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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: 802680-CCC (Child Care Center) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left the facility gym and went outside. The AV was unsupervised between two to five minutes and two staff persons (SP1 and SP2) were not aware that the AV had left the gym. Date of Incident(s): August 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 August 25, 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). The facility was located within a building that also had corporate offices for Fraser, therapy for children, and day treatment programs. The facility had multiple classrooms, including toddler rooms. There was also a large gym that had climbers and other play equipment. Additionally, there was an infant play area within the gym that had a half wall surrounding it and two gates to enter/exit. There were multiple doors in the gym, including classroom doors, a locked door that led to administrative offices, and double doors that opened into a lobby. The double doors had an alarm that sounded if the bars to push open the doors were touched. If the alarm sounded, then persons were to press a green button (that was located approximately seven feet up on the wall near the door) which stopped the alarm. To open the doors during an emergency, there were signs on the double doors that stated, “Push until alarm sounds. Door can be opened in 15 seconds.” Additionally, to open the doors without sounding the alarm, there was another sign on the door with directions on how to open the door. It noted that persons were to press the green “push to exit” button. Then, the person was to wait “two seconds” for the door to unlock for the person to exit. There was also a red button approximately three feet up on the wall that was handicap accessible that had the same purpose as the green button. However, per the P, this button was not “activated” at the time of the incident due to children being able to reach it. The sign also noted that if a “blue light” above the door was flashing, then persons were to press the green button to “reset the lock.” There was also a sign on the door with a large “stop” sign stating that only adults were allowed to open and close the doors. The lobby had chairs, tables, and benches. The lobby had three doors, including the gym door and a secured door (that staff had to use a key card to open) to staff and administrative offices. The office door was glass and had a large glass panel next to it. Additionally, there was an automatic sliding door that led to a small entrance where there was a trash can, shovel, and strollers. From there, there was another automatic sliding door that led outside to a sidewalk in the front of the building and the facility parking lot. Beyond the parking lot were nearby roads, single and multi-family housing, and businesses. The facility did not have cameras. The AV was approximately two and a half years old at the time of the incident and enrolled in one of the toddler classrooms. The AV was diagnosed with autism and was nonverbal and communicated with sounds and gestures. The P and the Incident Report Child Elopement Internal Review provided the following information: · On August 14, 2023, SP1 and SP2 worked in the AV’s classroom with five children, including the AV. At 10 a.m., the AV’s classroom entered the gym for their scheduled gym time. There was also another toddler classroom in the gym during this time. · At 10:15 a.m., the P, who was working elsewhere in the facility, heard a call on his/her walkie talkie from a staff person at the front desk, asking for a supervisor to come to the office. The P was doing something else so approximately one and a half minutes later, the P responded that s/he would be “on [his/her] way.” During this time, there was a “second” call asking if “someone was on their way.” The call sounded “more urgent” and the P responded that s/he was on his/her way. · Around 10:16 a.m., when the P arrived in the office, s/he saw that one of the office staff persons was holding the AV. The office staff told the P that they “did not know” if the AV was a child who attended the facility and the P said that the AV did. The office staff then told the P that an unknown bus driver was picking someone up from the facility and was parked outside. Around 10:14 a.m., the bus driver saw the AV running on the sidewalk without any staff person or parent present. The bus driver then stopped the AV, picked up and held the AV, and then asked the person s/he was picking up to go inside to notify a front office person who went out and got the AV. There were no injuries to the AV and the AV was not crying when the P saw him/her. · The P then walked with the AV to the gym. When the P and the AV entered the gym, SP1 and SP2 were each standing near one another and talking. The P told SP1 and SP2 that the AV had “gotten away.” SP1 and SP2 were both “wide eyed” and were not aware that the AV left and/or was unsupervised. · The P then had another staff person fill in for SP1 and SP2 and spoke to SP1, SP2, and the front desk staff persons about the incident. Based on the information the P determined that around 10 a.m., a parent of another child was sitting in the lobby with their child and was waiting for the bus. When the parent went out to the bus, the bus driver had the AV in his/her arms. The bus driver told the parent that the AV “just walked out” of the facility and that no “adult” was with the AV, so the bus driver “stopped” the AV. The bus driver then asked the parent to go back inside and let the front office know which the parent did. The front office staff then went outside and took the AV from the driver. · SP1 and/or SP2 stated that from approximately 10 to 10:10 a.m., there were three