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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: 1056589-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was in a classroom without staff person knowledge or supervision for approximately seven minutes. Date of Incident(s): December 12, 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 3, 2024; from documentation at the facility; and through four interviews conducted with a supervisory staff person (P), two facility staff persons (SP1 and SP2), and the AV’s family member (FM). This investigator also reached out to a community person (CP) via telephone for an interview, but the CP did not respond. This investigator met with the AV, but s/he did not provide information pertaining to this investigation. The AV was three and a half years old at the time of the incident and enrolled in the Triangulo (preschool transition) classroom. The facility was a stand alone building and had six classrooms. The Triangulo classroom was connected to the Corazon (preschool transition) classroom which was across the hall from the Rectangulo (preschool) classroom. SP1 provided the following information: · On December 12, 2023, around 4:15 p.m., SP1 lined up the children in his/her classroom to go to the Rectangulo classroom so that SP1 could leave for the day. SP1 got his/her notebook and bag, counted six children, saw their faces, and began to leave the classroom. The AV was at the end of the line and SP1 thought the AV asked for something from his/her cubby before leaving. · During the transition the CP was there to pick up his/her child and greeted SP1 during the transition. SP1 stated when s/he brought the children into the Rectangulo classroom for the end of the day, SP2 asked how many children SP1 had and SP1 told SP2 that s/he had already counted and that SP1 had six children, but one of them was with the CP. SP1 stated that s/he did not count once the children were in the Rectangulo classroom. · SP1 was done for the day, so s/he left the Rectangulo classroom and grabbed his/her belongings from another area and left. A little while after SP1 left, the P called to tell SP1 that the CP found the AV alone in the Triangulo classroom and that the AV was alone for five to six minutes. · SP1 stated s/he had a list with the names of the children on it as well as the iPad. SP1 said the list was in his/her bag that day and s/he handed the bag over to SP2 along with the iPad. SP1 was trained on transitions to use the list to count the children, make a line, bring the children to the next staff person, and then that staff person counted as well. SP2 provided the following information: · On the day of the incident around 4:30 p.m., SP2 was in the Rectangulo classroom with half of his/her class, the other half was in the gymnasium. Two family members walked into the classroom to pick up their children and then SP1 entered with his/her class. · At first SP2 told this investigator that SP1 told SP2 that s/he had six children, but then later stated SP1 did not tell SP2 how many children s/he had. SP2 said s/he counted five children and SP1 placed the list on the counter and left the classroom as s/he was done for the day. SP2 stated it was “busy” as family members were coming in. · SP2 stated that the CP entered the classroom and told SP2 that the AV was still in the other classroom. SP2 asked the CP to find the P since SP2 was alone in the classroom and could not leave. The P then entered the classroom with the AV who seemed “confused,” but was not crying. The AV then went to play in the classroom. The P asked SP2 what happened, so SP2 stated that s/he counted the children that came in. The P made sure SP2 knew what to do when children were brought to the classroom. · SP2 stated that s/he was trained on transitions to count the children, make sure they stayed in line, and then give the staff person the list of names. SP2 thought the AV was alone for five to seven minutes. The P provided the following information: · On the day of the incident around 4:30 p.m., the P was sitting at his/her desk when the CP approached the P stating that the AV was alone in the classroom hiding behind jackets. · The P then went into the Triangulo classroom and found the AV who told the P that s/he wanted his/her “stuffy” from the cubby. The P gave the AV his/her “stuffy” and they walked to the Rectangulo classroom. · Once inside the Rectangulo classroom, the P asked SP2 why the AV was alone. SP2 stated that SP1 did not bring the AV into the classroom. The P asked SP2 if s/he had the list from SP1 and SP2 stated that s/he did not look at it. The P reminded SP2 that when a staff person brings children to him/her to ask how many and which children were there. · The P then left the Rectangulo classroom, watched video footage, and then called SP1 who told the P that s/he counted the children, and that the AV was the last in line. The P stated that s/he had no prior concerns with how SP1 transitioned children. · The P stated that on the video s/he reviewed of the Triangulo classroom, and s/he saw SP1 line the children up and start walking backwards out of the classroom, but the AV did not move. After the class left, the AV hid under the cubbies in the jackets, until the CP came into the classroom and then the AV came out from under the jackets. The CP left the AV in the classroom and went to find the P. The camera view from the Rectangulo classroom was “blocked out a little bit,” but the children walked into the classroom and there were family members picking up. P1 stated that the AV was alone for “around four to five minutes.” (Note: