|
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: 1102890-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on the playground unsupervised for at least five minutes. Date of Incident(s): November 13, 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 December 11, 2023; from documentation at the facility; and through five interviews conducted with four facility staff persons (SP1, SP2, SP3, P), and the AV’s family member (FM). The facility was located in a church. The Toddler 2 classroom was in the second level. The classroom was a large open room with two windows that faced the playground area. The playground was a fenced in area on the side of the building that contained several play structures. There were two doors to the facility in the playground area. One door opened to a stairwell that went directly up to the Toddler 2 classroom. The large motor room was located next to the Toddler 2 classroom. The AV was 28 months old at the time of the incident and enrolled in the Toddler 2 classroom. The P said that on the day of the incident, s/he was informed that the AV had been left outside. When the P checked the facility’s cameras, s/he noticed that the classroom came inside at approximately 4:50 p.m. The P was not able to see where the AV was at that time as s/he was out of the camera view. At approximately 5:07 p.m., SP2 went outside the door and the AV came into view running towards SP2. Staff persons used an internet application to keep track of which children they had and how many children they had. During transitions staff persons counted and made sure they had each child. Staff persons “sandwiched” themselves around the children during transitions and counted the children to make sure they all got back to the classroom. SP1, SP2, and SP3 provided the following information: · On the date of the incident, SP1, SP2, and SP3 were outside on the playground with children from the Toddler 1 and Toddler 2 classrooms. Enough children had left for the day that the classes were combined with 13 children. · At approximately 4:50 p.m., SP1, SP2, and SP3 started gathering the children by the door that led to the toddler classrooms. SP1 stood at the front of the children and led them into the building to the motor room. SP2 was in the middle of the group of children carrying one child and SP3 followed the children inside and shut the door. · Once inside the children started removing their coats and boots and putting their shoes back on. The children then started playing in the motor room. At some point SP2 noticed that the AV’s shoes were still sitting out and thought maybe s/he had been picked up. SP2 checked and the AV’s jacket was not hanging up, so s/he checked the hallway and Toddler 2 classroom. The windows in the classroom were open and SP2 heard the AV “babbling” outside. · SP2 went outside and found the AV sitting on the far side of the playground. The AV did not seem upset, was not crying, and came over to SP2 when s/he called. SP2 checked the AV over and the AV did not appear to be hurt. · SP1 said s/he forgot to count the children. Normally staff persons counted the children as they came in through the door from outside. The staff person at the end of the line checked the playground and shut the door. · SP2 said s/he “miscounted or skipped” counting the children. Typically, when coming inside, one staff person went up the stairs and held the door open, another person was in the middle, and the third person in back checked the playground and closed the door. All staff persons were to count the children when coming inside. · SP3 said that s/he counted his/her children that were in the Toddler 1 classroom but did not count all the children. SP3 was a new employee and did not know s/he should count all the children and was unsure of some of the children’s names. Usually, the children were counted as they were going up the stairs and then once they got the classroom. According to www.wunderground.com, the outdoor condition at the facility, on November 13, 2023, at the time of the incident, was “fair” with a temperature of 43 degrees Fahrenheit (°F) and wind speed of 5 miles per hour (mph). The Policies & Procedures stated children were always supervised. The Risk Reduction Plan showed that children were supervised by staff persons and ratios were maintained on the playground. Staff persons positioned one staff person at the lead and another at the end and kept count of children. Facility documentation showed that staff persons were trained on the facilities policies and the Reporting of Maltreatment of Minors Act. 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: Information was consistent that on November 13, 2023, the AV was left on the facility’s playground without the knowledge or supervision of a staff person for approximately 17 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1, SP2, and SP3 were each not aware that the AV was still on the playground when they took the other children back to the classroom, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Although the playground was fenced, the AV, who was 28 months old, was unsupervised for seventeen minutes with no staff person available to intervene if the AV attempted to do something dangerous, injured him/herself, or in the event of an emergency. Therefore, 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 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. SP1, SP2, and SP3 were each trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. At the time of the incident, SP1, SP2, and SP3 were supervising children from the Toddler 1 and Toddler 2 classrooms, which were combined, on the playground. When the classes combined, there was no conversation between staff persons regarding how many children were present. Although children from both classrooms, SP1, SP2, and SP3 all walked into the building together, SP3 counted the children from Toddler 1 classroom, which s/he was responsible for when they entered the building. SP1 and SP2 each did not count any children from either classroom. Although the classrooms were combined at the time of the incident and that both classrooms left the playground as a group and went up together to the large motor room, SP3 counted the children s/he was responsible for which did not include the AV. Therefore, SP3’s responsibility was mitigated. SP1 and SP2 did not count any of the children at any point during the transition or confirm with other staff persons that the children had been counted. Therefore, 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 as it was a single incident, and the AV was not injured. 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 were not followed by staff persons. Staff persons involved were given corrective action and an additional policy was added to the program procedures. 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 January 24, 2024, 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.
|
