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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: 1064732-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: Allegation One: It was reported that an alleged victim (AV1) was in the facility’s indoor gymnasium without staff person knowledge or supervision for approximately five minutes. Allegation Two: During the course of this investigation, it was reported that another alleged victim (AV2) was in the facility’s gymnasium without staff person knowledge or supervision for approximately one to two minutes. Date of Incident(s): Allegation One: July 19, 2023 Allegation Two: June 8, 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 16, and September 19, 2023; from documentation at the facility; and through nine interviews conducted with three supervisory staff persons (P1, P2, and P4), four facility staff persons (SP1, SP2, SP3, and P3), AV1’s family member (FM1), and AV2’s family member (FM2). The facility was a standalone building. The building had a small parking lot, two fenced-in playgrounds, and a pond on the eastern side of the facility. Access to the pond was restricted by a five-foot chain-link fence around the playgrounds and eastern side of the facility. The facility was near a large office building which shared some parking lot space. The facility consisted of nine classrooms; two infant, four toddler and three preschool classrooms. The facility had an indoor gymnasium on the south end of the building with a capacity for 23 children and four staff persons, according to the facility floorplan. There were three doors to enter/exit the gymnasium; one door was an exterior door to the fenced-in outside toddler playground, one door was to a classroom, and one was a double door that connected to the main interior hallway of the facility. The gymnasium had a small playhouse, bins of various sized balls and building blocks, and other activity toys. The gymnasium had a direct outside view of the two fenced-in playground areas behind the facility. The toddler playground was for younger children, and the preschool playground was for older children. The Safety and Supervision Policy stated that all children must be within sight and sound at all times. When there were 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 (a rope with rings on it for children to grab onto). 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, s/he was 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. Facility documentation showed that SP1, SP2, SP3, P1, P2, P3, and P4 each received training on the Reporting of Maltreatment of Minors Act, the facility’s Risk Reduction Plan, and the facility’s Safety and Supervision Policy. 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. Allegation One: It was reported that AV1 was in the facility’s indoor gymnasium without staff person knowledge or supervision for approximately five minutes. AV1 was 29 months old and enrolled in a toddler classroom at the time of the incident. Due to his/her age AV1 was not interviewed. On July 19, 2023, the gymnasium had a large bounce house that was for a summer event that day. The bounce house had a large jumping area and a long, yellow slide on one side. The bounce house was set up in the middle of the gymnasium and there was space that allowed access to all sides. P1 provided the following information: · On July 19, 2023, around 11 a.m., P1 was sitting at the front desk and had a question for a staff person, so s/he walked to the gymnasium and found AV1 standing in front of the bounce house looking “confused.” P1 took AV1’s hand and brought AV1 back to his/her classroom. · When P1 opened the double doors to enter the hallway, SP1 was grabbing the lunch cart from the hallway and looked at P1 with AV1 and SP1 said, “Oh.” P1 told SP1 that s/he found AV1 alone in the gymnasium and P1 asked SP1 what time his/her classroom left the gymnasium, and SP1 responded, “We just left.” P1 told SP1 to go back into his/her classroom with AV1 and conduct a name to face count while P1 went back into the gymnasium to make sure no other children were in there. · SP1 walked back toward his/her classroom with AV1 and P1 heard SP1 tell AV1, “[AV1] when I tell you to line up you need to line up.” · P1 contacted his/her supervisor to make sure s/he followed the facility protocol. P1 requested video footage and while waiting on that, s/he talked to SP1 and SP2 about what happened and gave a written warning to both SP1 and SP2 about not following the facility’s policies. P1 stated that SP2 was “really quiet” but listened to what P1 told them. P1 said SP1 and SP2 did not have any questions at that time. · When P1 reviewed the video footage s/he saw SP1 in front by the double doors with the children and SP2 was at the back of the group. SP2 walked around one side of the bounce house to look behind it to make sure no one was there, and as SP2 walked back to the group, AV1 walked to the other side of the bounce house and stood there. P1 stated that SP1 and SP2 did not have the children use the walking rope as per facility policy and P1 was not able to tell if they performed a head count. · The facility used ProCare (an application used to track attendance and communicate with families), and P1 saw that SP1 and SP2 did not perform a name to face count in ProCare. P1 stated that SP1 and SP2 had 14 children that day. · Two days after the incident, SP1 told P1 that it “was all SP2’s fault” as SP2 was the last one out of the gymnasium. SP1 told AV1 to line up. P1 told SP1 that it was not AV1’s fault for not lining up as s/he was a toddler. SP1 provided the following information: · SP1 said there was a day that s/he worked with SP2, and they counted the children