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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: 1103780-CCC (Child Care Center) Investigator(s): Danielle Morrison/Shad Cook 651-431-5647 Suspected Maltreatment Reported: It was reported that two alleged victims (AV1 and AV2) were unsupervised on the facility playground. AV1 was without supervision for approximately 15 to 40 minutes and AV2 was without supervision for approximately 60 minutes. Date of Incident(s): August 15, 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 31, 2023; from documentation at the facility; and through nine interviews conducted with six staff persons (P1, P2, P3, P4, P7 and the SP), a facility supervisory staff person (P5), and AV2’s family members (FM1 and FM2). Attempts were made via phone and U.S. mail to contact and interview AV1’s family member (FM3), but the attempts were not successful. AV1 and AV2 were each 33 months old at the time of the incident and enrolled in the preschool classroom and due to their age, AV1 and AV2 were unable to provide information for this investigation. The facility was in the middle of a multi-use building that had two other businesses, one on either side. The building was located between Highway 53 with an exit ramp and a two-lane road that was part of a “T” intersection. The facility playground was on the side of the building and fenced with chain link fencing. The playground was partially visible from the “T” intersection but fully visible from the off ramp and a parking lot located directly next to the playground. The playground was accessed by leaving through a back door of the facility and walking approximately 50 feet along the back of the building to a gated entrance of the playground. There was a storage tent located within the fenced-in playground that stored strollers and larger toys. The storage tent had two zippers in the front that were used to access the inside of the tent. The playground had a second gate that led to the parking lot in front of the building. The facility had one large preschool classroom with a maximum capacity of 40 children. Within the classroom, staff persons had an assigned roster of children they were responsible for. This group of children was consistent from day to day unless new children started or to meet facility staffing needs. The preschool schedule provided the following information: · 10-11 a.m. – Outside · 10:45-10:55 a.m. – Bathroom/Water · 10:55-11:30 a.m. – Art Activities · 11:30-11:50 a.m. Lunch · 11:50 a.m.-12 p.m. – Lunch clean-up · 12-2 p.m. – Nap time Information obtained showed that on the morning of August 15, 2023, the SP, P1, a staff person (P6), and P7 worked in the preschool classroom with 30 children. At 10 a.m., the SP, P1, P6, and P7 took the children to the playground. Once the children entered the playground, P6 went on a scheduled break and did not return while the classroom was outside. The SP, P1, and P7 remained on the playground to supervise the preschool class. The facility Incident Report stated that on August 15, 2023, AV1 and AV2 were unsupervised on the playground as both “snuck away” from the group and crawled into the storage tent. During the incident, AV2 crawled into a stroller and buckled him/herself in. FM1 stated that AV2 recently moved into the preschool classroom. FM1 was notified by P5 that AV2 was left “unattended” in a stroller outside. P5 told FM1 that the incident was a result of “a miscommunication between the teachers on which group each teacher was watching.” FM1 was told AV2 crawled in a zip up tent with a friend (AV1) where strollers were located and was buckled in a stroller. AV2 was in the tent for 30 minutes. FM1 stated that AV2 did not say anything about the incident. FM1 did not have any prior concerns about the facility. FM2 was notified by P5 that AV2 was buckled into a car seat in a storage tent and the class went inside without AV2. (Note: All other information showed that it was a stroller.) FM2 stated AV2 appeared “fine.” FM2 did not have any concerns with the staff persons. FM2 said his/her concern was taken care of when the storage tent was moved to prevent a similar incident from happening again. P2 provided the following information: · On the date of the incident, prior to serving lunch to the preschool classroom at 11:30 a.m., P2 went outside for a break. When P2 got outside, s/he saw AV1 outside near the entrance of the facility. There was no one else outside with AV1. AV1 then ran towards P2. AV1 was “crying a little bit” but stopped when P2 brought him/her inside. P2 then brought AV1 inside to P3. P3 asked P2 to find P5 and to have P5 come to where P3 was with AV1 and P2 did so. · P2 stated that the classroom was divided into groups and AV1 was with the SP’s group. The other staff persons in the classroom were P1, P6, and P7, but P2 thought P6 was on break at the time this happened. · P2 said that it was “hot” that day around 80 degrees Fahrenheit. P2 stated s/he was not sure what time AV2 was found. P4 provided the following information: · Around noon on the day of the incident, P4 was cleaning lockers in the hallway right by the front door when P2 opened the front door to go outside for a break. AV1 ran up to P2, then saw P4 and ran up to him/her as AV1 used to be in P4’s classroom. AV1 was “hysterical, crying, and shaking.” AV1 was not able to verbalize what happened. · P2 then took AV1 to P3 and explained what happened. P3 walked AV1 back to his/her classroom. · P4 said the transition procedure to and from the playground was to do head counts and to do them “constantly.” P3 provided the following information: · On the day of the incident, at some point prior to 11:30 a.m., P3 was assisting in the preschool classroom covering for a staff person’s break (P3 could not remember if it was P1 or P6). Around this time, P2 came to the classroom and asked