|
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: 1100956-CCC (Child Care Center) Investigator(s): Beth Virden beth.virden@state.mn.us Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left the gym without a staff person’s knowledge or supervision. The AV was unsupervised in a public hallway, accessible to community persons, for two to three minutes before being discovered by an unrelated parent and returned to the classroom, unharmed. Date of Incident(s): February 5, 2024 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 February 22, 2024; from documentation at the facility; and through interviews conducted with a community person (CP), facility staff persons (SP1 and SP2), and a supervisory staff person (P). SP1 was also the AV’s family member. At the time of the incident, the AV was 16 months old and enrolled in the facility’s toddler classroom. The facility shared a building with a community church. The facility’s main door opened into a church hallway; this door remained locked and accessible with a keycode. The church hallway was not locked but rather accessible to anyone who entered the church. The building had more than one exterior door; one of which was directly outside the facility’s locked door. The facility used the church’s gymnasium (gym), which was at the end of this same church hallway. In order for a classroom to use the gym, they had to leave through the facility’s locked doors, walk down the church hallway, and enter through the gym double doors. The building, itself, was located on the outskirts of town. A parking lot wrapped around more than one side of the building and there was more than one vehicle entrance into the lot. The nearest road had a speed limit of 30 miles per hour. Trees, single and multi-family housing, other streets, ponds, and an industrial building were in the immediate vicinity. The CP said that on February 5, 2024, around the middle of the day, s/he entered the building and then went through the facility’s locked door to return his/her child from an appointment. After dropping his/her child off, the CP walked back through the facility’s door into the church hallway and saw a child (the AV) standing on the rug in the church hallway directly inside the exterior door leading to the parking lot. There was no one with the AV. The CP believed if the AV had been older, s/he could have pushed open the exterior door and left the building. “The doors outside are right there.” The AV did not look upset. The CP alerted a facility receptionist who brought the AV to the P. The P provided the following information: · On February 5, 2024, around 9:30 a.m., the receptionist brought the AV to the P. The AV had been found by the CP in the church hallway. The AV seemed “fine … not at all upset.” The P then brought the AV to the gym where SP1 and SP2 were with the AV’s classroom. SP1 had just returned from the bathroom and was starting to look for the AV. “[SP2] didn’t realize [the AV] had left. [S/he] was assisting two other children that needed help. [SP1] told me [s/he] heard [the AV] knocking on the bathroom door.” Based on the CP’s, SP1’s, and SP2’s statements, the P believed the AV was unsupervised in the hallway for two to three minutes. · At the time of the incident, the facility did not have a procedure regarding what should occur when one staff goes to the bathroom leaving one staff behind with children. The P believed staff would know to call for help if going to the bathroom would create an issue. Since this incident, the facility made changes so that every time a staff used the bathroom or left the room, they were required to call for someone else to step in while they were away. · Staff were trained to count the children before and after each transition and then throughout the day, like every 15 minutes or more frequently during busy times. The facility had an application (app) on each staff person’s cellphone for them to record their counts. In looking back at this incident, SP1 and SP2 did not record their counts on the app on February 5, 2024. SP1 and SP2 provided the following information: · SP1 said that on the morning of February 5, 2024, s/he was running late. Typically, SP1 preferred to drop the AV off in the classroom early, which allowed SP1 time to prepare for his/her workday, including using the bathroom. However, on this day, SP1 did not have time to use the bathroom prior to being in the classroom with all of the children. SP1 was working with SP2 on this day. · Around 9:15 to 9:30 a.m., SP1 and SP2 brought 14 children, including the AV, to the gym to play. Once there, SP2 said that s/he needed to use the bathroom. SP2 left while SP1 remained with the children. When SP2 returned, SP1 needed to use the bathroom. SP1 and SP2 each said that SP1 told SP2 that s/he was leaving for the bathroom and SP2 said, “Okay.” · SP1 said that when s/he prepared to leave the gym for the bathroom, the AV had his/her back turned. SP1 hoped to sneak out before the AV noticed; however, as soon as s/he walked out of the gym double doors, s/he heard the AV start crying. The AV had a history of getting upset when SP1 left the room. · SP1 entered the bathroom, which was about 15 feet from the gym double doors. There was more than one stall in the bathroom. SP1 closed the bathroom door behind him/her. While in the bathroom, SP1 heard, what sounded like the AV run up to the bathroom door and hit it with both hands. The AV was not able to open the door. About two minutes later, SP1 returned to the gym. SP1 did not see the AV in the hallway and began scanning the gym for him/her. SP1 noticed the AV was missing and almost simultaneously, the P entered the gym with the AV in hand. The AV was not injured and “not even upset.” SP1 believed the AV was unsupervised in the hallway for about two minutes. · SP2 said that when