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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: 1021279-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on a playground unsupervised for approximately 15 minutes. Date of Incident(s): December 19, 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 January 25, 2024; from documentation at the facility; and through five interviews conducted with four facility staff persons (SP1, SP2, SP3, P), and the AV’s family member (FM). The facility was located on the ground floor of a business building. There were sixteens classrooms in the facility including the Toddler 3 classroom. There was a fenced toddler playground outside that contained several play structures. From the Toddler 3 classroom, there were two long hallways before arriving at a door to the playground. The AV was 17 months old at the time of the incident and enrolled in the Toddler 3 classroom. The P provided the following information: · On December 19, 2023, at approximately 4:45 p.m., SP1 told the P that the AV was left on the playground by accident. SP1 said that it was discovered after the classroom had returned inside and were putting on children’s shoes. There was an extra pair of shoes that were the AV’s. SP1 ran back to the playground and found the AV. · SP1 said that s/he miscounted the children as there were many parents coming and going. The P asked what method they were using to count and SP1 said they were using a master list. The master list was a list of children from all three toddler classrooms. The children were crossed off throughout the day so that the staff persons knew when they could combine classes and cut staff persons while staying in ratio. · The P said that staff persons did a name to face count for transitions and use a laminated clipboard that had space to check off each child. A name to face count should be done when leaving the playground and when they had returned to the classroom. SP1, SP2, and SP3 provided the following information: · On the date of the incident SP1, SP2, and SP3 were outside on the playground with children from Toddler 2 and Toddler 3 classrooms. It was pick up time and the number of children had dropped to 14 so SP3 was going to leave the facility. · SP1 and SP2 were bringing the children inside, but SP3 stayed to assist them into the building. SP1 had a clipboard with the master checklist and walked inside first with most of the children. SP2 came in next bringing in the rest of the children. SP3 glanced around the playground and then came inside last. · There were several children that were trying to run down the hallway. SP1 got those children while SP2 got the other children on the rope. P3 said that s/he would help by walking down to the classroom with SP1 and SP2. SP3 left the class at the Toddler 3 classroom door and went to clean up his/her classroom (Toddler 2) before leaving his/her shift. · Once SP1 and SP2 arrived in the classroom with the children, SP1 changed several children’s diapers while SP2 assisted the children out of their winter clothing. SP1 started handing out shoes and noticed that the AV was not in the classroom, but his/her shoes were still in the classroom. · SP1 asked SP2 if the AV had been picked up and then SP1 peeked into the adjoining classroom to see if the AV was there. The AV was not in that classroom so SP1 went back out to the playground and found the AV on a climbing structure. The AV did not seem upset and was not crying. · SP1 said s/he “thought” s/he counted the number of children while leaving the playground and s/he thought the number matched the number on the clipboard but not do a name to face count. Staff persons “normally” counted the children when back at the classroom but SP1 and SP2 did not count the children when they arrived back at the classroom on the day of the incident. · SP2 said that SP1 counted the children and said they were all there. SP2 did not count the children and just took SP1’s “word.” “Normally” the children were counted once they were back in classroom, but SP2 was “guessing” they did not count, or it would have been noticed the AV was not in the classroom. · SP3 said that when the classroom came inside to the hallway, s/he asked SP1 how many children they had and SP1 said 10. SP3 counted and said that there were nine children on the walking rope and SP1 had a child, so they had 10 children. They then proceeded down the hallway towards the classroom. The FM had no previous concerns with the facility. Video footage showed that on December 19, 2023, at 4:27 p.m., SP1, SP2, and SP3 gathered the children at the door of the playground and brought them inside. (There was no video footage of the hallway.) At 4:30 p.m., the children entered the classroom from the hallway while hanging onto a walking rope. There appeared to be 10 children that entered the classroom along with SP1 and SP2. At that time there was already a community person and a child in the classroom gathering their belongings. SP1 had a clipboard in his/her hand and went over to the counter area out of camera view but was likely changing diapers. SP2 started assisting the children with taking off their jackets, snowpants, and boots. At 4:32 p.m., another community person came in to pick up a child and left. At 4:33 p.m., P3 