when they went to the gymnasium to play on the bounce house, but they went without the classroom’s walking rope because SP1 was not able to find it. When it was time to go back to the classroom, SP1 was putting on the children’s shoes as SP2 gathered the children. · When SP1 and SP2 lined up the children, SP1 was in the front of the group, guarding the door, because some children were trying to leave through the double doors. SP2 told SP1 s/he was going to look around the bounce house to see if there were any children there. SP1 said the bounce house was so tall s/he did not know if SP2 saw AV1 on the other side, and when they left the gymnasium around 11 a.m., AV1 was left behind for “like two minutes.” · SP1 stated they did not count when they left the gymnasium as children were trying to run out and it was an “accident” that AV1 was left in the gymnasium. When SP1 and SP2 returned to the classroom with the children, SP1 and SP2 prepared to have lunch. SP1 was told by P1 that SP1 and SP2 forgot AV1 in the gymnasium. When AV1 returned to the classroom, s/he seemed “like [his/her] normal self.” · SP1 stated that s/he and SP2 had 14 children that day and were responsible for AV1. SP1 said that s/he felt “horrible” about the situation and that s/he and SP2 should have counted the children. SP1 stated that s/he was trained to count the children and use the walking rope, but SP1 thought another staff person had taken the walking rope out of the classroom. SP2 provided the following information: · On the day of the incident, SP2 worked with SP1, and they brought the children to the gymnasium to jump on the bounce house in the morning. SP2 stated that s/he did not remember exactly how many children were there that day, but SP2 thought it was under 14 children, between 10-13 children. · When SP1 and SP2 went to leave with the children to go back to the classroom, SP2 checked one side to make sure there were no children around the bounce house, and there were none and then s/he checked the other side, and when SP2 came back to the door, SP1 already started letting the children leave. · SP2 stated that SP1 did not like to use the walking rope so they did not use it that day. When they returned to the classroom, SP2 sat down with a group, was reading a book to them, and told SP1 how many children s/he had seated by him/her. SP1 was on the other side of the classroom with some children. SP2 thought SP1 was changing diapers. · P1 came in and told SP1 and SP2 that AV1 was left in the gymnasium and that s/he reached out to his/her supervisors for support. SP2 stated that both s/he and SP1 were responsible for AV1 that day. SP2 stated that AV1 was “happy and giddy” when s/he returned to the classroom. · SP2 stated that a head count was not done prior to leaving the gymnasium as SP1 already started to let the children out. SP2 stated s/he was trained to count the children, hold on to the walking rope, and ideally have one staff person in the front of the line and one staff person in the back. SP2 stated that the classroom walking rope was in a locker or a closet out of reach of the children and it was not missing that day. P2 provided the following information: · P2 was not at the facility on the day of the incident but received a telephone call from P1 telling him/her what happened. SP1 and SP2 did not use the walking rope when transitioning from the gymnasium to the classroom and AV1 was left in the gymnasium for over five minutes. · The day after it happened, P2 received a telephone call from P1 stating that SP1 approached him/her stating that SP1 should not have signed the write up and that the incident was SP2’s fault. P2 also received a telephone call from SP1 and P2 told SP1 that s/he would talk to SP1 on Monday of the next week as P2 was off. · On the following Monday, when P2 returned to the facility s/he spoke with SP2 about the facility’s policies and what was not done by SP2 during this incident. SP2 was apologetic. SP1 did not take responsibility for what happened and blamed SP2. · P2 stated that the policy was to have children line up on the walking rope, count them over any threshold, count in the classroom, and then perform a name to face count. · P2 reviewed the video footage and saw the children gathered at the door, and SP2 went one way to look behind the bounce house and when s/he came back to the door, AV1 went to the other side of the bounce house. The group left the gymnasium and AV1 stood there looking “confused.” P1 walked into the gymnasium and saw AV1 standing there with no staff persons in sight. FM1 was made aware of the incident when s/he arrived to pick up AV1 that afternoon. FM1 said AV1 was not really aware of what happened and FM1 had no prior issues with the facility. This investigator reviewed video footage from July 19, 2023, for approximately six minutes and it showed that SP1 and SP2 were cleaning up and having the children go towards the front of the gymnasium. The double doors were not visible from the camera angle. · At 11:06:31 a.m., SP2 started to walk around one side of the bounce house and once s/he got to the end of the bounce house, s/he peered along the back of the bounce house and walked back toward the front of the bounce house. At 11:06:38 as SP2 peered around the back of the bounce house, AV1 started to walk along the other side of the bounce house toward the back of the bounce house. · At 11:06:46 a.m. SP2 and two other children were seen standing by the front of the gymnasium. SP2 pointed towards the doorway and then they walked and were no longer visible on camera. At that time AV1 was by the back door that led to the outside playgrounds. AV1 walked to the front corner of the bounce house and stayed