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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: 1083416-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on the playground without staff person supervision or knowledge for approximately five minutes. Date of Incident(s): December 21, 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 10, 2023; from documentation at the facility; and through five interviews conducted with two supervisory staff persons (P1 and P2), a facility staff person (SP), the AV’s family member (FM), and a community person (CP). The AV was 33 months old and enrolled in the Young Preschool (YP) classroom at the time of the incident. Due to his/her age the AV was not interviewed for this investigation. The facility was a stand alone building with two infant classrooms, two toddler classrooms, and four preschool classrooms. The facility playground was located on the side of the building behind another business and was surrounded by a four-foot-high fence with vertical slats and a gate with a latch. Just outside of the gate was a back entrance into the building for families to enter the building. The side of the playground with the gate was adjacent to a parking lot located at the back of the building and there was a main road that ran along the side of the playground opposite the gate with a posted speed limit of 25 miles per hour. The facility was closed for winter break from December 22, 2023, until January 2, 2024, for families. Staff persons returned to work on December 27, 2023. On December 21, 2023, around 4:30 p.m., the CP was picking up his/her children, and saw a staff person bringing in a group of children. The CP followed the group in, picked up his/her children, walked out of the facility after about five minutes with his/her children, and noticed a child (the AV) on the playground, playing with little cars. The CP was not sure if the AV was a child at the facility or a sibling who was waiting on the playground for his/her family member picking someone up inside, so the CP went inside and found P1. P1 immediately went outside and stated that the AV was a child at the facility and thanked the CP for letting him/her know. The CP then left to bring his/her children home. The CP stated it was a warm day around 40 degrees Fahrenheit. P1 provided the following information: · On December 21, 2023, around 5 p.m., P1 was going from classroom to classroom to assist staff persons when the CP told P1 that there was a child on the playground. P1 went to the playground and saw the AV playing on a toy trike. The AV was not in distress and seemed “oblivious” to being outside by him/herself. · P1 brought the AV inside and helped the AV take off his/her outdoor clothes and then brought the AV to the classroom the SP was in. P1 asked another staff person to step in for the SP so that P1 was able to talk to the SP about what happened. As it was at the end of the day, P1 stated they would discuss more when they returned from break on December 27, 2023. · P1 stated the SP apologized and at first took responsibility but then stated that s/he was distracted by another child. · P1 said the SP had seven children and came in with six. Staff persons were trained to count before and after leaving a classroom. There was a name to face list of children in the classroom for the day. · P1 believed the temperature was 26 degrees Fahrenheit. P1 said it was clear and there was no snow. P1 stated that s/he notified the FM when the FM next picked up the AV (Note: The facility’s Incident Report showed the FM was verbally notified on January 4, 2024.) The SP provided the following information: · Around 4:30 p.m., on the day of the incident, the SP took his/her classroom outside on the playground. It was around 40 degrees Fahrenheit. Around 5 p.m., the SP led his/her children through the gate, and the CP held the back door open for the SP and the children to enter the facility. The SP stated that two children were arguing as the class came inside. · The SP brought the children to the YP classroom for them to take off their outdoor clothes, wash their hands, and then brought them to the Pre-Kindergarten class for the end of the day pick up. The children were sitting at a table when P1 entered with the AV. At that point the SP thought the AV had been left in the classroom, not outside. · The SP stated that the AV seemed “normal” and wanted to play. The SP said s/he was “shocked” and “never” imagined s/he would forget “something” like that. The SP said that P1 stayed in the classroom and told the SP s/he was “mad” at the SP and the SP understood why P1 was upset. P1 said they would talk more the next week when they returned from break, so the SP went home. · The SP was trained to have the children form a line and count the children. The SP stated that s/he normally put the “little ones” in front and then s/he walked in after them. On this day, the SP did not do this as family members were picking up and the SP had to get the other children into the Pre-Kindergarten room by 5 p.m. for the end of the day. The SP stated that s/he did not count that day as s/he has so “little [number] of” children. P2 provided the following information: · On December 21, 2023, a little after 5 p.m. shortly after P2 left for the day, P1 called P2 to tell P2 that the AV had been left on the playground. As the facility was on break, P2 did not follow up with the SP until the next week. · When the SP and P2 talked about the incident after break, the SP told P2 that s/he was not aware s/he had forgotten the AV outside. The SP was within ratio and the other children were running around and the SP did not count them. The SP felt terrible about the situation and apologized to P2. · P2 said staff persons were trained to use the name to face sheet to write down when children arrived and left and when the classroom went to another location it was used for staff persons to conduct a name to face and count the children. The FM stated the incident happened either the Thursday or Friday before December 25, 2023, and that P1 told the FM the next time the AV was at the facility. P1 told the FM that the AV was forgotten on the playground and was found by the CP who told P1. P1 then went outside and brought the AV back inside. The AV was alone for “about five minutes.” The FM said the AV did not seem bothered. The FM had no prior concerns. The facility’s administration team reviewed video footage and noted that on Thursday, December 21, 2023, at 4:55 p.m., the SP left the playground with a group of children without conducting a headcount or confirming each child’s face to name. At 5 p.m., a family member discovered the AV alone on the playground and reported the incident to P1 who acted immediately and brought the AV into the facility. The AV was unsupervised for five minutes on the playground which was located adjacent to a busy street and a bus stop. This investigator reviewed video footage and saw the AV alone on the playground wandering around as traffic was moving by on the street adjacent to the playground. This investigator also saw P1 walking back inside holding the AV in his/her arms. There was no footage that showed the SP bringing the children inside. The facility’s Risk Reduction Plan stated, “[Staff persons] perform a head count when leaving their classrooms, and arriving in the playroom, playground or vice versa.” The facility’s Name to Face List Usage SOP (Standard Operating Procedure) stated, “[Staff Persons] will add to the list when their [children] enter and leave the classrooms during the day using the following letters:
In- “I” for each time a child enters the classroom. Out- “O” for each time when the children leave the classroom to go home. Playground- “P” for each time the children go to the playground. Gym- “G” for each time the children go to the gym. Field Trip- “F” for the time when children go to the buses for field trips.” The Name to Face Checklist for December 21, 2023, for the YP classroom did not show any children marked “P” for the playground in the afternoon or marked “I” for returning into a classroom from the playground. Facility records showed that the SP, P1, and P2 were each trained on the facility’s Risk Reduction Plan and the Maltreatment of Minors Reporting Act. According to www.wunderground.com, the temperature on December 21, 2023, at 4:53 p.m. was 38 degrees Fahrenheit (F°) in Minneapolis. 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: Consistent information was provided that on the afternoon of December 21, 2023, the SP took his/her class outside and while coming back inside, the CP held the door for the SP and the children. The SP did not perform a name to face or headcount of the children s/he brought inside. The SP brought the children inside to take off their outside gear and then brought the children to the Pre-Kindergarten classroom for the end of the day. The SP did not perform a headcount at this time either. The CP picked up his/her children and when exiting the building noticed the AV on the playground. The CP alerted P1 who went outside immediately and brought the AV back inside. The AV did not seem to be in distress when P1 saw him/her on the playground, and the AV was unsupervised for five minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Given that the SP did not perform name to face or conduct a headcount, and that the AV was alone on the playground adjacent to a busy street with no staff persons to intervene in case of an emergency or injury, 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 and 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. The SP was responsible for the supervision of the AV at the time of the incident. The SP was trained on the facility’s Risk Reduction Plan and the Maltreatment of Minors Reporting Act. Therefor the SP 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 the SP was responsible did not meet the 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 the SP. The facility retrained staff persons on name to face procedures. The SP no longer worked at the facility. 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 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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