P3 to come into the hallway. P3 did so and saw that P2 had AV1 with him/her in the hallway. P3 stated that P2 found AV1 outside in front of the building. · P3 and AV1 then walked back into the classroom to begin setting up for lunch. P3 said that when lunch was set up in the classroom, the cots for afternoon naps were also set up. At that point, P3 noticed AV2’s pacifier was on a classroom table, which AV2 “always” had with him/her. P3 said that when s/he saw the pacifier and not AV2, s/he immediately ran out of the classroom and to the outside playground to search for AV2. P3 searched the playground because AV1 and AV2 were “best buddies and did everything together.” P3 stated that if AV1 was left behind, AV2 probably was left behind. The remainder of the staff persons in the classroom searched the classroom for AV2. · P3 searched the playground but did not see AV2. Then, P3 searched the storage tent and discovered AV2 buckled in a stroller and AV2 could not get out. P3 stated AV2 appeared “fine,” was brought inside, given a drink, and brought to the preschool class for lunch and nap time. · P3 stated that the preschool classroom had between 25-35 children each day. Each staff person in the preschool classroom had an assigned group of children s/he worked with. This group was listed on an index card made by P5. · P3 said the transition procedure to and from the playground was head counts at the fence, door, bathroom, and then in the room, which each staff person should do for their assigned group. P1 provided the following information: · Each staff person in the preschool classroom had the same assigned group of children s/he was responsible for listed on an index card. The index cards were used by each staff person for the supervision of children. P1 stated that AV1 and AV2 were assigned to the SP’s index card. · Tablets were also utilized to show which children were checked-in as being present at the facility each day. When the children were brought outside to play, staff persons brought binders, a clipboard, and attendance sheets with them to aid in supervision. While outside, staff persons kept track of the children they were assigned on the index card but monitored “all” the children for safety. · On the date of the incident, at 10 a.m., the SP, P1, P6, and P7 began to bring their individual groups to the playground for morning playtime. When the 30 children were on the playground, P6 went on his/her scheduled break. The SP, P1, and P7 supervised the 30 children for the duration of the time on the playground. The SP, P1, and P7 transferred the children from P6’s index card to their cards to help supervise those children outside and transition them back inside the facility. · At 10:45 a.m., when it was time to go inside, P1 took his/her group in. The SP and P7 were still on the playground with their groups. After P1’s group was inside, his/her children worked on an activity while the SP and P7 came inside with their two groups of children. · During this time P1 recalled another child telling either the SP or P7 that s/he heard something in the tent while they were outside. The SP stated s/he thought s/he did too, but the SP did not check it out while they were outside. P3 had come into the classroom to help with supervision until P6 returned. · P1 stated s/he saw P4 out in the hallway and P4 told P1 that AV1 was found crying outside in the parking lot of the facility. P1 stated that AV1 was found between 11:15 and 11:20 a.m. P1 described AV1 as “very shaken up” when s/he returned to the classroom. · P1 returned to the classroom and told the SP that AV1 was left outside. The SP seemed surprised by this. P1 told the SP to do a headcount of his/her assigned group to which the SP responded, “Okay.” The SP did a head count and said, “We’re good,” and P1 asked the SP if s/he was positive, and the SP replied, “Yep.” · When the children were ready for lunch, P1 noticed an extra tray and initially believed P2 gave an extra tray for the classroom. The children then ate lunch. When it was time for nap, there was an additional cot, and staff persons realized they were missing a child. P3 then asked where AV2 was and if AV2 was in the bathroom. The SP replied that s/he “might be.” P1 and P3 asked the SP to check if AV2 was in the bathroom because AV2 was part of the SP’s group of children. P3 then left to go look for AV2. · A few minutes later, between 12 and 12:15 p.m., P1 was told that P2 found AV2 buckled into a stroller inside the storage tent on the playground. (Note: All other information showed that P3 found AV2.) · P1 stated that when transitioning from the playground, staff persons were to line the children up and count the children. Once inside the children sat down on the benches, shook out their shoes, and the staff person checked them in using their names. · P1 said there were times if a child was “rampy” with other children in their group, they might go with another staff person. P1 thought another child was moved that day, but the SP was responsible for AV1 and AV2. P7 provided the following information: · On the date of the incident, around 10 a.m., the class of 30 preschoolers was brought outside by the SP, P1, P6, and P7. As soon as the children entered the playground, P6 went on a scheduled break. Once outside on the playground, there were 3 staff persons (the SP, P1, and P7) with 30 children. · P7 stated that the SP was responsible for AV1 and AV2 that day in the preschool classroom because they were on the SP’s index roster card. · Between 11 and 11:05 a.m., when it was time to return inside, P1 brought his/her group of ten children inside. After P1 returned inside, a parent dropped off his/her child onto the playground as the remaining preschool children were lining up to go inside, making the total count of children outside 21. · At approximately 11:15 a.m., the SP and P7 