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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: 810015-CCC (Child Care Center) Investigator(s): Danielle Morrison/Shad Cook 651-431-5647651-431-6587 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised on the toddler playground for approximately 34 minutes. Date of Incident(s): August 31, 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 13, 2023; from documentation at the facility; and through four interviews conducted with a facility supervisory staff person (P), two staff persons (SP1 and SP2), and the AV’s family member (FM). This investigator met the AV and attempted to interview the AV but due to his/her age, the AV was unable to provide information regarding this incident. The AV was three years old and enrolled in the preschool classroom at the time of the incident. The facility was located on the corner of a strip mall complex with several other places of business. The facility had a playground area on the outside end of their building space which was visible to passerby on Highway 65 and a service road. The playground space was split into separate toddler and preschool playgrounds. The entire playground structure was surrounded by a five-foot metal fence that included three gates. One gate was at each end of the toddler and preschool playgrounds near the parking lot and the third was an interior fence with a gate that divided the two playgrounds into separate play areas. The gates at the end of the playgrounds were locked from the outside. To access the toddler playground, the staff persons and children went out a facility door that led directly to the preschool playground and then walked approximately 20 to 30 feet and entered the toddler playground via the internal gate. The toddler playground consisted of playground equipment, open space for the children to play, and a large-sized tree that provided shade for the playground area. The preschool playground had playground equipment, open areas for creative play, and a short basketball hoop. The facility had video of the playgrounds that was in the upper corner of the building on the preschool side. The toddler playground was furthest from the camera. A tree obstructed the view of a portion of the toddler playground equipment. The Safety and Supervision Policy stated that all children must be within sight and sound at all times. When there was more than one staff person in an area (i.e., a classroom or playground), staff persons were to spread out to better supervise the entire area and place themselves in an area where they could see the entire group. Additionally, staff persons were to supervise the children at all times, including while on the playground. Staff persons were to rotate throughout the classroom and/or playground to be constantly aware of the activities of the children. Staff persons were “never” to leave children unsupervised. The Risk Reduction Plan stated that when transitioning from one area to another, children were to form a line using a walking rope. Staff persons were to call the children by name to hold on to the walking rope. Staff persons were to use “face to name” every time the walking rope was used. One staff person was to be at the front of the line and one staff person was at the back of the line. If only one staff person was present, they were to be at the front of the line facing the children. Staff persons were to count the number of children transitioning to ensure all children were present. On August 31, 2023, at 5 p.m., the Attendance Summary by Classroom showed that there were 15 children, including the AV, in the preschool A and preschool B classrooms (which were combined at the time of the incident) with SP1 and SP2. Between 5 and 5:37 p.m., eight children were checked out of the facility with their parents. The P and the Internal Review Form completed by the P provided the following information: · On August 31, 2023, shortly before 5 p.m., the P was setting up for a family event that was to happen later, on the preschool playground, including setting up a bounce house. SP1 and SP2 were with approximately 15 preschoolers, including the AV, and around this time, they brought the group to the toddler playground to play so the bounce house could be set up on the preschool playground. · At 4:59 p.m., the P asked SP2 to get water for the children and then the P moved to the toddler playground with SP1. When SP2 returned with water for the children, s/he asked the P for a break for personal reasons, which “was not a set break, and caught [the P] off guard.” The P said that to accommodate for SP2’s break, the P, SP1, and SP2 would transition the children from the toddler playground to the preschool playground so that the P could assist SP1 with maintaining the ratio and supervision of the children. · The P and two children then went through the gate to the preschool playground and walked to the entrance of the bounce house where s/he assisted them with taking off their shoes. SP1 and SP2 completed the transition of the remaining children from the toddler to preschool playground and SP1 shut the gate behind him/her. Once the children transitioned to the preschool playground, SP2 went on break for ten minutes and then returned to the preschool playground. At some point after SP2 returned, parents began to arrive for the event and two to three additional staff persons came outside to the preschool playground for the event. · At some point, (35 minutes later via video footage), a staff person told the P that s/he thought s/he heard what sounded like a child crying on the toddler playground. The P went to the playground and found the AV crying with his/her knee “stuck” in an opening on the playground equipment (Note: Information was consistent that the area where the AV’s leg/foot/knee was stuck was on the side of a platform, that accessed a slide, which children could use to look through). The opening the AV’s knee/foot/leg was stuck was a long vertical opening that had wider openings at each end and narrowed in the middle. The openings were approximately two to three feet in length. The P was unable to lift the AV and pull/push his/her knee/foot/leg back through the opening it was “stuck” in, so the P asked another staff person for help. The staff person lifted the AV while the P helped move the AV’s leg through the wider opening of the piece of playground equipment until it came out. The P checked the AV for injuries, but the AV did not have any visible injuries. The AV and the P then returned to the preschool playground. · Immediately after the event ended, the P reviewed video footage. The P said that after the AV was moved to the preschool playground, s/he asked SP1 if a sweep of the toddler playground was completed and SP1 said, “Yes.” However, the video footage showed that SP1 did not walk around the toddler playground to conduct a physical sweep before s/he moved to the preschool playground. The facility used an application on a tablet (Pro Care) and a paper document to conduct name to face counts. However, SP1, SP2, and the P did not use the walking rope or do name to face when transitioning. They performed a head count but after the incident realized that they were “not accurate” with the count. · Following the incident, the P spoke to SP1. SP1 believed the AV initially went to the preschool playground but then went back to the toddler playground by opening the gate from the preschool playground to the toddler playground on his/her own. However, video footage did not show that the AV walked back through the gate to the toddler playground.
