|
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: 1089589-CCCC (Certified Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: Allegation One: It was reported that an alleged victim (AV) was outside the facility unsupervised for almost two hours. Allegation Two: It was reported that a child was left outside the facility unsupervised. Date of Incident(s): July 14, 2023, and prior 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 1, 2023; from documentation at the facility; and through four interviews conducted with two facility staff persons (P1 and P2), the AV’s family member (FM), and the AV. The facility was located in a large school building. Through the front door was a small entrance area. To the left of the entrance area were four classrooms that the facility utilized. At the end of the hallway was another hallway that ran perpendicular. To the left on this hallway were lockers that the children used. Past the lockers were two bathrooms. Past the bathrooms was the door that led to the outside area. To the left of the door was a large, fenced playground area with equipment. The Policy and Procedure Manual indicated that staff persons supervised children at all times. Staff persons were responsible for the ongoing activity of each child, appropriate visual or auditory awareness, physical proximity, and knowledge of activity requirements of each child’s needs. The Risk Reduction Plan stated that children could get lost or leave without permission. Staff persons used walkie communication when the children were transitioning between spaces. Staff persons were to be aware of who was using the bathroom and how long they were gone. Facility documentation showed that all staff persons were trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. Allegation One: It was reported that the AV was outside the facility unsupervised for almost two hours. The AV was four years old at the time of the incident and enrolled in the facility’s summer program. The AV turned five during the month of the incident and was entering kindergarten in the fall, so s/he was able to be enrolled in the program as a school age student. The AV said s/he went outside to see if anyone was outside and s/he got locked out. The AV did not “feel good” and said, “Help.” A staff person (determined to be P1) found the AV outside. The AV said s/he was outside for 20 minutes. DHS received information that on July 14, 2023, a community person (CP) saw a child that was approximately four years old standing by him/herself by the side facility door. The CP attempted to call the facility with no answer so called 9-1-1. The CP sat with the AV for almost two hours before a staff person came out another door. The staff person was leaving for the day. The staff person began yelling at the AV. P1 provided the following information: · Through the front entrance was a lobby area with a magnetic board. Each child was given a magnet with his/her name on it. When each child arrived, they grabbed his/her magnet and choose an activity area. The child then went to the activity area and put his/her magnet on the board in that area. The staff person at the front desk used a walkie talkie to communicate with the staff person in the chosen area to let them know the child was coming. When the child got to the area, the staff person alerted the front desk. · During transitions the children grabbed their magnets and lined up. When they arrived in the new area or classroom, they put their magnets on the board in that classroom. Staff persons counted periodically to make sure they had the corresponding number of children as magnets on the board. If a child wanted to go to a different area. They took their magnet and the staff persons communicated via walkie talkie with the other staff person until the child arrived at his/her new area. · The facility used four classrooms, the gym, the lunchroom, bathrooms, and the outside playground. There was a bathroom in one of the classrooms which children were encouraged to use if possible. When there were larger transitions or more children needed to use the bathroom, the children used the large bathrooms down the hall. Children were allowed to use the restrooms without a staff person, but staff persons would walkie to P1 or P2 if a child had not returned after a short period of time. · On the day of the incident, the facility had taken all the children on a field trip. At approximately 3:30 p.m., after returning from the field trip, the group of children and staff persons split into two. One group went to the lunchroom for a snack and the other group went to the bathrooms to change their clothing. The AV was in the group that went to the bathrooms to change clothing. After the children changed clothing, they were to return to one of the classrooms of their choice for the next activity. · One staff person (P1 did not recall who and was not able to find information on which staff person this was) remained by the bathroom and waited outside of the bathroom for the children to change. At some point, the staff person was needed in a classroom and the AV was the last child in the bathroom changing so the staff person told P1 via walkie talkie that the AV had not yet finished changing. P1 and the staff person thought the AV was able to finish changing and make his/her way to the classroom when done.
· After five to ten minutes, P1 walkied to the classrooms to see if the AV had returned to a classroom and no one had the AV with them. · P1 checked the bathrooms and when s/he did not find the AV, checked all the other classrooms and areas that the facility used. P1 then checked upstairs and other areas of the building that the facility did not use. At approximately 4 p.m., the AV was still not found so P1 checked outside and saw the AV at the outside door with the CP. The AV appeared calm and was apologetic. · The AV had been in a classroom setting before but was not used to the facility’s programming that allowed children to make choices. In the past the AV had left to use the bathroom without informing staff persons. P1 thought it was possible that the AV thought the outside playground was open as an option for activity, or that s/he got lost or turned around, as s/he was newer to the building. The FM also said the AV was “sneaky” and “wanders.” P2 stated that s/he worked the day of the incident and that when they returned to the facility, some of the children went to the bathroom to change. Staff persons do not go into the bathroom with the children but spread out in the hallway to assist as needed. P1, P2, and some other staff persons went to classrooms to wait for children to arrive for the next activity. The FM said the AV reported that s/he ran out of the facility. The FM reminded the facility that the AV needed close supervision as s/he was still in “Pre-K.” The AV had a habit of “being sneaky” and running away. Law enforcement information showed that on July 14, 2023, a call was received at 3:13 p.m., that a child had been locked out of the facility. The caller said the same type of incident occurred two days ago. The caller called the facility but did not receive an answer. In a follow-up call at 4:05 p.m., the caller said a staff person came out to get the AV, but similar incidents had happened on three different occasions. According to www.wunderground.com, the outdoor condition at the facility, on July 14, 2023, at the time of the incident, was “mostly cloudy” with a temperature of 87 degrees Fahrenheit (°F) and