instances where each had to assist the AV. This included with putting the AV’s shoes back on, redirecting the AV away from the infant area due to “limited visibility,” and also redirecting the AV from climbing on shelves in the gym. · At some point, the P also spoke to the parent who was waiting for the bus. The parent said that s/he did not see the AV walk past him/her in the lobby to go outside. However, the parent said that s/he was not paying “attention” as to who was “coming and going” because s/he was on his/her phone. Additionally, at some point, the parent left the lobby to use the restroom but did not recall what time that occurred. · The P also determined that between 10:10 and 10:12 a.m., there was a tour of the facility with a “prospective parent” who had gone through the double gym doors with a staff person. The double door had an alarm but there was no indication that the alarm sounded around the time of the incident. Typically, after someone opened/closed the doors, the doors “immediately” automatically closed and the alarm would be reactivated. Once the AV was able to exit the gym to the lobby, the AV was then able to get outside via the “automatic” sliding doors. · The front desk staff told the P that they did not see the AV leave the facility from their office. · The P said that on multiple occasions following the incident, the P checked the double gym doors to see if they were locked to try to figure out how the incident could have happened. The P said that “ninety-nine percent” of the times s/he checked, the doors were locked, but there were a “couple [of] instances” when the P found that the doors were not locked and no alarms sounded. There were also times where there was a “couple [of] seconds” delay where the doors did not lock right away after being opened. The P “assumed” that on the date of the incident, when there was the tour and the gym doors were opened, the AV was able to leave “unnoticed” due to this couple of seconds delay. However, the P was not aware of any issues with the door specifically at the time of the incident. · The AV had a history of trying to leave the group but staff persons always “caught” the AV. The AV also “hovered” near doors and “ran” towards open doors. Staff persons knew that the AV had a history of leaving the group so typically remained near the AV. · Staff persons were trained to spread out to supervise the children in the gym. Staff persons were to “watch” the exits and also do head counts on a “frequent basis.” Additionally, a staff person was typically positioned near the door in the gym to keep kids away from it so children were not “hovering” when people went “in and out.” · Although the AV was not injured, risk to the AV being unsupervised outside included vehicles and “going far” once s/he was outside. Other concerns also included community persons who the AV might encounter. · The P did not have any concerns with SP1’s and SP2’s supervision of children prior to the incident. SP1 provided the following information: · SP1 did not recall the date of the incident but, around 10 and 10:30 a.m., SP1 and SP2 took the toddler children, including the AV, to play in the gym. There were one or two other classes in the gym during that time. SP1 did not recall how many children they had but they were within ratio. After approximately five to ten minutes of being in the gym, SP1 and SP2 saw the P and the AV walk into the gym. The P told SP1 and SP2 that “someone” found the AV outside which SP1 said was “awful.” There were no injuries to the AV. However, the incident was “very serious” and risks to the AV included that “someone” could have “taken” the AV or s/he could have gotten “hurt,” including by a car in the road. · SP1 and SP2 were “confused” and did not know how the AV exited the gym. SP1 did not think that the AV was able to open the double doors because there was a “super high” button that “only adults” could reach, which needed to be pressed to unlock the door. There was also a “loud” alarm on the doors exiting the gym into the lobby. If someone tried to open the doors, an alarm sounded. SP1 said s/he and SP2 would have heard if the alarm sounded as they had heard it on prior occasions. SP1 and SP2 thought that someone had either exited or entered the gym and that during that time, the AV “escaped.” Additionally, following the incident, the P “checked” the door and determined that there was a three second delay after someone opened the door and before the door locked so the AV could have left during that time. However, both SP1 and SP2 did not see anyone exiting or entering the gym doors around the time of the incident. · SP1 thought that s/he last saw the AV two to five minutes prior to the P notifying him/her of the incident. SP1 did not recall what the AV was doing but said that typically, the AV liked to run around the “perimeter” of the gym. · SP1 initially said that s/he did a head count prior to the incident while in the gym and that the AV was part of that count. However, SP1 later said that s/he did a head count “everyday” but specifically could not recall the date of the incident. · Staff persons were trained to supervise the children by being within sight and hearing of them. While in the gym, staff persons were to have their “eyes” on the children but also engage and play with them. When there were multiple classrooms in the gym at the same time, such as what occurred on the date of the incident, staff persons “focused” on their class but “watched” other children to ensure they did not exit or “get hurt.” Staff persons were responsible for the supervision and counts of their own class. Staff persons also tried to “spread out.” However, at the time of the incident, SP1 was talking to SP2 when the P notified him/her that the AV was found outside. SP1 said that s/he and SP2 were “not as spaced out as we could have been.” · The AV had a history of attempting to leave the room but had not been unsupervised prior. This included when parents came to pick up children in the classroom, the AV would attempt to leave and staff persons had to redirect the AV. There was a door in the classroom that led to a “courtyard” and the AV also attempted to “push” on that door because the AV “loved to spend time outside.” On prior occasions, the AV attempted to exit the gym via a gate that separated the gym from some of the classrooms, so a staff person typically stood near there. SP1 could not recall if the AV had tried to exit the main gym door prior.
