|
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: 1076380-CCC (Child Care Center) Investigator(s): Kimberly Anderson 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 20 minutes. Date of Incident(s): August 24, 2024 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 September 8, 2023; from documentation at the facility; and through five interviews conducted with three facility staff persons (P2, SP1, and SP2), a supervisory staff person (P1), and the AV’s family member (FM). The facility had multiple classrooms including two preschool classrooms. The facility also had two large, fenced playgrounds, including a toddler playground and a preschool playground. The fence was chain-link, and the playground was visible to passersby from the parking lot and nearby roads. The preschool playground had an open grass area, a concrete basketball court area, and a climbing structure with a slide. The preschool classrooms had windows that faced the playgrounds. The AV was three years-old at the time of the incident and enrolled in one of the preschool classrooms. The facility’s Weekly Sing In/Out Sheet stated that on August 24, 2023, SP1 and SP2 were working in one of the preschool classrooms with 16 children, including the AV. The Incident/Accident Report dated August 24, 2023, and written by SP2, said that at 10:40 a.m., the AV was “missed” and left outside. Another teacher (who was not named but was later determined to be P2) found the AV and brought the AV to his/her classroom. P2 provided the following information: · At approximately 10 a.m., P2 was on the preschool playground with his/her children and transitioned them inside. At the same time, SP2 was transitioning his/her children, including the AV, inside. · On the day of the incident, around 10:15 and 10:20 a.m., P2 heard a child from his/her classroom say that someone was on the preschool playground. P2 looked out the window and saw the AV standing underneath a blue canopy on the playground. P2 then went outside and brought the AV inside. The AV was not crying and the AV did not have injuries. P2 then informed a supervisory staff person (P3) of the incident. · The facility used name to face counts to keep track of the children in each classroom. Each class had a checklist on a clipboard of the children for that classroom. When the class lined up during a transition, a staff person called each child by name, the child verbalized a response, a checkmark was placed by the name of the child, and then the child entered the class or transition area. P1 provided the following information: · P1 did not recall the date of the incident but on that date, around 10:15 a.m., P1 went to the preschool classroom to assist SP2 with coverage while SP1 went on his/her break. Shortly after P1 entered the classroom, P1 asked SP2 how many children were in the room and SP2 said there were 13 or 15 children. P1 also began counting. As P1 was doing the count, P3 came to the classroom door and told P1 that that P2 found the AV outside. P1 asked SP2 to do a name to face count and that was when SP2 discovered that s/he was missing a child. · The AV was left outside without supervision for approximately 20 minutes based on the time the preschool class came inside to when the AV was located on the playground by P2. · Staff persons were trained to complete a “name to face” count when entering or exiting a room, every hour in the classroom, and when entering and leaving the playground. Additionally, before the class could enter the classroom after coming inside, a “name to face was required to make sure all kids outside the class made it inside.” · P1 did not have concerns with SP1 or SP2, including regarding supervision of children, prior to the incident. · P1 was not aware of any risks to the AV being unsupervised and stated that the weather was a “little cloudy” and “warm” but “not hot.” SP1 provided the following information: · SP1 said that on August 23, 2023, (later determined to be August 24, 2023), around 9:30 a.m., SP1 and SP2 took the preschool classroom outside on the playground. Between 10 and 10:15 a.m., SP1 told SP2 that a child needed to use the bathroom so SP1 brought the child inside as SP2 started to line up the rest of the children on the playground to transition inside. · When SP2 and the other children entered the building, SP1 stood in the classroom by the door so s/he could monitor the child in the bathroom as the rest of the class started to come inside the room. · SP1 and SP2 then had the children sit on the group time rug and SP1 and SP2 did a head count. SP1 counted 15 children several times, which SP1 said did not match the clipboard checklist which showed that there should have been 16 children in attendance. SP1 then told SP2 that s/he only counted 15 children and SP2 said that the classroom attendance only had 15 children. Approximately five minutes later, P1 came into the classroom to relieve SP1 for a scheduled break.