wind speed of 9 miles per hour (mph). Relevant Rules and/or Statutes: Minnesota Statutes, section 245H.13, subdivision 10 states that staff must supervise each child at all times. Staff are responsible for the ongoing activity of each child, appropriate visual or auditory awareness, physical proximity, and knowledge of activity requirements and each child's needs. Staff must intervene when necessary to ensure a child's safety. In determining the appropriate level of supervision of a child, staff must consider: (1) the age of a child; (2) individual differences and abilities; (3) indoor and outdoor layout of the child care program; and (4) environmental circumstances, hazards, and risks. Minnesota Statutes, section 245H.08, subdivision 4, paragraph states, kindergarten includes a child of sufficient age to have attended the first day of kindergarten or who is eligible to enter kindergarten within the next four months. Conclusion for Allegation One: A. Maltreatment: Information was consistent that on July 14, 2023, the AV went outside and was locked outside of the facility. Law enforcement records showed that the CP saw the AV outside and called 9-1-1 at 3:13 p.m. In a follow-up call, at 4:05 p.m., the CP reported that P1 had found the AV and taken him/her inside. Although P1 thought the children returned to the facility at 3:30 p.m. and that the AV was only without staff person supervision for 10-15 minutes, given the 9-1-1 call happened at 3:13 p.m., it was likely the AV was outside for approximately 45 minutes without the knowledge or supervision of a staff person, which was a violation of Minnesota Statutes, section 245H.13, subdivision 10. Although the AV, who was four years old at the time of the incident, was considered a school age child at the facility, given that s/he left the facility and was in the community, in a location that could expose the AV to community dangers, and that staff persons were not with the AV to intervene in the event of an injury or emergency, 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. Facility documentation showed that staff persons at the facility received training on the Reporting of Maltreatment of Minors Act and on the Risk Reduction Plan prior to the incident. Facility practice was for children to walk to and from different areas of the building independently and staff persons used walkie talkies to communicate children coming and going. Staff persons were not assigned to supervise specific children and did not typically go into bathrooms with the children. The day of the incident, after a field trip, several children including the AV went to the bathroom to change. P1 and P2 went to classrooms and other staff persons remained in the hallway and near the bathrooms. After changing, children were supposed to go to one of the classrooms of their choice. The staff person who remained near the bathrooms needed to go to a classroom to assist so told P1 that the AV was still changing. They both thought the AV was able to finish changing and then go to the classroom of his/her choice after. Given the design and location of the classrooms and bathrooms, the transition from the field trip, the facility practices, and the number of children at the time of the incident, staff persons’ ability to supervise any specific individual child likely was hindered. According to facility practice, P1 and other staff persons were not required to remain with the AV in the bathroom and were not required to remain with the AV when s/he went to a classroom of choice after. Therefore, P1’s and other staff persons’ responsibility was mitigated, and the facility was responsible for maltreatment of the AV. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious because the AV was not injured. The facility is exempt from licensure under Minnesota Statutes, section 245A.03, subdivision 2, clause (12), but is certified under Chapter 245H. Therefore, Minnesota Statutes, Chapter 245A, including the authority to issue a sanction or fine under section 245A.07 does not apply. Minnesota Statutes, section 245H.07, subdivision 1, paragraph (b), states that when considering decertification, the commissioner shall consider the nature, chronicity, or severity of the violation of law or rule. The facility did not have any previous maltreatment determinations or certification violations related to supervision and otherwise has not demonstrated chronic noncompliance with certification standards. There was no information provided that the AV sustained any injury. Therefore, the commissioner did not decertify the facility but issued a maltreatment determination with certification violation citations. Allegation Two: It was reported that a child was left outside the facility unsupervised. DHS received information that two weeks prior to July 17, 2023, the CP saw a child that was approximately two years old standing outside the side door of the facility. The child became “hysterical” and cried trying to get inside. The CP comforted the child when a staff person opened the door and let the child back into the building. The facility enrolled only children that were going into kindergarten through going into fourth grade at the program. P2 said that on one occasion, a family member came to pick up a child. P2 was the greeter and called for the child on P2’s walkie. After five or ten minutes, P2 asked the family member if the child had come to the front entrance yet. The family member said that the child did but then the FM told the child to go back to grab his/her water bottle that s/he left outside. P2 went outside and found the child outside the playground door. P2 explained to the child that s/he should not go outside without a parent or staff person as the doors locked. The child and P2 went back to the front of the building and the child left with his/her family member. P2 did not remember the child’s name but knew that s/he was younger most likely going into first grade. The child was outside for no more than five minutes. P1 and P2 did not have any information about any other child being outside unsupervised. P1 spoke with all other staff persons, and no one remembered any incident where a child was outside unsupervised. Conclusion for Allegation Two: Although DHS received information that sometime in late June 2023, or early July 2023, a child who was approximately two years old was outside on the playground unsupervised, given that the program did not serve children in that age range, and that staff persons did not remember any incident in which a child was unsupervised except an instance where a child went to retrieve a water bottle after his/her family member arrived and was responsible for the child’s supervision at that time, and that without any further information, there was not a preponderance of the evidence that there was a failure to supply care or supervision required for a child’s physical health when reasonably able to do so. It was not 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.) 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 continued to work with the AV about not wandering off and making sure the AV let staff persons know where s/he was going. Action Taken by Department of Human Services, Office of Inspector General: On February 2, 2024, the facility was issued a Maltreatment Determination with certification violations. The maltreatment determination and certification violations are subject to appeal. 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.
|