were lining children up and counted 19 children. P7 counted and looked at all the children in his/her group and confirmed they were all present. The SP then told P7, “They are all here.” P7 then brought his/her ten children inside followed by the SP with his/her group. · Once they were inside, staff persons got the children ready for lunch. Between 11:35 and 11:40 a.m., AV1 was found crying in the parking lot by P4 (Note: All other information showed that P2 found AV1). When AV1 returned to the classroom s/he seemed “fine.” · As the staff persons were getting blankets set out on the children’s cots for naptime, it was noticed that AV2’s pacifier was there, but AV2 was not so they started looking for AV2. P7 stated that at one point s/he went into the hallway and AV2 was in the hallway and had been found outside by P2 buckled in the stroller in the tent. (Note: All other information showed that P3 found AV2.) When P7 saw AV2, s/he seemed “scared” and was crying. · Staff persons were trained to do head counts while outside at the gate, at facility door, in the hallway, and once back to the classroom. P7 did not know if the SP did a headcount after his/her group came inside the building. · P7 stated that it was warm with a little bit of a breeze and got hotter throughout the day. · P7 said that sometimes children will be moved to a different group if they were not listening, but AV1 and AV2 were not shifted on the day of the incident. The SP provided the following information: · On August 15, 2023, the SP worked in the preschool classroom with P1, P6, and P7. There were 30 children including AV1 and AV2, and the SP was responsible for the supervision of AV1 and AV2. However, on the day of the incident, the SP “did not remember” that AV1 was in his/her group but remembered AV2. At some point, the SP, P1, and P7 took the children outside to the playground while P6 was on break. · When it was time to transition the class inside for lunch, P1 was the first to leave the playground with his/her group of ten children and returned inside. · The SP and P7 remained on the playground with their groups of children including AV1 and AV2 from the SP’s group. Prior to going inside, a parent dropped his/her child off on the playground, making the total count of children on the playground 21. The SP then sent a text message to P5 notifying him/her of the additional child. · Typically, staff persons brought the children inside with their assigned groups spaced apart at five-minute intervals. However, on the date of the incident the SP said s/he brought his/her group of children inside at the same time as P7 because it was close to lunch. · At 11 a.m., the SP returned inside the building with his/her group of children and when they got inside, the SP counted first and then looked around. The SP thought AV2 returned inside, that s/he changed AV2’s diaper, and then AV2 went and sat with his/her sibling in P1’s group. The SP said AV1 was not normally in the classroom because it was AV1’s first day visiting in preparation to move to this classroom and “all together it was a little overwhelming.” The children used the bathroom or had their diapers changed, and moved onto an activity before lunch was served. After the activity started, P2 and P4 found AV1 outside in the front of the facility. The SP stated AV1 was outside for approximately 10-20 minutes. · Later when the SP was looking for AV2 to give AV2 his/her pacifier, P3 asked how many children were in the classroom and P3 realized that AV2 was not in the classroom, so P3 ran out of the classroom to look outside for him/her because AV1 had been found outside and they were friends. AV2 was found “a little after 12 p.m.” The SP said that when AV2 returned to the classroom, his/her cheeks were a little “red.” · The SP felt it was his/her “fault” and s/he had “bad” dreams about what could have happened to AV1 and AV2 including “that [they] could have died.” · The SP said the transition procedure included counting the children, maintaining the small groups, and utilizing name to face. The SP said that on that day, s/he “somewhat” did that. The SP was on the playground and walked around in a circle checking the playground. · Regarding counting 19 children instead of 21, the SP said, “I guess my brain malfunctioned and did not realize we had more than we were supposed to have. · The SP stated that it was warm that day between 70-80 degrees Fahrenheit. P5 provided the following information: · The preschool children were divided into four groups and each staff person in the preschool room had a set roster of children they were responsible for supervising. · P5 said that when transitioning to the playground, each staff person and their assigned children left in five-minute increments from the classroom to go outside to the playground. The individual groups started at 10 a.m. Then beginning at 10:40 a.m., the same five-minute increments were used when leaving the playground to return into the classroom to allow each group time to do things such as shake sand from shoes, monitor bathroom use, and start diaper changes. · On the morning of August 15, 2023, the SP, P1, P6, and P7 were assigned to the preschool classroom and had 30 children in their room. At some point, the preschool class went to the playground and P6 left for break. When the preschool class started to transition inside the facility, a parent dropped off a preschooler directly on the playground, making the class size 31. · At approximately 11:10 a.m., P5 was in the toddler room and was told by P3 that P2 found AV1 walking outside in the parking lot and crying by the front door. P5 and P3 assessed and comforted AV1 and both brought AV1 to the preschool room. · P5 then spoke to the SP who was the last staff person on the playground when the preschool came inside and AV1 was in the group of the SP. The SP told P5 