· When transitioning from one play area to another, staff persons were trained to line the children up at the gate, call them by name, and complete the name to face count. Then, staff persons were to do a “sweep” of the area to check for any “lingering” children and then if all were present, the children would pass through the gate to the other playground or return inside the building. A name to face count and a “sweep” were not done by SP1 at the time of the incident. According to the P, “part of that was [his/her] fault,” as s/he “rushed” SP1 and SP2 to get to the preschool side. The P opened the gate and let the children start going through. As two of the children started to walk through it, the P followed them to the bounce house. SP1 was the last one left on the toddler playground. Video footage of the incident provided the following information: · At 4:59:02 p.m., the P entered the toddler playground and then SP2 left the playground. · Between 4:59:18 and 5:00:28 p.m., the P walked around the internal fence-line of the toddler playground and supervised the children who played on the playground equipment. · At 5:03:03 p.m., SP2 returned with water, but stayed on the preschool side. SP2 appeared to talk with the P at the gate. The P then left the toddler playground through the gate to the preschool playground and had two children come with him/her. (Note: The AV was not one of the two children with the P.) The P touched the top of the heads of the two children. SP1 remained on the toddler playground with the other children, including the AV. SP2 remained on the preschool playground. · At 5:03:19 p.m., the P walked with the two children off camera. · At 5:03:21 p.m., SP1 and SP2 transitioned 13 children from the toddler playground to the preschool playground. (Note: The AV was not in view of the camera at this point. The classroom attendance record showed that at 5:01 p.m., a child was picked up by his/her family member, leaving 14 children, including the AV, with SP1 and SP2.) · At 5:03:52 p.m., the 13th child entered the preschool playground from the toddler playground followed by SP1 who shut the gate from the toddler playground. SP1 and SP2 then walked further into the preschool playground off camera. (Note: At this point no other children were in view of the camera on the toddler playground.) · At 5:37:19 p.m., the P entered the toddler playground and walked around the playground equipment in a clockwise direction. At 5:37:41 p.m., the P walked up the slide onto the playground equipment. (Note: The P was partially visible in shadow through a round opaque plastic covering on the equipment and at this point likely found the AV.) The P moved up and down and at times his/her head was visible. (Note: At this time, it was likely that s/he was assisting the AV who was stuck in the equipment.) · At 5:39:15 p.m., another staff person entered the toddler playground and stepped up the slide onto the playground equipment and eventually took over for the P who got off the equipment and moved in view of the camera by the toddler equipment. (Note: At this time, the P and the staff person were likely freeing the AV from the equipment.) · At 5:40:30 p.m., they free the AV and then are out of view of the camera until 5:41:41 p.m., when the P and the other staff person, who was carrying the AV in his/her arms, walked away from the playground equipment towards the preschool playground. · At 5:41:49 p.m., the P walked off camera around the bounce house and at 5:42:05 p.m., P3 with the AV in his/her arms, walked off camera. SP1 provided the following information: · On August 31, 2023, the facility was in the process of getting ready for their end of summer celebration. That afternoon, SP1 worked with SP2 in the preschool class with approximately 15 children. At some point, when they were outside on the preschool playground, the P installed a bounce house, so SP1 and SP2 took the children to the toddler playground. · At the time, the weather was “really warm and sunny” and many of the children commented that they were hot and wanted water. The P then entered the toddler playground to supervise with SP1 while SP2 went inside to get water for the children. · After approximately 4 minutes, SP2 returned to the playground with water and the P said, “Let’s just bring them over,” (to the preschool playground) and the P opened the gate to the preschool playground. Then, the P walked through the gate to the preschool playground with two children. During this time, SP2 remained on the preschool side near the gate while SP1 was on the toddler playground near the gate. SP1 did not know if the AV was part of the group of children who moved to the preschool playground because “some kids were leaving [the facility and getting picked up by their parents] and some were coming in [for the event that was occurring on the preschool playground.” Additionally, SP1 did not have the checklist outside with him/her for the preschool class which was used for name to face counts and attendance. SP1 did not remember if s/he counted the children as they transitioned from the toddler playground to the preschool playground. SP1 said s/he did not see any children or movement on the toddler playground prior to his/her move to the preschool playground and shutting the gate behind him/her. · At some point during the event, the P notified SP1 that s/he found the AV unsupervised. SP1 