came into the classroom, placed something on the table and then left the room. At 4:38 p.m., 4:40 p.m., and 4:42 p.m., family members arrived to pick up children. SP1 and SP2 continued to assist the children with taking off their outside clothes and putting on their shoes. At 4:43 p.m., SP1 appeared to count the children as s/he pointed at a few of the children and then looked at the clipboard. At 4:45 p.m., SP1 picked up a pair of shoes off a table and looked around. SP1 looked at the clipboard and then went into the adjoining classroom for a few seconds. Then SP1 went over to the locker area and looked in a locker before leaving the classroom. At 4:46 p.m., SP1 entered the playground and found the AV on a large play structure. SP1 lifted the AV off the equipment and carried him/her inside. At 4:47 p.m., SP1 enters the classroom carrying the AV. According to www.wunderground.com, the outdoor condition at the facility, on December 19, 2023, at the time of the incident, was “mostly cloudy” with a temperature of 36 degrees Fahrenheit (°F) and wind speed of 5 miles per hour (mph). The Employee Handbook stated that children must be within sight and sound at all times. Staff persons accurately counted children at each transition. The Child Care Center Risk Assessment and Reduction Plan stated that when transitioning from one area to another area, children formed a line using a walking rope. Staff persons called the children by name to hold onto the walking rope. Staff persons used a name to face count every time the rope was used. One staff person was at the front of the line and one staff person was at the back of the line. Staff persons counted the number of children transitioning to ensure that all children were present. Facility documentation showed that staff persons were trained on the facilities policies including the Employee Handbook and The Child Care Center Risk Assessment and Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states that a child must have supervision at all times and that supervision is defined as occurring when a program staff person is within sight and hearing of a child at all times so that the program staff person can intervene to protect the health and safety of the child. Conclusion: A. Maltreatment: Information was consistent that on December 19, 2023, the AV was left on the facility’s playground without the knowledge or supervision of a staff person for approximately 19 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1, SP2, and SP3 were each not aware that the AV was still on the playground when they took the other children back to the classroom, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Although the playground was fenced, the AV, who was 17 months old, was unsupervised for nineteen minutes with no staff person available to intervene if the AV attempted to do something dangerous, injured him/herself, or in the event of an emergency. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health when reasonably able to do so. It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so and/or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. SP1, SP2, and SP3 were each trained on the facility’s policies including the Employee Handbook and The Child Care Center Risk Assessment and Reduction Plan and the Reporting of Maltreatment of Minors Act prior to the incident. At the time of the incident, SP1, SP2, and SP3 were supervising children from the Toddler 2 and Toddler 3 classrooms, which were combined, on the playground. The number of children had decreased enough that SP3 was leaving his/her shift leaving SP1 and SP2 responsible for the children. SP3 stayed with the group assisting until they came to the classroom door. SP1 said s/he counted the number of children while leaving the playground and s/he thought the number matched the number on the clipboard but did not do a name to face count or count the children when they arrived back in the classroom. SP2 said SP1 counted the children as they left the playground, but no count was completed when they returned to the classroom. SP3 said s/he asked SP1 how many children they had and SP1 said 10. SP3 counted and said that there were nine children on the walking rope and SP1 had a child, so they had 10 children. SP3 walked to the classroom door and left SP1, SP2, and the children there. Each SP1, SP2, and SP3 were responsible for the supervision at the time that the AV was left on the playground. Although SP3 was leaving the facility, s/he stayed to assist SP1 and SP2 in getting the children lined up and into the building to ensure that all children returned inside. SP1, SP2, and SP3 were responsible for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which SP1, SP2, and SP3 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV was not injured. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed when staff persons did not complete a name to face count of the children. Staff persons involved received corrective action. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1, SP2, and SP3 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, SP2, and SP3 were each responsible for maltreatment is subject to appeal. On March 6, 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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