This was the amount of time before the CP found the AV.) · The P stated that the policy on transitions was for staff persons to count the children and use name to face, and when bringing children to another classroom have the list, backpack, and iPad. If a staff person was alone, s/he was to walk facing the children, and when the staff person was leaving the classroom, s/he had to say which children were staying in the classroom. The FM stated that the P called to let the FM know that the AV was alone in a classroom. The FM was not able to remember the time frame of how long the AV was alone but stated that the AV was not impacted by the event and had no repercussion of something being amiss. The FM had no prior concerns with the facility and stated the AV “loved” SP1. On December 12, 2023, a supervisory staff person reviewed video footage, and on December 13, 2023, an administrative staff person reviewed video footage and they saw SP1 line up his/her children in the Triangulo classroom, grab his/her emergency backpack, go to the front of the line, and walk out of the classroom with the children at 4:30 p.m. The AV was the last child in line, and s/he did not go out with the rest of the group. The AV stayed in that area for about three minutes and then went over by the cubbies. At 4:34 p.m. the CP walked into the classroom and saw the AV alone. It looked as though the CP talked to the AV, and then left his/her older child in the classroom with the AV while s/he found a staff person. At 4:37 p.m., the CP returned to the classroom with the P. This investigator reviewed footage, but it did not show SP1 leaving the Triangulo classroom, and the angle from the camera in the Rectangulo classroom made it so that the total number of children lined up to enter the classroom was not entirely visible. The facility’s Procedure for Supervision policy stated that, “Children must be supervised at all times. Children are within sight and/or hearing of a staff [person] at all times.” In 1Core (an application used to for attendance), staff persons used the list for name to face and it was used at every transition, and it was the responsibility of both the [staff] person handing over and the [staff] person receiving. The facility’s Safety, Emergency, and Accident Polices and Risk Reduction Plan stated, “Head counts using the name to face procedure will be conducted frequently and before and after any transition times (boarding a bus, exiting a building, moving between rooms, going outside to the playground, etc.)” Facility records showed that the P, SP1, and SP2 were each trained on the facility’s Risk Reduction Plan and the 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: Consistent information was provided that on the afternoon of December 12, 2023, SP1 brought his/her children out of the Triangulo classroom into the Rectangulo classroom at the end of his/her shift. During this transition, the AV was left in the classroom and was found by the CP who reported to the P and the P went and brought the AV from the Triangulo classroom into the Rectangulo classroom. SP1 stated that s/he lined the children up with the AV at the back of the line, counted six children, and proceeded to go to the Rectangulo classroom. Once inside that classroom SP1 stated s/he told SP2 that s/he counted and there were six children, but one was with the CP. SP2 stated that it was “busy” when SP1 brought the children into the classroom. Initially SP2 stated that SP1 told him/her that SP1 had six children, but later stated that SP1 did not tell SP2 that, but that SP1 dropped off the children and placed his/her list on the counter. When the children entered, SP2 counted five children. A little bit later, the CP told SP2 that the AV was still in the other classroom. SP2 asked the CP to find the P since SP2 was in a classroom alone. SP2 stated that when the P brought the AV in the classroom, s/he seemed confused, but then went to play. The AV was unsupervised for approximately seven minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although SP1 stated s/he counted prior to leaving the Triangulo classroom, given that SP1 did not count the children again upon entering the Rectangulo classroom, and that no staff person was present to intervene if the AV was injured, or in 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 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. Although SP2 initially stated that SP1 told him/her that SP1 had six children, but then stated SP1 did not tell SP2 that, given that SP2 did count the number of children SP1 brought into the classroom, that the AV did not leave the Triangulo classroom so SP2 was not responsible for the AV’s supervision at the time of the incident, and that SP1 stated s/he told SP2 that s/he had already counted and had six children but one was with the CP, SP2 was mitigated from his/her responsibility of supervision of the AV during the transition. However, at the time of the incident, SP1 was responsible for the AV’s care and supervision and had received training on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Therefore, SP1 was responsible for the 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 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 adequate but not followed by SP1 and SP2. SP1 and SP2 both received written warnings and were received additional training on safety and supervision. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1 was responsible for maltreatment is subject to appeal. On March 15, 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.
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