did not know how long the AV was unsupervised on the toddler playground. · At the time of the incident, SP1 did not fully check the playground by conducting a sweep but “should have done that.” SP1 stated that s/he was trained on the facility’s supervision and transitions policies, which included the use of the walking rope and a walk around the playground to make sure no children were left behind. SP2 provided the following information: · On the date of the incident, SP2 worked with SP1 in the preschool classroom but did not remember how many children were present. At some point, SP1 and SP2 took the children outside to play. They normally used the preschool playground but, on that date, the preschool playground was unavailable because the P was setting up a bounce house for a family event that was later that evening. · SP2 and SP1 supervised the preschool class on the toddler playground and at some point, once the P was done setting up the bounce house, the P said to move the children to the preschool playground. The P opened the gate and the children walked to the preschool playground. SP2 did not remember which staff person was the last to leave the toddler playground. SP2 said a name to face was not done for the transition to the preschool playground. SP2 then asked the P if s/he could take a break for personal reasons and SP2 took a break for approximately ten minutes and then returned to the playground. · At an unknown time later, the P told SP2 that s/he found the AV unsupervised on the toddler playground. · According to SP2, the transition procedure for the playground was that the children were to be lined up on the playground, staff persons called out their name, checked a mark next to the child’s name on a checklist, and brought them inside. The children were counted when the class passed through doors. SP2 said this was not done when the children transitioned from the toddler playground to the preschool playground. · SP2 stated that SP1, the P, and him/her were responsible for supervising the children at the time of the incident. The FM stated that on September 7, 2023, the P notified him/her via voicemail of the incident. The FM said that the AV seemed fine and did not have any injuries. The AV told the FM that “[a staff person] saw me on the playground.” The FM had no concerns with the facility and said that “they normally do a good job.” Facility documentation showed that SP1, SP2, and the P were trained on the Safety and Supervision Policies, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act, 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 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; and that children are required to be supervised at all times.
Conclusion: A. Maltreatment: Information from all sources was consistent that on August 31, 2023, the AV was left unsupervised on the toddler playground for 34 minutes without the knowledge or supervision of a staff person, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. A staff person heard crying and notified the P who went to the toddler playground and found the AV with his/her foot/leg/knee “stuck” in the playground equipment. The P and another staff person together removed the AV from the equipment. The AV was not injured and the three returned to the preschool playground. Although the P, SP1, and SP2 were on the other side of the fence on the preschool playground, none noticed that the AV was missing and/or that the AV was stuck in playground equipment and unable to free him/herself. Given this, and that the AV was three years-old and left unsupervised for 34 minutes without staff knowing, which exposed the AV to dangers and the inability of staff persons to intervene, there was a preponderance of evidence that there was a failure to provide the AV with necessary care and a failure to protect the AV from conditions and/or actions that seriously endangered the physical and/or mental health of the AV 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. Facility documentation showed that SP1, SP2, and the P received training on the Reporting of Maltreatment of Minors Act and on facility policies and procedures, including supervision, prior to the incident. While on the playground, SP1 and SP2 were responsible for the care and supervision of the children including the AV. However, prior to the incident, the P came onto the toddler playground to assist in supervising while SP2 went inside to get water for the children. Upon SP2’s return to the playground, the P, SP1, and SP2 all transitioned the children to the preschool playground, leaving the AV was unsupervised on the toddler playground. SP1, SP2, and the P were each 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 SP1, SP2, and the P were each 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 reasonably 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. This included regarding staff following the name to face counts or using the walking rope during transitions. Following the incident, all staff persons were re-trained on the safety and supervision policies. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and the P were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1, SP2, and the P 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 the P were each 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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