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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: 801667-CCC (Child Care Center) Investigator(s): Kim Anderson/Van Mulheron Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on the facility playground without a staff person’s (SP) supervision or knowledge for up to 13 minutes. Date of Incident(s): September 14, 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 September 27, 2023; from documentation at the facility; and through three interviews conducted with a facility supervisory staff person (P1), a staff person (P2), and the AV. Attempts were made via phone and U.S. mail to contact and interview the AV’s family member (FM), but those attempts were unsuccessful. A staff person (SP) was contacted via telephone and an interview was scheduled for an upcoming date. However, the SP did not answer the phone at the scheduled time and did not respond to messages left. The facility was a two-story standalone building located next to a gas station, a four-lane divided road with a speed limit of 45 miles per hour, and an on ramp to a highway. Upon entry to the facility on the right were steps leading to the second floor where the preschool through school age classrooms were located. There was a hallway to the left of the stairs which led to the facility’s management office, two infant classrooms, and two toddler classrooms. There was a parent kiosk located past the stairs where parents checked their children in and out for the day. Past the parent kiosk was the exit to the preschool playground. The playground exit door was a full glass door. The playground had a five-foot vertical fence that surrounded the perimeter of the playground and one that separated the toddler playground from the preschool playground. On the preschool playground was a two-level play structure with a bridge that connected a larger structure to a smaller structure. There was a five-foot gate located ten feet to the right of the facility door. The gate had an alarm located near the top that beeped if the gate opened. On the exterior of the gate was a gravity gate latch that kept the gate closed but allowed people to enter if needed. The gate led to the side of the facility and into the parking lot. The playground was visible to passersby on the four-lane road and those using the on ramp to the highway. A video camera was located on the exterior of the facility facing the play structures. At the time of the incident, the AV was approximately four years old and enrolled in one of the preschool classrooms. The facility used ProCare [a mobile application (app) platform used to communicate with families and streamline administrative functions]. The facility’s Safety and Supervision policy stated that, “all children must be within sight and sound at all times.” Additionally, staff persons were to “always know the exact number of children [they were] responsible for,” including the child’s name, and where they were at all times. Children were to “always be supervised on the playground.” The facility’s Risk Reduction Plan stated that, “When transition [sic] from one area to another, children will form a line using a walking rope. Staff will call the children by name to hold on to the walking rope. Staff will use face to name every time the rope is used. One staff will be at the front of the line and one staff will be at the back of the line. Staff will count the number of children transitioning to ensure all children are present.” The facility’s Incident Review stated that on September 14, 2023, at approximately 5:21 p.m., the AV was left on the preschool playground without the SP’s supervision or knowledge for 13 minutes. The AV said that on the day of the incident, the AV was “playing and hiding from [his/her] teacher and friends.” P1 and P2 provided the following information: · P2 stated on September 14, 2023, P2 and the SP were working in the AV’s classroom. At 4:30 p.m., the SP took ten children, including the AV, to the playground while P2 stayed in the classroom with the other children. The SP had a list of the ten children s/he was responsible for while on the playground and was used to keep track of the children while outside. As children left for the day, the SP was to cross off the name of the child that had left. While they were outside, four children had been picked up by their families. · At approximately 5:15 p.m., the SP returned to the classroom with five children, not including the AV. P2 then checked ProCare to match the children who had returned to the classroom. P2 saw that in ProCare, the AV was marked as still in attendance so P2 asked the SP about the AV and the SP told P2 that the AV left for the day. At 5:29 p.m., P2 checked the AV out of ProCare. Additionally, P2 noticed that other children who went home with their families while on the playground, were not crossed off the list, and did not return to the classroom so P2 also checked those children out of ProCare. At that time, P2 and the SP had ten children, not including the AV, and P2 told the SP that s/he could go home. · P1 stated that at approximately 5:30 p.m., a parent was at the parent kiosk and saw the AV on the playground through the exterior playground door. The parent came to the office and notified P1. P1 immediately went outside and found the AV near the two-level play structure, and realized the AV was alone. P1 stated that the AV was “teary eyed but not crying” and had no injuries. · At 5:37 p.m., P1 came into the classroom with the AV. At that time, P1 and P2 did not discuss the incident because it was parent pick up time. P2 stated that the AV did not appear to be upset and was not crying. According