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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: 1101179-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on a playground without staff person (SP1, SP2, and SP3) knowledge or supervision for approximately five to ten minutes. Date of Incident(s): October 3, 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 October 19, 2023; from documentation at the facility; and through seven interviews conducted with a supervisory staff person (P1), five facility staff persons (SP1, SP2, SP3, P2, and P3), and the AV’s family member (FM). The facility was connected to a church. There was a main entrance to the facility on one side of the building and another door on the lower level of the church that the staff persons used to bring the children to and from the playground. The lower-level door led to a parking lot that staff persons and children crossed to get to the gate of the playground which was approximately 130 feet from the lower-level door. The playground was rectangular in shape and had a three-foot-high chain link fence surrounding the area. The playground was divided by a fence for different age groups. There were various toys and climbing structures on the playground and a playhouse was located near the gate for children to play in. The playground was 176 feet from a main road in front of the church which had a posted speed limit of 40 miles per hour. The AV was 26 months old and enrolled in the toddler classroom at the time of the incident. Due to his/her age the AV was not interviewed for this investigation. P2 provided the following information: · On October 3, 2023, around 11 a.m., P2 and P3 took the infant children out in strollers for a walk. It was a “sunny, warmer day” and the infants did not need sweatshirts on. P2 and P3 left the infant classroom and exited the building through the main door and walked towards the playground. On the second lap around the building, P2 thought s/he saw something on the playground and thought s/he was seeing things so P2 asked P3 if there was a child on the playground. · P2 and P3 immediately went over to the playground and the AV was standing quietly by the gate on the inside of the playground. P2 stated that there had not been another staff person outside for at least 10-15 minutes. P2 did not see the AV the first time s/he and P3 went by the playground so P2 was not sure if the AV was in a spot they could not see or if the AV was hiding. · P2 and P3 brought the AV back towards the building as SP1 was coming out the lower-level door because the tablet had been left outside. P2 did not think that SP1, SP2, nor SP3 knew the AV was still outside. SP1 was “shocked” and stated that SP3 had counted the kids and when SP1 was coming back outside to get the tablet, everyone else was almost back to the toddler classroom. SP1 was “frazzled” about how they missed a child and to P2’s knowledge SP1 went straight to P1 to inform him/her of the incident. · P2 stated that the policy was to be within eyesight of the children and when transitioning back inside from the playground to do a headcount before opening the gate. Depending on the ages of the children, the staff persons were to spread out among the children when walking back to the facility. P2 stated that s/he was aware that the staff persons “tried” to use a “rope train” with the children when transitioning but depending on the children’s ages, the children did not always comply to holding the rope. P3 provided the following information: · P3 said the toddler classroom went inside between 10:55 and 11 a.m. and then s/he and P2 brought the infants outside in the strollers. P3 stated to get around the building it took about 5-10 minutes. That day was sunny and beautiful, so it was “maybe even longer.” On the second lap P2 and P3 noticed movement on the playground, so they ran over there and saw the AV in the corner of the playground looking at the facility. · P3 said s/he tried to call P1, but the call did not go through. The time of the call was 11:19 a.m. P3 said the AV looked “confused” but s/he was not crying. P2 and P3 brought the AV back to the facility as SP1 was coming outside to look for the tablet, not the AV. P3 said SP1 did not seem “upset” by the incident. P3 stated that SP1 took the AV back inside and P2 and P3 went back inside with the infants. P1 came down to the infant classroom and had P2 and P3 write down what had happened. · P3 stated that if there were three teachers, one teacher was in the front of the line, one was in the middle, and one was in the back of the line when going in from outside. P3 said that a headcount should be done before leaving the fenced in area, when walking, and once in the building. P3 stated that there was a color rope that staff persons could use, but it was not being used. On October 3, 2023, the FM received a telephone call from P1 and was told about the incident with the AV. The FM was told it was between five to ten minutes that the AV was on the playground before the AV was found by another staff person. The FM stated that it was a “rare heat wave” and was around 80 degrees Fahrenheit (80°F) on the day of the incident. SP1 provided the following information: · SP1 was outside on the playground with the toddler children and SP2 and SP3. SP1 said it was “hot” that day but did not remember what the AV was wearing. SP1 remembered seeing the AV lined up to come inside. SP1 said s/he asked SP2 and SP3 to count the children and SP1 counted as well, and they had 17 children. · SP1 said staff persons touched the children on the head when they counted but did not remember who touched the AV’s head that day. SP1 stated that they used the rope to come inside, and s/he was in the back of the line, SP3 was in the middle, and SP2 was in the front of the line. SP1 stated that they counted again once inside. · Another staff person needed the laptop so SP1 went back outside to get it and that was when SP1 saw the AV with P2. SP1 asked P2, “Where was [the AV]?” and P2 stated the AV was in one of the playhouses outside. SP1 took the AV and went to find P1 to tell him/her what happened. P1, the AV, and SP1 then went to the toddler classroom to talk to SP2 and SP3 about what happened. · SP1 said the policy was to count and make sure all of the children were there and then everyone went inside. SP1 thought the AV was outside for 15 minutes and when s/he saw the AV, the AV did not seem to be in distress and the AV went and played when they returned to the toddler classroom. SP2 provided the following information: · SP2 said it was overcast and “kind of chilly” on the day of the incident. SP2 was on the playground with SP1 and SP3. SP2 was in the lead by the gate talking to children and s/he remembered the AV was in line because s/he had a brightly colored jacket on. SP2 opened the gate and walked out. SP2 said that the group walked slowly and by the time s/he reached the door to go inside, SP1 was still not outside the gate from the playground. SP2 did not remember if s/he performed a count that day and was not sure if SP1 or SP3 did. · SP2 waited at the bottom of the stairs until SP1 and SP3 came in and then they all walked to the toddler classroom with the children. SP2 arrived at the toddler