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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: 830403-CCC (Child Care Center) Investigator(s): Kimberly Huettl Anderson/Van Mulheron Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised for approximately two minutes in the facility’s office and hallway. Date of Incident(s): August 10, 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 29, 2023; from documentation at the facility; and through four interviews conducted with a facility supervisory staff person (SP1), two staff persons (P2 and SP2), and the AV’s family member (FM). The facility consisted of five classrooms, including an early preschool room. Near the entrance of the facility was an office and the classrooms were located beyond that down a hallway towards the back of the facility. The office contained toys that were available for children to play with when families visited the facility. Separating the office/entrance of the facility from the classrooms was a soft retractable gate that was typically closed during the day. The children’s bathrooms were across the hall from the early preschool classroom. A video camera was located in the hallway in an upper corner between the office and the front door. The AV’s enrollment form stated that at the time of the incident, the AV was approximately two and a half years old and enrolled in the facility’s early preschool program. The facility’s Child Care Risk Reduction Plan stated that when “transitioning” from one area to another staff persons were to count the number of children transitioning to ensure all children were present (Note: There was no information regarding the gate in the facility policies and procedures, including the Risk Reduction Plan). The facility’s Supervision policy stated that all children must be within sight and sound at all times. The facility’s written documentation regarding the incident stated that on August 10, 2023, at approximately 10:37 a.m., the AV was in one of the bathroom’s with SP2 and other children, including (C1 and C2). SP1 and another staff person (P2) were assisting the remaining children who were in the early preschool room. Once the AV, C1, and C2 were done in the bathroom, SP2 sent them back to the early preschool classroom. SP2 thought SP1 knew s/he sent three children. However, SP1 was only aware of C1 and C2 returning to the classroom. At approximately 10:40 a.m., another staff person (P1) returned the AV to the classroom and stated that the AV was found in the hallway. Video footage showed that the AV was unsupervised, in the hallway and in the office, for approximately two minutes. Facility documentation, and interviews with SP1 and SP2 provided the following information: · On August 10, 2023, at approximately 10:37 a.m., SP1 said that s/he was in the office when s/he went to the early preschool room to assist. There were 13 children in the early preschool classroom with SP2 and P2. SP1 came in as SP2 took the AV and six other children to the bathroom. SP1 stayed with P2 and the remaining six children in the classroom. · During this time, another child in the classroom had a toileting accident so SP1 brought the child to SP2 in the bathroom and then took three children who had finished toileting using the bathroom back to the classroom. At this time the AV was still in the bathroom with SP2. · A child in the bathroom with SP2 had a toileting accident so SP2 opened the bathroom door and stood at the door and called out asking SP1 for a change of clothes. SP1 was standing at the early preschool doorway and threw the change of clothes to SP2 who was at still standing at the bathroom door. · SP1 and SP2 then provided conflicting information. SP2 said that after SP2 s/he received the clothes, s/he told SP1 that s/he was sending C1, C2, and the AV back to the classroom and then did so. SP2 said that s/he did not confirm if SP1 heard him/her before s/he closed the bathroom door because s/he needed to attend to another child who was crying in the bathroom. SP1 stated that s/he was aware of only C1 and C2 being sent back. As C1 and C2 walked across the hallway to the early preschool classroom, C2 started crying and would not go into the classroom. SP1 went and picked C2 up and brought him/her to the classroom. SP1 thought that this was when the AV “slipped” by staff persons and went towards the office. · At approximately 10:40 a.m., P1 saw the AV walking toward P1 in the hallway and the AV said, “I found toys.” P1 picked the AV up and walked to the office to see if there was anyone in the office. When there was no one in the office, P1 took the AV to his/her classroom. The AV was not in distress and was not injured. · When the AV was returned to the classroom, s/he joined the classroom routine with the other children. Additionally, after the AV was returned to the classroom, SP2 returned from the bathroom with the remaining children. Neither SP1 nor SP2 were aware that the AV did not return to the classroom and was in the office and hallway. SP1 reviewed video footage of the incident and provided information regarding what s/he saw that was consistent with the video reviewed below. SP1 then told the FM about the incident. · SP1 and SP2 each said that they were to use name to face counts when transitioning children. SP1 also stated that they were to use a walking rope when transitioning children