there, looking around and playing with his/her hair until 11:11:47 a.m. at which time AV1 walked to the corner of the gymnasium and out of view of the camera. · At 11:11:53 a.m., AV1 walked back into view of the camera and stood by the bounce house. At 11:12:32 a.m. AV1 started walking towards the door and at 11:12:34 a.m., P1 was seen on camera coming from the direction of the double doors. P1 took AV1’s hand and at 11:12:51 a.m. they walked out of camera view in the direction of the double doors. This investigator reviewed video footage from inside the classroom which showed that at 11:06:57 a.m. the classroom door opened, and three children ran inside. SP1 walked in with an additional six children, then two more children followed behind SP1 with SP2 who entered the classroom last at 11:07:13 a.m., and then SP2 shut the door. After this SP2 went and washed his/her hands and SP1 walked around the classroom moving some pieces of furniture. SP2 went to a cabinet in the classroom, retrieved a book, and set it on a chair. SP2 then walked over and looked at a tablet on the counter, set it down, and then walked into a bathroom area to assist a child who had gone in to go to the bathroom. SP2 walked out of the bathroom area, grabbed the tablet, walked over to the chair, then walked back to the bathroom area with the tablet in hand. This was where the video ended at 11:09:59 a.m.
Conclusion for Allegation One: Consistent information was provided that on July 19, 2023, SP1 and SP2 were in the gymnasium with a group of children including AV1. There was a bounce house in that space that day and when the classroom was lined up to go back to the classroom, SP2 walked on one side of the bounce house to make sure there were no children left and when s/he walked back toward the front of the gymnasium, AV1 walked on the other side of the bounce house. SP1 and SP2 stated that they did not count the children when they left the gymnasium and did not use the walking rope as was the facility policy. AV1 did not seem to be distressed and video footage showed AV1 was without supervision for approximately six minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although SP1 thought AV1 was without supervision for “like two minutes,” and it was an “accident,” given that neither SP1 nor SP2 counted the children when leaving the gymnasium or arriving back in the classroom did not use the walking rope, that a name to face count was not completed, and that no staff person was in the gymnasium to intervene in case of an emergency or injury, there was a preponderance of the evidence that there was a failure to supply AV1 with necessary care and a failure to protect AV1 from conditions or actions that seriously endangered his/her physical and 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 responsible for the care of AV1 on the day of the incident. SP1 and SP2 were trained on the facility’s Safety and Supervision Policy, the facility’s Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act, therefore SP1 and SP2 were responsible for maltreatment of AV1. 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 SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and AV1 did not sustain any 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. Allegation Two: During the course of this investigation, it was reported that AV2 was in the gymnasium without staff person knowledge or supervision for approximately one to two minutes. The toddler playground had climbing structures and play equipment for the children. The door from the toddler playground into the gymnasium locked from the outside. The windows looking into the gymnasium had a reflective tint on them so that it was not possible to see into the gymnasium at a quick glance. The playgrounds were surrounded by a five-foot chain-link exterior fence. There was an interior fence that divided the toddler and preschool playgrounds. There was a gate that was used to move between the playgrounds. There was another gate on the opposite side of the toddler playground at the edge of the building. This gate led to a path that led along the side of the building to the parking lot. About halfway down that path was a coded door used by staff persons, children, and family members to get into the building from the toddler playground. AV2 was almost 30 months old and enrolled in the toddler classroom at the time of the incident. Due to his/her age AV2 was not interviewed for this investigation. P2 provided the following information: · On June 8, 2023, P2 was on the preschool playground with children and family members for a family event. SP3 motioned P2 over to the toddler playground and told P2 that a family member had opened the door from inside the gymnasium to ask SP3 a question. After that SP3 conducted a head count and noticed AV2 was missing, so SP3 checked all of the “hidey holes” on the toddler playground and then peeked into the gymnasium and saw AV2 sitting on a chair. · P2 stepped onto the toddler playground so that SP3 could go inside and get AV2. P2 stated that the outside door was locked and SP3 was not able to get in that way, so s/he went the coded door part way down the path on the side of the building to get inside. · P2 stated s/he was able to see AV2 through the window and AV2 was “testing” out all of the chairs in the gymnasium and then went over to a projector that was used for the family event, P3 arrived in the gymnasium and then SP3 arrived inside the gymnasium. · P2 stated that AV2 was happy, and it was just over a minute that AV2 was without supervision. P2 said that SP3 had seven children at the time and P2 did not review video footage because AV2 was within sight and sound within a “few seconds” of going