· SP1 returned to the facility approximately two hours later and P1 told SP1 about the AV being left outside. SP1 felt s/he “failed” the AV because s/he brought the other child inside to use the bathroom. However, SP2 was the staff outside with the AV when they transitioned inside. · When it was time to come inside, staff persons were trained to line the children against a wall on the playground where staff counted and checked the list on the clipboard. Staff persons called the names of the children one by one, the child verbally responded when they heard their name, and staff persons then placed a checkmark by the name of the child. Then, staff completed a playground sweep and ensured all children were accounted for before coming inside. One staff person remained by the outside door and counted the children as they entered the building. The other staff person was positioned in the hallway near the classroom door. When the children were lined up in the hallway by the classroom, they were counted and if the count matched the checklist, staff persons completed a name to face count and then closed the door to the playground. When the children entered the classroom, they sat on a group time rug and the “final count” was completed. · On the day of the incident, SP1 stated that the transition procedure was not done in the manner it should have been completed. On that date, SP2 had the clipboard outside while SP1 was inside with the child using the bathroom. When SP1 came inside for the child to use the bathroom, SP2 was out of ratio on the playground with the rest of the preschool classroom. SP2 provided the following information: · On August 24, 2023, at 9:30 a.m., SP2 was outside on the playground with SP1 and 16 preschool children. When it was time to go inside between 10 and 10:15 a.m., SP1 took a child in to use the bathroom. SP2 then did a name to face count using a “name to face sheet” and lined the remaining children against the outside wall. SP2 then brought the children inside. Approximately 15 minutes later, P2 found the AV unsupervised on the playground and P2 returned the AV to the classroom. The AV was “fine.” · SP2 said the morning of the incident was "rough,” because the children were not sitting still and kept moving, which caused SP2 to “miscount” the children. SP2 stated that s/he “probably” counted one of the children twice. SP2 did a “quick sweep” of the playground prior to returning inside but said it was “not thorough enough.” SP2 thought s/he had all of the children and took responsibility for the incident. · SP2 was trained to do name to face counts every hour or whenever the class went through a door. Additionally, when children came inside, staff persons were trained to line the children up along a wall and count them. The counts were kept on a name to face sheet on a clipboard. · SP2 stated the risks to the AV outside without supervision included a potential fall off the climber and tripping on the cement. The FM stated that P3 notified him/her of the incident. The FM did not know how long the AV was outside without supervision and questioned if head counts were conducted to prevent situations like that of the AV. The facility Supervision Policy stated that staff persons should be aware of how many children were in their care and where all children were at all times. The playground was considered an extension of the classroom with the same supervision standards and ratios. However, staff persons should consider other supervision “challenges” which the outdoor environment presents. The facility Employee Handbook Policies and Procedures stated that all children were to be supervised within sight and sound at all times. Staff persons were never to leave a child unsupervised. The Safety and Supervision Policy stated that staff persons were to spread out on playground, so they were within sight of all children when outside and that they were to know how many children were in their care at all times. Staff persons were to conduct name to face hourly checks to track the children in their care and to conduct name to face checks during transitions from one area to another. Facility records showed that P1, P2, SP1, and SP2 were each trained on the Safety and Supervision Policy, job responsibilities specific to the individual’s position at the facility, and the Reporting of Maltreatment of Minors. 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: On the morning of August 24, 2023, SP1 and SP2 were on the playground with 16 preschool children including the AV. SP1 and SP2 provided consistent information that SP1 brought a child inside to use the bathroom which left SP2 outside with the remaining children. SP2 said s/he lined up the remaining children, did a count, and then entered the building from the playground to bring them back to the classroom. Approximately 15 minutes later, P2 found the AV unsupervised on the playground, which was a violation of Minnesota Rules, part 9503.0045, subpart 1, item A and Minnesota Statute section 245A.02, subdivision 18. Although the AV was found uninjured in an enclosed fenced in area, given the AV’s age, that the AV was left unsupervised on the playground for approximately 15minutes, 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 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. 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 trained on the Safety and Supervision Policy, job responsibilities specific to the individual’s position at the facility, and the Reporting of Maltreatment of Minors. Immediately prior to the incident, SP1 and SP2 were the staff persons responsible for the supervision of the children on the playground, including the AV. SP1 and SP2 provided consistent information that SP1 took a child inside to use the bathroom and that SP2 remained on the playground getting the children ready to come inside. SP2 was then responsible for ensuring the remaining children, including the AV, returned inside. Therefore, SP1’s responsibility was mitigated and SP2 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 SP2 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not sustain any injuries or require the care of physician. 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 their policies regarding being within “sight and sound” of children were not followed. The facility retrained staff persons on the facility’s supervision policies. Action Taken by Department of Human Services, Office of Inspector General: SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 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 the disqualification of SP2. The determination that the SP2 was responsible for maltreatment is subject to appeal. On February 28, 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.
|
