children. SP3 stated that the policy was to have the children grab the ring rope, do name to face, and count the children. P1 said SP2 and SP3 were outside with the toddler children and came inside not using their normal route through the preschool playground to enter through the exterior Toddler B classroom door but went inside from the toddler playground through the exterior preschool door into the preschool classroom to the Toddler B classroom. SP3 told P1 that P3 brought AV2 inside after SP2, SP3 and the rest of the class was inside. P1 said FM2 picked up AV2 about ten minutes later so s/he told FM2 s/he needed to gather more information. SP2 said s/he was carrying items in and just let the children in and SP2 asked SP3 if s/he checked the playground and SP3 said, “Yes.” SP3 told P1 that both SP2 and SP3 checked the playground. P3 told P1 that AV2 was playing by the fence when s/he found him/her and AV2 was not crying. This investigator reviewed video footage and saw the toddler class enter the Toddler B classroom through the shared bathroom with the preschool classroom. There were a few family members picking up other children at that time. SP2 and SP3 spoke with those family members and interacted with the other children. Approximately nine minutes later, SP2 and SP3 got the children seated at a table to do an activity. After about two minutes P3 opened the door from the preschool playground into the Toddler B classroom with AV2 in his/her arms and set AV2 down in the Toddler B classroom. AV2 walked in and went to the carpet. SP2 brought his/her hands to his/her mouth and to the back of his/her head and then back to cover his/her mouth. SP3 went to the carpet and picked up AV2 and carried AV2 over to the other children. According to www.wunderground.com, the temperature on August 1, 2023, between 4 p.m. and 5 p.m. was 85 degrees Fahrenheit (F°) and was partly to mostly cloudy. Conclusion for Allegation Two: A. Maltreatment: On August 1, 2023, SP2 and SP3 brought a group of toddler children inside from the toddler playground and AV2 was left on the playground for approximately ten minutes without staff person knowledge or supervision which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. AV2 was found by P3 who was outside on the preschool playground. P3 brought AV2 inside to SP2 and SP3. AV2 did not seem to be in “distress” over the incident. Neither SP2 nor SP3 counted the children when coming inside and did not use the rope to assist with the transition. SP2 asked SP3 if all of the children were inside and SP3 responded, “Yes.” Although SP2 said SP3 stated all children were inside, and that AV2 was not injured and found inside the chain link fence, given that neither SP2 nor SP3 counted the children during the transition or were aware that AV2 was not in their care, and that no staff person was present on the playground to intervene if AV2 was injured or in case of an emergency, there was a preponderance of the evidence that there was a failure to supply AV2 with necessary care and a failure to protect AV2 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. SP2 and SP3 were responsible for the supervision of AV2 at the time of the incident and were trained on the facility’s Safety and Supervision Policy, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. SP2 and SP3 were responsible for maltreatment of AV2. 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 SP2 and SP3 were responsible did not meet statutory criteria to be determined as recurring or serious. It was a single incident and AV2 sustained no injuries. 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, SP2, and SP3. SP1 was retrained on supervision. SP2 and SP3 received a written warning. Action Taken by Department of Human Services, Office of Inspector General: SP2 and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 and SP3 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 SP2 and SP3 were each responsible for maltreatment is subject to appeal. On December 15, 2023, the facility was issued a Correction Order for the violations 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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