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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: 1007914-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised for 16 minutes in a classroom. Date of Incident(s): December 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 December 28, 2023; from documentation at the facility; and through four interviews conducted with three facility staff persons (SP1, SP2, P), and the AV’s family member (FM). The AV was 33 months old and enrolled in the Early Preschool classroom. The facility was located on the bottom floor of a high rise building. There was a large open great room past the entrance of the facility with classrooms surrounding the great room. The Early Preschool classroom was on the left side of the great room. The classroom had lockers directly through the entrance and opened up to a larger room with multiple tables and play areas. The P provided the following information: · On the date of the incident, the P and another staff person were working in the great room. The P learned that a parent came to pick up a child out of the Early Preschool classroom propping the door open while the class was lined up and ready to go outside. The parent requested a snack be sent with his/her child so SP2 went to grab the snack. The child had the same pink jacket as the AV. The AV likely went behind the door at some point while SP1 and SP2 were interacting with the parent. · The parent left and SP1 and SP2 continued out the door with the classroom and went outside to the playground. After approximately 15 minutes, another parent came to pick up his/her child and went to the classroom to get their things. The parent told the P that the AV was inside the classroom. The AV was smiling and did not seem distressed, and the P brought the AV outside to the playground to play. · The P had been standing within five feet of the classroom and did not hear any noise from the AV while s/he was alone in the classroom. The AV would have been physically able to open the door, but the children were taught that doors were a “teacher touch.” · The P viewed the video footage and felt that s/he could see that SP1 and SP2 had counted the children while lining them up on a walking rope. Staff persons used a tablet or a white board in the classroom to count the children before they left the classroom and after they got to the playground. The P had no prior concerns with SP1 or SP2. SP1 and SP2 provided the following information: · SP1 and SP2 worked in the classroom and were getting the children ready to go outside. The children put their coats on and then grabbed onto a walking rope. SP1 and SP2 counted the children. · As the classroom was leaving, a parent arrived to pick up his/her child. There was also another child misbehaving. SP2 was at the end of the line and went into the classroom to grab a snack for the child that was leaving. The child that was leaving and the AV had the same coat. The classroom headed out the door through the great room to the playground. · After approximately 5-15 minutes, P1 came out and said that the AV was left in the classroom. SP1 said s/he completed a count of the children before they left the classroom but did not do a count once they were outside in the playground. SP2 was not sure if s/he counted the children at any other point after the classroom as the incident was a “whole blur.” One child was leaving, and another child was acting out. SP2 said that another count “might” have been completed and “might have been off.” Video footage from the classroom showed that on December 14, 2023, at 3 :29 p.m., SP2 can be seen walking with a child in a coat towards the door. SP1 and the other children were most likely at the doorway out of the camera’s view. At 3:30 p.m., SP2 and the same child walked back to the kitchen counter and SP2 grabbed something and returned to the doorway. Although the doorway was not visible in the camera’s view, in a reflection from a mirror, two children in similar coats can be seen next to each other for a few seconds, then only one child remained. At 3:45 p.m. the child’s reflection disappears. Video footage from the great room showed that on December 14, 2023, at 3:30 p.m., the classroom exited through the great room towards the entrance. The children were on a walking rope with SP1 in the front and SP2 at the back. The FM had no prior concerns. The Employee Handbook stated that children must be within sight and sound at all times. The Child Care Center Risk Assessment and Reduction Plan stated that when transitioning from one area to another area, children formed a line using a walking rope. Staff persons called the children by name to hold onto the walking rope. Staff persons used a name to face count every time the rope was used. One staff person was at the front of the line and one staff person was at the back of the line. Staff persons counted the number of children transitioning to ensure that all children were present. A form entitled COUNT! showed that staff persons counted the number of children while lining up to go outside. Staff persons then counted outside before the children released the rope. When it was time to go back inside. Staff persons counted the number of children outside and again once inside the facility. Facility documentation showed that SP1 and SP2 were trained on the facilities policies including the Risk Reduction Plan and the Employee Handbook 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 December 14, 2023, the AV was left in the classroom without the knowledge or supervision of a staff person for approximately fifteen minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 and SP2 were each not aware that the AV was still in the classroom when SP1 and SP2 took the other children outside, 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. SP1 and SP2 had the children lined up, counted and ready to go outside when a parent came to the classroom to pick up his/her child. The parent asked SP2 to grab a snack for the child and SP2 grabbed the snack and returned to the line. At some point the AV who was wearing a similar coat as the child that left got off the rope and was left in the classroom while the class went out to the playground. SP1 and SP2 did not count children once they arrived at the playground. Approximately 15 minutes later another parent arrived to pick up his/her child and found the AV in the classroom. Although the classroom was inside the facility, the AV, who was 33 months old, was unsupervised for 15 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 and SP2 each worked in the AV’s classroom and were responsible for supervision of the classroom at the time of the incident. SP1 and SP2 were each trained on the facility’s policies, including the Risk Reduction Plan and the Employee Handbook and the Reporting of Maltreatment of Minors Act. 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 and procedures were adequate but not followed when staff persons did not complete a name to face count of the children. Staff persons were retrained on supervision policies and received corrective action. 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 February 14, 2024, the facility was issued a Correction Order for the violations 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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