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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: 807399-CCC (Child Care Center) Investigator(s): Danielle Morrison/Shad Cook Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on the facility playground without a staff person’s knowledge or supervision for approximately five minutes. Date of Incident(s): September 18, 2023 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); subdivision 18, paragraph (a); and subdivision 23, paragraph (a): 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 October 4, 2023; from documentation at the facility; and through six interviews conducted with three facility staff persons (P3, P4, and the SP), two supervisory staff persons (P1 and P2), and the AV’s family member (FM1). The AV was not interviewed due to his/her age. There was a church that was connected to a building that housed the facility which had multiple classrooms including a toddler classroom and a private school for grades Kindergarten through eighth grade. The facility and the school shared access to a gym. The toddler classroom was across from the gym, near the entrance of the facility. The building the facility was located in had two outdoor playgrounds, one for the facility and one for the school. The facility playground was enclosed by a four-foot-tall chain link fence with a gate that opened onto a sidewalk that ran along the facility. The gate had a sign that stated, “Adult supervision required during play times.” The facility entrance had a set of exterior doors, a vestibule area, and a set of interior doors. To access the playground, the children exited the facility from the exterior set of doors near the vestibule and walked approximately 50 feet to the enclosed playground. The facility did not have cameras outside but had them in the vestibule area. The AV was 30 months old at the time of the incident and enrolled in the toddler classroom. P3 provided the following information: · P3 stated on the day of the incident, around 4:50 p.m., s/he walked to the front door of the facility to leave for the day and noticed “concerned faces” of other family members. P3 then heard one family member say, “I did not know if [s/he] was supposed to be out there,” and P3 was unsure what that meant. Then, P3 saw P4 walk out the door and P3 followed P4 and saw the AV on the playground. The AV was “fine.” · P3 walked the AV back into the building and asked the AV who s/he was with on the playground and the AV said the name of the SP. P3 brought the AV to the gym to drop him/her off with the closing staff persons (the SP was not one of the closing staff persons). P3 then went to the toddler classroom and saw another staff person cleaning. This staff person told P3 that s/he left the SP on the playground with the children to come in and clean. As P3 left the toddler classroom, the SP was walking down the hallway so P3 pulled the SP aside to tell him/her that the AV was left outside. P3 said the SP was “completely bewildered” and went “ghostly white that that had happened.” It was during that time that the AV was picked up by a family member (FM2). · P3 then called P2 and told him/her about the incident. · Staff persons were trained to count the children when coming inside from the playground. The facility used the Brightwheel (an application used to keep track of the number of children present). Staff were trained to count, walk inside, and count again. P3 did not have any prior concerns with the SP, including the SP’s supervision of the children. P4 provided the following information: · On the day of the incident, around 4:50 p.m., P4 was in the library where the facility’s afterschool program was held, when another teacher told him/her that there was a child on the playground and asked if P4 could check to see if it was one of the children from the program. P4 said P3 also overheard this and then they both went outside to the playground and saw the AV on a slide. The AV appeared “happy.” When P3 and P4 brought the AV inside, FM2 was there to pick the AV up. P3 then spoke to FM2 who did not seem “upset.” P3 “[sprang] into action” and “took charge of the situation” (talking to the SP). · P4 said that the SP was working in the AV’s classroom at the time of the incident. The SP typically did an “amazing job” with the children. · According to P4, the transition procedure from the playground was that the children were to line up and then staff persons were to do a head count prior to going inside. P1 provided the following information: · P1 was not at the facility when the incident occurred but said that on that date, P2 called to inform him/her of the incident. P1 stated the AV was outside without supervision for approximately five minutes. · The day after the incident, P1 talked with the SP about the incident. According to the SP, at the time of the incident, the children were lined up to come in from the playground, and the SP counted when the group was about to leave and come back inside. The SP also told P1 that s/he did not count the children in the vestibule because there were “a lot” of family members coming in and out. The children were then directly brought to the gym where family member pick-up occurred at the end of the day. The SP was normally in another classroom but was familiar with the children in the AV’s classroom. P1 said the SP felt “awful” about what had happened. · Staff persons were trained that when children came in from the playground, the children were to form a line and then staff persons were to count the children at the playground, in the vestibule, and should count when they return to the classroom. P2 provided the following information: · On September 18, 2023, P2 stated s/he was not at the facility that day, but s/he received a telephone call from P3, around 5:10 p.m., saying that the AV was left outside without supervision. P3 provided information to P2 that was consistent with the information P3 provided during his/her interview. · After P2 spoke with P3, s/he called P1 to let him/her know what happened. P2 then called the SP and spoke to the SP about the incident. The SP told P2 that s/he counted the children when they left the playground and that there were four children. The SP said that s/he did not count when s/he entered the vestibule which was the SP’s “mistake.” · When P2 watched the video footage, s/he determined that the incident occurred at approximately 5 p.m. P2 stated it was “very busy” with lots of children coming and going with family members. P2 saw the SP come through the first set of double doors with his/her children and stop to unlock the second set of double doors and went inside. There were no cameras in the lobby so P2 was not able to see what the SP