to P2, the AV enjoyed going outside but did not like to come back inside. Often, P2 had to coax the AV to line up and the SP had seen P2 do so on prior occasions. · P1 watched the facility’s video footage which showed that the AV was left unsupervised on the playground for 13 minutes. P1 notified the FM at pick up and stated that the FM was” surprised “but “understanding.” P1 reassured the FM that the AV had no injuries. · P2 worked with the SP since May 2023 and trained the SP on safety and supervision routines. P2 had seen the SP complete safety and supervision routines as children went to the playground. This included that P2 had trained and observed the SP monitor the children on the playground, had seen the SP inspect the playground for children prior to going inside, and crossed children off the attendance list if they had left with family members for the day. · P1 and P2 stated that they believed the AV was safe while unsupervised because of the high fence around the playground. The AV was too small to climb over the fence or to reach the gate latch. P1 stated that the weather was cloudy and warm. · Prior to this incident, P1 and P2 had no concerns about the SP, including the SP’s supervision of children. Information from www.weatherunderground.com showed that it was 83 degrees Fahrenheit and partly cloudy on the date of the incident There were two videos of the playground provided from the incident one was 9 minutes and 57 seconds and the other was 13 minutes and 25 seconds. The view of the door was not within sight of the camera. The videos showed the following: · At 5:20 p.m., the SP was on the playground with seven children, including the AV. · At 5:20:05 p.m., the SP picked up a backpack and a walking rope (used to line children up) and then walked toward the door. The AV was on the play structure bridge between the upper and lower sections. · At 5:20:20 p.m., the SP walked towards the door and the children started to line up. However, the video did not show if the SP used the walking rope as the door was not within view of the camera. · At 5:20:43 p.m., the AV and one child were on the play structure. The AV was seen looking out from behind a column and hiding. Five other children were lined up by the door. · At 5:21:05 p.m., the sixth child (who was on the play structure with the AV) lined up. The AV was still on the play structure but not in view of the camera. At this point video footage showed that the AV had not left climber. · At 5:21:12 p.m., the door opened (a glare from the door can be seen in the video.) Prior to this, the SP did not walk around the playground to check for any extra children. · At 5:21:25 p.m., the door shut (a glare from the door can be seen in the video). The AV was still in the upper part of the play structure but out of sight of the SP and video footage showed that the AV had not left the upper part of the play structure. · From 5:21:32 p.m. – 5:25:53 p.m., the AV was seen looking out from the play structure, playing, and what appeared to be yelling for help. · From 5:25:53 p.m. — 5:34:13 p.m., the AV came off the play structure and was seen looking through the infant classroom windows, checking the playground door, looking up at the second story windows, and crying. · At 5:34:13 p.m., P1 was seen walking outside and towards the AV. P1 then brought the AV inside and back to the preschool classroom. · The AV was unsupervised for approximately 13 minutes. Facility records showed that P1, P2, and the SP were trained on the facility’s Safety and Supervision policy, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. 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: On September 14, 2023, the AV was unsupervised on the playground for approximately 13 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18. Information showed that at approximately 5:15 p.m., the SP returned from the playground and when P2 asked the SP about the whereabouts of the AV, the SP told P2 that the AV had been picked up. However, at approximately 5:30 p.m. another parent saw the AV on the playground and notified P1, who went outside to the AV, and then returned the AV to the classroom. At that time, the SP had left for the day and had not realized s/he left the AV on the playground. The conduct of leaving the AV, who was three years old outside for 13 minutes without staff person’s knowledge or supervision exposed the AV to community dangers including unknown persons, community hazards, and did not allow for staff person’s intervention 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 his/her 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; 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 trained on the facility’s Risk Reduction Plan, the facility’s Supervision Policies and procedures, and the Reporting of Maltreatment of Minors Act prior to the incident. The SP was responsible for the care and supervision of the children on the playground including the AV. When the SP returned inside, s/he told P2 that the AV had been picked up while they were on the playground, when in fact the AV was left on the playground by the SP. The SP then left the facility at the end of his/her shift. The SP was 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 the SP was responsible did not meet statutory criteria to be determined as recurring or serious because this 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. The SP no longer worked at the facility. 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 disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. On January 26, 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.
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