SP1 left the gym, s/he was bent down addressing two children who were fighting and crying. The rest of the children were spread out playing in the gym. SP2 was aware SP1 had left the gym. However, when the AV was returned to the gym by the P, SP2 learned that the gym double doors were stuck on a doorstop and did not close completely when SP1 left for the bathroom. · After addressing the two children who were fighting and crying, SP2 sat at a table, took a drink of water, and checked his/her cellphone app to read a message from another parent. At that point, SP1 returned to the gym and almost simultaneously, the P arrived with the AV in hand. SP2 did not know the AV left the gym. SP2 believed the AV was unsupervised in the hallway for “probably two to three minutes.” · SP1 and SP2 were trained to count children before and after each transition. On the day of the incident, SP1 and SP2 each counted the children as they entered the gym, and all were accounted for. SP1 and SP2 each said that they also counted the children, while in the gym, at some point prior to SP1 leaving for the bathroom, and all were accounted for. SP1 and SP2 each forgot to record the counts on the facility’s app but said that the counts were completed, just not documented. · SP1 said that SP2 was on his/her cellphone when s/he left and when s/he returned to the gym. The facility’s policies and procedures stated the following: · Safety is an ongoing and primary focus. The following rules must be adhered to: Never leave a child unattended; Always count the children before and after transitions; Do name to face in Bright Wheel to verify children; and Be sure that staff-to-student ratios are followed at all times. · Children are always supervised when in the hallway … Children are always supervised both in the building and outside. Facility documentation stated that SP1, SP2, and the P received training on the facility’s policies and procedures and the Reporting of Maltreatment of Minors Act.
Relevant Minnesota Statutes and Rules: 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. Additional licensing concerns: · Based on staff interviews and documentation provided by the program, it was determined that on February 5, 2024, two staff persons were supervising 14 children ranging in age from 15 months to two years old. The minimally acceptable staff-to-child ratio for the toddler age category is 1:7; however, having a 15-month-old (infant) present dropped the ratio to an infant ratio of 1:4. Two additional staff were required. Minnesota Rules, part 9503.0040, subpart 1, states that the staff-to-child ratios must be always maintained. A licensing violation was determined. · Based on staff interviews and documentation provided by the program, it was determined that on February 5, 2024, a 15-month-old infant was combined with toddlers in the gym. Minnesota Rules, part 9503.0040. subpart 3, item B, (1), states that during the center's regular hours of operations, infants must not be grouped with children of other age categories. A licensing violation was determined. Conclusion: On February 5, 2024, the AV left the gym without a staff person’s knowledge or supervision. The AV was unsupervised in a public church hallway for around two minutes before being discovered by the CP and returned to the facility. The failure to ensure the AV was always supervised was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 told SP2 that s/he was leaving the gym to use the bathroom. SP1 counted the children at some point prior to leaving the gym, and all were accounted for. SP2 was aware SP1 left the gym. SP2 was the sole staff person in the gym at that point. Consistent information was provided that the AV left the gym shortly after SP1. Minnesota Statutes, section 260E. 30, subdivision 3 states 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. Although the AV was unsupervised for two minutes, it was determined SP2’s actions were a nonmaltreatment mistake for the following reasons: 1) At the time of the incident, SP2 was performing duties identified in the center's childcare program plan. SP2 was in the gym with the toddler classroom and at that time, addressing two children who were fighting and crying. In addition, the gym double doors were stuck on a doorstop and did not close completely likely when SP1 left the gym and the AV likely followed SP1 out of the gym at that point because SP1 heard what sounded like the AV run up to the bathroom door and hit it with both hands; 2) SP2 was not determined responsible for a similar incident of maltreatment within the previous seven years; 3) SP2 was not determined responsible for a similar nonmaltreatment mistake under this paragraph within the previous four years; 4) The AV was uninjured and did not require medical care after the incident; and 5) Except for the period when the incident occurred, the facility and SP2 were both in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake to the AV by SP2 was not maltreatment. 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; 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). 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 and procedures were adequate but not followed. The facility made changes regarding instructions when staff used the bathroom and requiring staff to always carry a handheld radio. Action Taken by Department of Human Services, Office of Inspector General: SP2 was not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which SP2 was responsible met the criteria to be determined a nonmaltreatment mistake. SP2 was notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP2 is responsible might not be considered a nonmaltreatment mistake. On March 13, 2024, the facility was issued a Correction Order for the violations 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.
|