classroom door and as they arrived a child bit another child so SP2 dealt with that and SP2 thought SP1 and SP3 would do a count when they entered the toddler classroom. · SP2 stated that s/he did not remember what the children and SP2 and SP3 were doing once they were back in the classroom but SP1 realized that the staff persons forgot the tablet out on the playground and went back to retrieve it. About five minutes later P1 went to the classroom and asked SP2 and SP3 how many children they had because the AV was left on the playground. SP2 and SP3 were not able to provide P1 with an accurate count. P1 left and then came back in with SP1 and the AV. SP2 stated the AV seemed “fine” and “unfazed” by the incident. The FM picked up the AV shortly after the AV returned to the toddler classroom. · SP2 stated that the facility used BrightWheel on the tablet for checking children in and out and messaging family members, but SP2 did not know if BrightWheel was used for transitions. SP2 said s/he was not aware of any policy on transitioning children but stated that it was normal that every staff person counted. · SP2 thought there were 13 children on the day of the incident but was not “one hundred percent sure.” SP3 provided the following information: · SP1, SP2, and SP3 were out on the playground with the children. SP3 said it was sunny outside and the children did not need jackets on. · SP3 stated s/he did not count that day, but that SP1 and SP2 did before the toddler classroom went outside, but that they did not count on the way inside. The group got back inside and staff persons started changing the children’s diapers and preparing for lunch when P1 came to the toddler classroom and told them that the AV had been left outside on the playground. When the AV came back into the classroom, s/he seemed “okay.” SP3 thought it was maybe 10 to 15 minutes. · SP3 said the policy was to make sure to count the children to see how many the staff persons had with them both inside and outside. SP3 said s/he used the tablet to check children in and out, but during transitions SP3 used the tablet to see how many children were in each classroom. SP3 did not remember how many children were in the toddler classroom that day. P1 provided the following information: · Around 11:07 a.m. P1 was sitting with a group of preschool children. After about five to ten minutes P1 saw the toddler class walk by and then SP1 came to him/her with the AV and said the AV was left outside on the playground and was found by P2 and P3. P1 said the AV was “calm.” P1 then went to the toddler classroom with SP1 and the AV to let SP2 and SP3 know that the AV was left outside. · P1 stated that P3 tried to text him/her about the AV being outside, but P1 did not receive that text. The text message showed it was sent at 11:19 a.m. P1 thought the AV was outside for about five to ten minutes. · P1 spoke with SP1, SP2, and SP3. P1 said SP3 had no idea what was going on, SP2 tried to count or was counting but got distracted by something, and SP1 was not aware the AV was left outside until s/he went back out to retrieve a laptop. SP1 seemed “shaken up” by what happened, SP2 seemed “weirdly calm” so P1 did not know if it was “shock.” SP3 tried to talk to P1 about what happened but P1 did not think SP3 knew what had happened. · P1 was new to the facility but stated that the teachers should have counted before leaving the gated area and then counted the children inside. P1 said the facility used an application called BrightWheel to check children in with and it showed the number of children present. P1 stated there were 17 children present on the day of the incident. The facilities Emergency and Accident Policies and Procedures stated, “The playground [was] fenced in, away from traffic,” “Children will be counted when leaving, returning, and several times in between,” and “A staff person will be at the front of the line with another [staff person] at the end of the line.” The facility’s Employee Handbook stated, “Children must be supervised at all times while at [the facility]. At transition times children will be counted in and out of the room.” Facility records showed that SP1, SP2, SP3, P2, and P3 were trained in the facilities Emergency and Accident Policies and Procedures and the Reporting of Maltreatment of Minors Act. Facility records showed the toddler classroom had 17 children in attendance on the day of the incident. According to www.wunderground.com, the temperature on October 3, 2023, at 10:55 a.m. was 77 degrees Fahrenheit (F°). 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.
Conclusion: A. Maltreatment: On October 3, 2023, SP1, SP2, and SP3 were on the playground with the toddler classroom. The group went inside. SP1 stated that all three staff persons counted that day, SP2 did not remember if anyone counted but knew s/he was distracted when the toddler classroom came inside by a child biting another child, and SP3 stated that a count was done before leaving the toddler classroom to go outside, but a count was not done leaving the playground to come inside. P2 and P3 took the infant children in strollers around the facility and noticed the AV was on the playground and there were no staff persons present. P2 and P3 brought the AV back to the facility and ran into SP1 who was coming back outside to retrieve the tablet. SP1 brought the AV to P1 and told him/her what happened and then SP1, P1, and the AV went to talk to SP2 and SP3 about the AV being left on the playground. The AV did not seem to be in distress when P2 and P3 found him/her, and it was believed that the AV was outside by him/herself between five to ten minutes but could have been as long as 15 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 there was conflicting information from SP1, SP2, and SP3 regarding if or when the children including the AV were counted, that SP1, SP2, and SP3 did not know the AV was missing from the classroom, and that the AV was found alone on the playground by P2 and P3 after an unknown amount of time from 5 to 15 minutes with no staff persons to intervene in case of an emergency or injury, there was a 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 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. SP1, SP2, and SP3 were responsible for the supervision of the AV at the time of the incident. SP1, SP2, and SP3 were trained on the facility’s Emergency and Accident Policies and Procedures which stated that children needed to be counted when leaving, returning, and several times in between. Therefore SP1, SP2, and SP3 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, SP2, and SP3 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV did not sustain any 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. All staff persons were retrained on supervision. SP2 and SP3 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1, 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 SP1, SP2, and SP3 were each responsible for maltreatment is subject to appeal. On January 10, 2024, the facility was issued a Correction Order for the violations outlined in this report and for failure to document orientation training. 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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