from classrooms. When they took children to the bathroom, staff persons were to wait until all the children completed toileting before they transitioned the children back to the classroom. If there was another group who needed to use the bathroom, staff persons were to wait until they returned with the first group. SP1 and SP2 stated that the transition routines were not completed on the day of the incident because there were several children who had toileting accidents prior to their turn toileting and C2 was having difficulty with the transition. Video footage provided by the facility was 8 minutes and 44 seconds long. The video showed the entrance to the facility. On one side of the hallway was a closed door that led to the laundry room and staff break room and on the other side was a counter top, with a widow and directly next to the window a corner of a doorway to the office was visible. In the upper right corner between the window and the door was a video monitor that had multiple windows on display. At 2:58 the AV walked into view at the bottom corner of the video and immediately walked out of view of the camera towards the doorway next to the window. At 3:55, the AV came into view from the office into the hallway, looked down the hall, then turned around and walked back toward the office and out of view. At 4:03 the top of the AV’s head was seen for one second. At 4:34, the AV came into view from the office and turned appearing to walk back down the hallway off camera. At 5:00 P1 came into view holding the AV and looking around the lobby area including into the office via the window and at the video monitor. The AV was holding toys and did not appear to show any signs of distress. At 5:08, three additional children joined P1 and the AV in the lobby area and at 5:20 a fourth child came into view. At 5:27 they all left view of the camera appearing to walk down the hall. The FM said that SP1 told him/her about the incident immediately afterwards. The FM was relieved that the AV was safe but expressed concerns that name to face counts were not conducted. The facility’s personnel file showed that P1, P2, SP1 and SP2 were trained on the facility’s Child Care Risk Reduction Plan, the Reporting of Maltreatment of Minors, and the Supervision policy 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: On August 10, 2023, the AV was unsupervised in the office and the hallway for approximately two 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. At the time of the incident, SP2 was in the bathroom with a group of children including the AV and SP2 and P2 were in the classroom with the other group of children. SP2 stated that s/he told SP1 that C1, C2, and the AV were returning to the classroom but SP1 stated s/he did not know the AV was returning. After the children left the bathroom, SP2 closed the bathroom door and assisted a child who was crying while SP1 helped C2 who did not want to return to the classroom. Minnesota Statutes, section 260E. 30, subdivision 3 states that rather than making a determination of substantiated maltreatment by an individual, the commissioner of human services shall determine that a nonmaltreatment mistake was made by the individual. A nonmaltreatment mistake occurs when: (1) at the time of the incident, the individual was performing duties identified in the center's child care program plan; (2) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; (4) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; and (5) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing requirements relevant to the incident. Although the AV was unsupervised in the office for approximately two minutes, SP1’s and SP2’s failure to ensure clear communication to one another about the AV was determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, SP1 and SP2 were preforming job related duties. SP1 and SP2 were each involved in helping children. SP2 returned to the bathroom to assist with a child who was crying and SP1 helped C2 who did not want to return to the classroom. (2) SP1 and SP2 have not previously been found responsible for a similar incident that resulted in a finding of maltreatment. (3) SP1 and SP2 have not previously been found responsible for a similar incident that resulted in a finding of a nonmaltreatment mistake in the past. (4) The AV was uninjured and did not require medical care after the incident. (5) Except for this period when the incident occurred, the facility, SP1, and SP2 were in compliance with licensing requirements. The nonmaltreatment mistake to the AV by SP1 and SP2 was not maltreatment. 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. Action Taken by Facility: The facility conducted an internal review and determined that their policies and procedures were adequate but was not followed at the time of the incident. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not determined as a perpetrators of maltreatment of the AV because the Department of Human Services found that the incident for which SP1 and SP2 were responsible met the criteria to be determined a nonmaltreatment mistake. SP1 and SP2 were notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP1 or SP2 is responsible might not be considered a nonmaltreatment mistake. On January 24, 2024, 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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