did after that. After reviewing video footage, it was determined that the AV was outside without supervision for five minutes. · According to P2, staff persons were to line up and count the children prior to going inside. Staff persons were count when the children entered the vestibule, and again when they got to the gym or the classroom. Video footage from the camera inside the vestibule of the entrance doors facing the outside doors of the facility showed that on September 18, 2023, at 5:08:37 p.m., the SP entered the facility with three children walking behind him/her. The SP went to unlock the next door, but it was opened from the inside by a child leaving with his/her family member. The SP and the three children entered the second door at 5:08:53 p.m. At 5:12:26 p.m. the family member who had previously walked out with his/her child who held the door for the SP came back into the building. At 5:12:58 p.m., the family member walked back out of the building and looked in the direction of the playground. At 5:13:24 p.m., P3 and P4 went outside towards the playground and at 5:14:00 p.m., the family member was visible outside of the building and walked towards the playground. At 5:14:32 p.m., P3 and the family member were visible outside of the doors, P3 then opened the outer double doors and P4 and the AV were visible outside the door at 5:14:46 p.m. P4 entered the building and the AV walked off camera, still in sight of P3, and then entered the building with FM2 at 5:15:05 p.m. (Note: The AV was unsupervised for approximately five minutes.) The SP said that on September 18, 2023, around 5 p.m., the SP had four children, including the AV, in his/her classroom. The SP took the children outside to the playground. The SP said ten minutes before family members picked-up, the children wanted to go inside to the gym. The SP lined up the children and the AV was at the end of the line. The SP counted the children, including the AV, but then saw one of the children’s coats on the playground. The SP went to pick the coat up which took “seconds,” and then opened the gate to walk the children back to the entrance of the facility. There was a facility “rule” that staff persons were to count in the vestibule. However, on the day of the incident, there were other family members and children in the vestibule, so the SP walked the children directly to the gym and dropped the children off. When the SP walked out of the gym, P3 notified the SP that the AV had been found alone, and that the SP had left the AV unsupervised on the playground. The SP felt “terrible.” The AV was unsupervised for approximately five minutes. The SP thought that the AV left the line when the SP went to get the coat and said that s/he made a “mistake” and should have counted again when s/he went to get the coat. FM1 had no concerns with the facility and said that the incident was “an honest mistake.” The Parent Handbook stated that children were to “always be supervised by a skilled teacher or assistant.” According to the Risk Reduction Plan, children were with staff persons at all times. Facility documentation showed that the SP, P1, P2, P3, and P4 were each trained on the Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. 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: A. Maltreatment: Consistent information was provided that on the afternoon of September 18, 2023, the AV was left outside on the facility playground without the knowledge or supervision of a staff person for approximately five minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The SP counted four children, including the AV, before s/he left the playground but then saw a coat which s/he picked up, and then s/he did not count again prior to leaving the playground and did not count at any point when s/he returned into the building. The SP brought three children to the gym and then was leaving for the day. In the meantime, P3 and P4 were made aware the AV was outside and they went out to the playground to bring the AV back inside. The AV seemed “fine” and “happy.” P3 and P4 brought the AV back inside at which time FM2 picked up. The SP said that s/he walked the children directly to the gym, dropped the children off, and when s/he walked out of the gym, P3 notified the SP that the AV had been found alone. However, P3 said that after bringing the AV inside, s/he brought the AV to the gym and dropped him/her off with the closing staff persons (who was not the SP). P3 then went to the toddler classroom and saw another staff person cleaning. This staff person told P3 that s/he left the SP on the playground with the children to come in and clean. As P3 left the toddler classroom, the SP was walking down the hallway so P3 pulled the SP aside to tell him/her that the AV was left outside. Video footage showed the AV was without staff person supervision for approximately five minutes. Although the SP initially counted the children prior to leaving the playground, the SP did not count immediately prior to leaving the playground, entering the building, or when leaving his/her group in the gym. The SP was unaware the AV was no longer with the group, and given the information provided by P3, the SP had left his/her group of children in the gym for a period of time, given that P3 returned the AV to the gym, went to the toddler room and then saw and notified the SP. Given the AV’s age, that the AV was left unsupervised on the playground for approximately five minutes, and that no staff person was present on the playground to intervene if the AV was injured or in the event of an 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 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. The SP was responsible for the care and supervision of the AV at the time of the incident. The SP was trained on the Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. The SP was 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 the SP was responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV 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. Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures were adequate, but not followed by the SP. The facility implemented an additional procedure of documenting headcounts and name to face checks on Brightwheel to increase accountability. The facility also met with each staff person and explained the expectation that staff were to count their children frequently in the classrooms and during every transition. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was 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 the SP was responsible for maltreatment is subject to appeal. On February 21, 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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