that there was “confusion” on the playground because some children switched groups based on their “behavior.” (Note: There was no information that these children were AV1 or AV2). · Then at some point, P3 found AV2’s pacifier in the classroom and asked where AV2 was and ran out of the facility to the playground. P5 said P3 found AV2 buckled in a stroller inside the storage tent on the playground. · P5 said that the SP would have left the playground between 10:50 and 11:05 a.m. based on the classroom schedule to return to the classroom so AV1 was unsupervised for 20-30 minutes. P5 did not know how long AV2 was unsupervised because s/he “never looked at a clock” but thought that AV2 was found prior to noon. · P5 stated that the SP was the last one on the playground and the SP had AV1 and AV2 assigned to his/her index card for the day, so the SP was responsible for the supervision of AV1 and AV2. · Staff persons were trained to spread out across the playground to monitor the two gates and to stop children from going toward the front gate, which was near the building parking lot. The front gate was behind the storage tent. The storage tent was off limits to the children and was strictly for storage. P5 said staff persons were to position themselves by the tent to ensure that children did not access it. The facility Risk Reduction Plan stated that staff persons were to have children in view at all times, including while outdoors. Staff persons were aware of the number of children they had with them at all times. During transitions, children were supervised at all times following staff person to child ratios. Staff persons had a daily attendance sheet with them at all times and were to continuously do head counts. Head counts were done when exiting a room and when entering a new room to ensure all children are present. According to Weather Underground (www.wunderground.com), on August 15, 2023, from 11 a.m. to 12 p.m., the weather in Virginia, Minnesota was 76 degrees Fahrenheit. Facility documentation showed that P1, P2, P3, P4, P5, P7, and the SP, and each received training regarding the Risk Reduction Plan, and Reporting of Maltreatment of Minors Act. Relevant Rules and Statutes: Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A, state that “supervision” means 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; and that children are required to be supervised at all times. Conclusion: A. Maltreatment: On August 15, 2023, AV1 and AV2 were left unsupervised on the facility playground without the knowledge of staff persons which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. AV1 was without supervision between 15 and 30 minutes and AV2 was left without supervision between 35 and 60 minutes. P2 and P4 found AV1 crying in the parking lot of the facility. P4 described AV1 as “hysterical, crying, and shaking.” At some point after AV1 was found, AV2’s pacifier was found in the classroom and P3 went outside and found AV2 buckled in a stroller in the storage tent. P3 said that AV2 was “fine” when s/he was found. However, P7 said that when s/he saw AV2 in the hallway after being found, AV2 was “scared” and was crying. When both returned to the classroom, they were “fine.” Given that AV1 and AV2, who were each 33 months old, were left unsupervised for 15 to 30 minutes and 35 to 60 minutes respectively without staff persons knowing, each was exposed to community dangers and community persons, and staff persons would not have been able to intervene if necessary or in the event of an emergency there was a preponderance of evidence that there was a failure to provide AV1 and AV2 with necessary care and a failure to protect AV1 and AV2 from conditions and/or actions that seriously endangered the physical and/or mental health of AV1 and AV2 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. 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. On the day of the incident, P1, P6, P7, and the SP were on the playground with 30 children, each with a list of children they were responsible for on a card. The SP has AV1 and AV2 on his/her card. P6 went on break and did not return to the playground. When it was time to go inside, P1 went inside with his/her 10 children. Soon after, P7 and the SP went inside with their children at the same time, counting all of the children. P7 then verified the children listed on his/her card were present and they went inside. Although P1, P6, and P7 were also on the playground at some point, P6 was mitigated from responsibility because s/he was on break and did not return to the playground, P1 was mitigated from responsibility because s/he took the children s/he was responsible for inside prior to the other groups, and P7 was mitigated from responsibility because s/he did not have AV1 or AV2 on his/her card and s/he verified that the children on his/her card were present before going inside. The SP was trained on the Risk Reduction Plan and the Reporting of Maltreatment of Minors Act and was responsible for the care and supervision of AV1 and AV2 both who were on the SP’s card. Therefore, the SP was responsible for the maltreatment of AV1 and AV2. 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 because it was a single incident that impacted two alleged victims and AV1 and AV2 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 determined that policies and procedures were adequate but not followed including regarding staff persons following name to face counts. Following the incident, the storage tent was moved outside of the playground fence. Additionally, staff persons were to do a visual sweep of the playground during and after use. 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 the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On March 15, 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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