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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: 1046297-CCC (Child Care Center) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised on the facility playground for approximately one hour. Date of Incident(s): June 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 June 27, 2023; from documentation at the facility; and through two interviews conducted with two facility supervisory staff persons (P1 and P2). The FM and this investigator also communicated via email and that information is below. Attempts were made via phone, U.S. mail, and text message to contact and interview a staff person (SP) but the attempts were not successful. The facility had multiple classrooms, including preschool rooms. The AV was approximately four years old at the time of the incident and enrolled in one of the preschool classrooms. The Child Care Center Risk Assessment and Risk Reduction Plan said that the facility had three fenced in play areas including one for infants and toddlers, a preschool playground, and a space for basketball and biking. The facility “backed up” to a “busy street [Dodd Boulevard].” When transitioning from one area to another, children were to form a line using a walking rope. Staff persons were to then call the children by name to hold onto the walking rope and use a name to face count each time the walking rope was used. P1, P2, and the Internal Review Form provided the following information: · On June 20, 2023, the SP was outside in the fenced in preschool playground with 10 children, including the AV. At approximately 4:22 p.m., the SP began the “process” of bringing the children inside. The SP “believed” that s/he had all 10 children and opened the door to bring the children to the classroom. Once back to the classroom, the class “carried on as normal.” · At approximately 5:22 p.m., the SP realized that the AV was not in the classroom. (Because the SP did not provide information it was unknown how the SP realized the AV was missing.) The SP then “immediately” contacted P2, who was in another preschool classroom (that faced the playground), via the facility phone. The SP told P2 that the AV was not with him/her and asked P2 if the AV was with him/her. P2 told the SP that the AV was not with him/her and that the AV was in the SP’s “count.” The SP told P2 that s/he “hoped [the AV] was not outside.” P2 then “immediately” went to his/her classroom window and saw the AV on the preschool playground near a climbing wall. P2 opened a door that s/he had in his/her classroom that exited to the playground and asked the AV to come to P2, which the AV did. P2 said that the AV was not crying and did not seem “upset.” There were no injuries to the AV. The SP then told P2 that s/he “could not believe [s/he] forgot [the AV] outside.” (Note: The Internal Review said that the SP left the AV unsupervised on the playground for approximately one hour. P2 thought that the AV was unsupervised for 30 minutes based on the time the SP’s classroom went inside around 4:35 or 4:40 p.m. to when the SP notified P2 of the incident around 5 p.m.). · The AV then remained in P2’s classroom until the FM picked the AV up. When the FM picked the AV up, s/he was notified of the incident. The FM was “somewhat disappointed but forgiving.” The FM said that the AV “tends to run” from the FM while outside. · When coming inside from the playground, staff persons were trained to line the children up and each child was to take a “ring” from the walking rope to hold. Staff persons then did a name to face count using the classroom attendance (which was on a tablet) to ensure that each child “matched” the attendance list and then went inside. Once they were inside, staff persons were to do another name to face count to ensure all the children were present. At some point after the incident, P1 spoke to the SP who said that s/he did not use the “rope” but thought that all the children were in line prior to returning to the classroom. P1 said that if the SP had used the rope, the incident would not have happened. This included because using the rope provided a “visual” to see if any children were missing as the ropes had 10 rings, which was how many children the SP had. · The SP was “very remorseful” regarding the incident. P1 said that the SP had worked at the facility for about three to four years and there were no prior similar incidents. P2 said that the SP’s supervision at times was “lacking” as the SP got “tunnel vision” and “forgets about anything else around [him/her].” · The facility reviewed video footage from the playground during the incident but it was “hazy and did not offer much clarity.” (Note: This investigator viewed the video footage and observed similar.) · P1 and P2 said that risks to the AV being unsupervised included that it was a “warmer day” and that the AV could have gotten “heat stroke.” Additionally, the AV could have reached and opened a gate on the playground to exit but had not done so prior. The gates were also not locked from the outside so P1 said that someone could have opened the gate and accessed the AV. The facility also “backed up” to a busy road and there were apartment buildings nearby. The FM said that s/he was made aware of the incident from the facility but from his/her “understanding,” the AV was only unsupervised for a “few minutes.” According to Accuweather.com, the temperature in Lakeville, Minnesota on June 20, 2023, ranged from 64 to 88 degrees Fahrenheit. The Safety and Supervision Policy said that staff persons were to “never leave the children unattended for any reason.” All children were to be within sight and sound at all times. Staff persons were to always know the exact number of children they were responsible for and where they were at all times. The Transition Policy said that during transitions including to and from the playground, the walking ropes “must” be used and there were “no exceptions.” The children were to line up using the rope and staff persons were to count the number of children lined up on the rope using a name to face count. Staff persons were to then do a “sweep” of the playground prior to leaving. All children must hold onto the rope and staff persons were to ensure that all children were accounted for prior to closing the playground door. Staff persons were to also count the children using a name to face count once back in the classroom. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies and procedures, including the Safety and Supervision Policy and the Risk Reduction Plan, 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: P1, P2, and the facility Internal Review provided consistent information that on June 20, 2023, the AV was left outside on the facility playground unsupervised and without a staff person’s knowledge for between 30 to 60 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 the AV, who was approximately four years old, was outside unsupervised without the knowledge or supervision of staff persons for 30 to 60 minutes, and that the AV had access to dangers including community persons entering the playground or the AV exiting the playground which was accessible to community dangers, there was a preponderance of 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 the AV’s 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 and/or 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. The SP was responsible for the care and supervision of the AV at the time of the incident. The SP was trained on the facilities policies and procedures, including regarding supervision; the Risk Reduction Plan; and the Reporting of Maltreatment of Minors Act. The SP 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 the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it 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 determined that policies and procedures were adequate but not followed at the time of the incident. This included that children were to be within sight and sound of staff persons at all times, yet the AV was unsupervised for one hour. The SP no longer worked at the facility. There were no similar prior incidents. 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 December 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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