SP2 provided the following information: · On August 14, 2023, SP1 and SP2 took their class to the gym, which typically lasted from about 10 to 10:20 a.m. SP2 thought that his/her classroom had five children, including the AV. There was another classroom in the gym at the same time. Within five to ten minutes of arriving to the gym, SP1 and SP2 did a “name to face” count, which included the AV. Around this time, the AV had taken off his/her shoes, which the AV had a history of doing, so SP2 assisted the AV with putting them back on and then the AV continued to play. SP2 then began throwing a ball for some of the children and during this time, another teacher (from another classroom) told SP2 that the AV was trying to climb on something. SP2 then went to “check” on the AV and brought the AV to the “middle” of the gym, where a staff person from another classroom was playing music for children. SP2 then began assisting other children as SP1 began talking to SP2 about his/her “weekend” while they continued monitoring the children, including a child who had a history of “biting” other children. · Around 10:15 a.m., SP2 saw the P enter the gym with the AV. The P then told SP1 and SP2 that the AV was found outside. SP2 was not aware that the AV left the gym until the P returned the AV. SP2 was not aware of any injuries to the AV and the AV was not crying. However, risks to the AV being unsupervised included cars if the AV went into the street or parking lot. · SP2 and SP1 were “in shock” when the P notified them of the incident. The AV had “never” played near the gym doors prior and had not attempted to exit via those doors. The AV typically liked to be near a “light board” towards the back of the gym. However, the AV had a history of trying to open a gate near the light board and “run” out but there was typically “always” a staff person near there who could “grab” the AV. Additionally, at times while in the classroom, the AV was “antsy” and wanted to go outside and attempted to open the classroom door to the courtyard. Staff persons “tried to keep a close eye” on the AV the “best they could” while still watching the other children. · SP1 and SP2 also did not know how the AV exited the gym to get outside because the gym doors “should” be locked. If someone “pushed” on the door to exit, an alarm sounded unless a staff person pressed a button, which was located at the top of the door. On prior occasions, SP2 heard the door alarm sound and it was “pretty loud.” At the time of the incident, no staff person heard the door alarm sound. Additionally, SP2 did not see anyone enter or exit the gym. The AV could have also exited via a classroom to the outside but the classroom doors were closed while they were in the gym. If the AV got outside from a classroom, s/he would have been in an enclosed courtyard and would have had to exit that. There was also a door to the administrative offices but that had a “code on it” that only staff persons had access to. If the AV went through the administrative offices, the AV would have passed a staff office prior to exiting through the lobby outside and no staff person saw the AV exit. · SP2 thought that the AV was unsupervised for approximately two to three minutes based on the time s/he moved the AV towards the middle of the gym to when the P came into the gym with the AV. · Staff persons typically did name to face counts when they arrived in the gym, “halfway” though, and prior to leaving. These counts were typically every five to ten minutes and SP1 and SP2 did those on the date of the incident. The last head count was around the time SP2 moved the AV to the middle of the gym. If the AV was not found when s/he was, SP2 said that s/he and SP1 would have done another head count when they were getting ready to leave the gym, which would have been around 10:20 a.m. · Although there was another classroom in the gym at the time of the incident, SP1 and SP2 were responsible for the supervision of the AV. The FM did not have any concerns with the incident or the facility. Following the incident, the facility and the FM filled out “paperwork” so that the AV had a staff person assigned to him/her for transitions. The Fraser School Staff Handbook said that all children were to “be under the direct supervision of a qualified staff member at all times.” Safety was the “primary concern during gross motor time” due to the high activity level, the number of children, and the “ranges of abilities” of the children. All staff persons were to remain actively involved in assisting the children as needed and supervising interactions. There was to be no sitting by staff persons or “excessive” adult to adult interaction. Staff persons were to move around and position themselves in areas requiring the “most supervision.” Staff persons were to take a head count “frequently” and know how many children were in the gym. Staff persons were to also conduct a name to face attendance check before and after each transition to and from the gym. The Risk Reduction Plan said that there was a “risk” of children “darting” into empty classrooms from areas such as the gym so staff