inside. · P2 stated that the key to the outside door was located in P4’s desk. Staff persons and children entered the building from the side coded door when returning in from outside. P2 stated since the incident both preschool and toddler staff persons had keys to immediately access the door off of the toddler playground into the gymnasium. SP3 provided the following information: · On the day of the incident, SP3 was outside with seven children and a family member walked onto the playground from inside the gymnasium to go out and then through to the other playground. SP3 thought afterwards that AV2 slipped inside when that family member walked outside. · SP3 did not see AV2 go inside, but AV2 had been on the toddler playground with SP3 for “a little bit.” SP3 stated s/he monitored the playground, performed a head count, and noticed s/he was missing AV2. SP3 called P2 over from the preschool playground and told P2 that AV2 was not on the playground so SP3 was going to look for AV2 and asked P2 to watch the toddler children on the playground. · SP3 stated s/he did not know AV2 was in the gymnasium when SP3 called P2 over to watch the toddler children. SP3 followed his/her exit routes to see where AV2 might have gone. By the time SP3 got to the gymnasium and back out to the toddler playground, someone else had already brought AV2 back outside. SP3 stated AV2 seemed “fine” when SP3 saw AV2 after the incident. SP3 thought AV2 was without supervision for “maybe a couple of minutes.” P3 provided the following information: · On the day of the incident, P3 was grabbing supplies from the supply closet located next to the gymnasium, when s/he saw AV2 in the gymnasium by him/herself. P3 stated that AV2 did not look “scared” when P3 found AV2. · P3 opened the door to the toddler playground and asked SP3 if AV2 was one of his/her children. P3 said SP3 looked “relieved” and that SP3 knew AV2 was not on the playground with SP3. P3 did not remember if s/he told P2 or P4 about what happened, but they told P3 they would handle it. P4 provided the following information: · On the day of the incident, P4 was with P2 on the preschool playground for a family event. SP3 was on the toddler playground with seven children. P2 went to the toddler playground and then asked P4 while P4 was standing next to the interior fence if AV2 was on the preschool playground. · P4 made a full circle around the preschool playground and by the time s/he got back to where s/he was previously, P2 was coming back onto the preschool playground from the toddler playground. Later, P4 heard from P2 that SP3 did a name to face count, did not see AV2, then saw AV2 in the gymnasium, so SP3 asked P2 to come watch the toddler children so SP3 was able to go inside and get AV2. · P4 stated that AV2 was not sure how long AV2 was without supervision in the gymnasium, but from the time P2 asked P4 to check the preschool playground for AV2 to when P2 returned to the preschool playground, it was less than a minute. P4 mentioned that the outside door locked and prior to this P4 suggested there be a gymnasium door key in a bag staff persons used. P4 stated that parents had to leave on the side of the building through the gate that led to the parking lot or re-enter the building through the coded side door. FM2 was not aware of the incident and had no prior concerns. Conclusion for Allegation Two: On June 8, 2023, SP3 was outside on the toddler playground with seven children including AV2. P2 and P4 were on the preschool playground helping with a family event. SP3 stated that a family member walked out of the door from the gymnasium onto the toddler playground and after that SP3 performed a head count and noticed that AV2 was not on the playground. SP3 alerted P2 to let him/her know so that P2 could watch the other toddler children while SP3 went inside to find AV2. SP3 went to the side coded door and by the time s/he made it to the gymnasium, someone had brought AV2 outside. SP3 thought it was a couple of minutes. SP3 thought AV2 slipped inside when a family member came outside through the gym door. P2 stated that s/he was able to see AV2 in the gymnasium and saw AV2 trying out chairs and playing with the projector. P2 said P3 came into the gymnasium and saw AV2 and then SP3 arrived in the gymnasium. P2 said it was just over a minute from when SP3 alerted P2 to when SP3 returned outside with AV2. P3 stated that s/he found AV2 in the gymnasium and when P3 returned AV2 to SP3, SP3 looked “relieved” and knew AV2 was missing. Although AV2 was found in the gymnasium without a staff person inside supervising him/her which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, given that SP3 was performing duties as required by the facility’s policies at the time of the incident, and it was not a time SP3 was required to perform a head count, but SP3 followed the facility’s Safety and Supervision Policy by being aware of the children’s activities, and that once SP3 noticed AV2 was no longer on the playground, SP3 took immediate action to locate AV2, there was not a preponderance of the evidence that SP3 failed to protect AV2 from conditions or actions that endangered AV2’s physical or mental health. 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 (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures adequate, but not followed by SP1 and SP2. SP1 and SP2 received a written warning. SP1 no longer worked at the facility. The facility’s policies and procedures were followed by SP3. 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 and for failure to report Allegation Two according to reporting requirements. 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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