|
AMENDED 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.” NOTICE: This Amended Maltreatment Investigation Memorandum supersedes a version dated January 12, 2024, which must be destroyed. The original version contained an inaccurate statement in the Action Taken by Facility section of this report. The amended version contains the correct information.
License Number and Program Type: 801508-CCC (Child Care Center) Investigator(s): Lindsay Arth/Alice Percy Minnesota Department of Human Services Lindsay.Arth@state.mn.us 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised in a classroom for approximately seven minutes. Two staff persons (SP1 and SP2) were unaware that the AV was left in the classroom. Date of Incident(s): July 5, 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 3, 2023; from documentation at the facility; and through four interviews conducted with a facility administrative staff person (P), SP1, SP2, and the AV’s family member (FM). The AV was five years old and enrolled in the preschool classroom at the time of the incident. The facility was located in one section of a church building. The preschool classroom was located within the facility’s area of the building and was a large room with tables and chairs placed along one side of the classroom. On the other side of the classroom was a “group” area that included a large rug. Next to the rug, two large pillows were placed in a “quiet” corner of the classroom and the two pillows were separated by a small bookcase. A set of double doors led from the classroom to a hallway that went past the classroom door in both directions. Additional classroom doors also opened onto the hallway. A second hallway ran from the classroom door to a door at the end of that hallway that led outside to the playground. The outside door was equipped with a push bar that was used to open the door. Along the hallway between the classroom door and the outside door was another door which provided access to the children’s bathroom. The bathroom door was approximately 22 feet from the classroom door. The FM stated that the AV told the FM that s/he fell asleep in the classroom and when s/he woke, s/he realized s/he was alone, and said, “Hey, wait for me.” One of the staff persons then saw the AV and took the AV outside to the playground where the other children were playing. The AV told the FM that s/he was not unsupervised “very long.” The AV did not sustain any injury while s/he was unsupervised. The AV was “very chill” about the incident. The P, SP1, and SP2, and the facility’s documentation provided the following information: · On July 5, 2023, SP1 and SP2 worked in the preschool classroom with 11 children. That morning, SP1 served the children breakfast while SP2 supervised the children in the group area as the children finished eating. SP1 said that the AV was one of the first children to finish eating and joined the group supervised by SP2 (Note: SP2 said that the AV was in the “quiet” corner near SP1). · SP1 stated that at approximately 9 a.m., when most of the children were finished eating, the children were “getting a bit restless,” so s/he suggested that SP2 take the children who had finished eating to the playground while SP1 remained with the children who were still eating (Note: SP2 said that it was SP2 who suggested taking the children outside but that SP1 “was okay with that.”) Additionally, around this time, some of the children said they needed to use the bathroom so SP1 also told SP2 that s/he would take those children to the bathroom once everyone finished eating, prior to joining SP2 and the other children outside. · SP2 said that s/he got the children ready to go outside but was in a “hurry to get outside” because the children were “restless.” · SP1 stated that SP2 began to take a group of seven or eight children out of the classroom, but then stopped at the door to the bathroom and “pulled children as they finished snack” out of the classroom and to the bathroom. SP1 stated that it “became very chaotic” and s/he did not know which children were with SP2 and which children remained with SP1. SP1 believed that SP2 took all of the children outside except for the last child to finish eating. SP1 “did not think to look” for the AV because s/he believed s/he left the classroom with SP2 and the other children. SP2 said that there was a “lack of communication” in general between him/her and SP1 but “thought” that s/he had “almost all” the children with him/her except for the AV, who was in the classroom with SP1. Prior to leaving the room with the children, SP2 “saw” the AV with SP1 in the quiet corner so “thought [SP1] would be okay bringing [the AV] outside.” · SP1 stated that once the last child finished eating and “a couple minutes after [SP2] finished with the kiddos in the bathroom,” SP1 cleaned the table and took the remaining child outside to the playground. Neither of the staff persons counted the children when they arrived at the playground. However, both said they were trained to count children, including during “each transition.” · At 9:07 a.m., SP2 returned to the classroom “to grab something” and found the AV standing by the door to the classroom. The AV was not crying, but looked “confused.” SP2 believed that SP1 left the classroom at 9 a.m. SP2 took the AV to the playground and told SP1 that the AV was left unsupervised in the classroom. SP1 believed the AV was unsupervised in the classroom for approximately 10 minutes. SP2 stated that s/he believed SP1 was aware the AV remained in the classroom when SP2 left with the other children, but SP1 stated that s/he believed the AV left the classroom with SP2. SP2 believed SP1 sent the AV to the quiet area, but SP1 stated that s/he believed the AV joined the other children on the rug and SP1 did not know s/he went to the quiet area. · Later that day, the AV told SP1 that s/he fell asleep in the quiet corner of the classroom. SP1 stated that the AV was “very nonchalant” when s/he told SP1 about falling asleep. After the incident, SP1 moved the quiet area with the two large pillows to a more central area of the classroom so that it was easier to see if a child was lying on one of the pillows. · The P was not at the facility at the time of the incident, but was told about the incident later. The P contacted the FM and told him/her about the incident. · Consistent information was provided that SP1 and SP2 had interpersonal conflicts that interfered with their communicating clearly with each other. According to the facility’s Supervision Policy and Procedure, the staff persons were required to be within sight and hearing of the children at all times. The staff persons were trained to count the children before and after each transition from one area to another. Each time the staff persons took the children to the playground, they were to count the children as they entered the playground and ensure that the number of children entering the playground area matched the number of children on the white board attendance sheet that was maintained for each classroom. Facility documentation showed that SP1, SP2, and the P each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including regarding the supervision of children, prior to the incident. 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 July 5, 2023, SP1 and SP2 worked in the preschool classroom with 11 children. Shortly before 9 a.m., SP2 took a group of children to the bathroom and then to the playground, while SP1 waited in the classroom with what s/he believed to be one child who was stilling eating breakfast. Neither SP1 nor SP2 were aware that the AV went to the “quiet” area and had fallen asleep on one of the pillows. After the other child finished eating, SP1 cleaned the table and took the child outside to join the other children on the playground. Neither SP1 nor SP2 were aware that the AV was not part of the group on the playground. At 9:07 a.m., SP2 returned to the classroom to get something and saw the AV standing by the classroom door “looking confused.” Leaving the AV unsupervised in the classroom for approximately seven minutes was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart1, item A. SP1 believed the AV was unsupervised for approximately ten minutes and SP2 believed the AV was unsupervised for seven minutes. The AV did not sustain any injury while s/he was unsupervised. Although the AV was not injured, given that SP1 and SP2 each failed to ensure that all of the children were on the playground once the group had completed its transition, and that the AV being left inside the classroom for approximately seven minutes alone without any staff persons knowledge, did not allow for staff persons intervention in the event of any emergency placing the AV at risk, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care required for his/her physical or mental health and a failure to protect the AV from conditions that seriously endangered his/her physical or mental health. 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. SP1 and SP2 were each responsible for the supervision of the AV at the time of the incident and were trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including regarding the supervision of children. SP1 and SP2 were 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 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious. It was a single incident and the AV sustained no injuries. 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 the facility’s policies were adequate but were not followed by SP1 and SP2. After the incident, all of the staff persons were re-trained on the facility’s policies. SP2 no longer worked at the facility. 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 12, 2024, the facility was issued a Correction Order for the violation outlined in this report and for failing to report maltreatment as required.
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.
|