persons were to keep their classroom doors closed. While in the gym, there were four classroom doors which were “set into the wall providing small hiding spaces for children.” Staff persons were trained to monitor those areas and move around the gym to “ensure constant supervision by sight.” The main door in the gym had a timed release and the alarm would sound when “activated.” There was a button to open this door that was out of a child’s reach that needed to be pushed prior to the gym door opening. Additionally, the facility was located in a residential and commercial area and there was both “foot and vehicle” traffic. There was a storm water retention pond nearby the facility which held standing water during “some portions of the year.” There were also parking lots on the south and east sides of the facility. The facility only had two exit/entrance doors that exited the facility that did not enter into a fenced in area. This included the main entrance door and a door away from the classroom areas near the kitchen/offices. Facility documentation showed that the P, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies on the supervision of children, including the Risk Reduction Plan, 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, 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: On August 14, 2023, the AV left the gym and was found outside by a community person for approximately two to five minutes without the knowledge or supervision of SP1 or SP2, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was not injured, given the AV’s age at the time of the incident, his/her diagnoses of autism, his/her history of attempting to leave the group, that the AV was found outside alone, that staff persons were not aware the AV left the gym or the facility, and that the surrounding area where the AV was found included environmental hazards and community persons, placed the AV at an increased risk of harm. Minnesota Statutes, section 260E. 30, subdivision 3, stated that rather than making a determination of substantiated maltreatment by an individual, the commissioner of human services shall determine that a nonmaltreatment mistake was made by the individual. A nonmaltreatment mistake occurs when: (1) at the time of the incident, the individual was performing duties identified in the center's child care program plan required under Minnesota Rules, part 9503.0045; (2) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; (4) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; and (5) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing requirements relevant to the incident. SP1 said after approximately five to ten minutes of being in the gym, SP1 and SP2 saw the P and the AV walk into the gym. SP2 said within five to ten minutes of arriving to the gym, SP1 and SP2 did a “name to face” count, which included the AV. Around this time, the AV had taken off his/her shoes, which the AV had a history of doing, so SP2 assisted the AV with putting them back on and then the AV continued to play. SP2 then began throwing a ball for some of the children and during this time, another teacher (from another classroom) told SP2 that the AV was trying to climb on something. SP2 then went to “check” on the AV and brought the AV to the “middle” of the gym, where a staff person from another classroom was playing music for children. Around 10:15 a.m., SP2 saw the P enter the gym with the AV. SP1’s and SP2’s actions or conduct were determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, SP1 and SP2 were each performing job related duties, as required by the facility’s policies, including participating in activities with children. Given the free play design of the gym, it was not reasonable that each staff would know where each child was at every moment and within the five to ten minutes they were in the gym, SP2 interacted with the AV twice so was aware of the AV’s presence; (2) Neither SP1 nor SP2 had been previously found responsible for a similar incident that resulted in a finding of maltreatment or a nonmaltreatment mistake in the past. (3) Neither SP1 nor SP2 had been previously found responsible for a similar incident that resulted in a finding of a nonmaltreatment mistake in the past. (4) The AV was uninjured and did not require medical care after the incident. (5) Outside of this incident, the facility, SP1, and SP2 were in compliance with all relevant licensing requirements. The nonmaltreatment mistake to the AV by SP1 and SP2 were not maltreatment. 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 determined that policies were adequate but not followed regarding children being “under direct supervision through sight and sound and frequent name to face counts.” Following the incident, the facility met with “facilities management” to address the gym double doors. This included that following the incident, the facility discovered that due to “fire code,” any time the alarm went off, the doors remained unlocked until they were “reset” by putting in a code or pressing the green button. Because of this, the door was frequently unlocked which had been a “false sense of security.” The facility also reinforced the need for staff persons to watch the area around where parents or other persons entered the gym. The facility also updated the AV’s plans to “highlight the eloping and increased staff monitoring to assure safety.” Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which SP1 and SP2 were responsible met the criteria to be determined a nonmaltreatment mistake. SP1 and SP2 were notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP1 or SP2 were responsible might not be considered a nonmaltreatment mistake. On February 16, 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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