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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: 1100426-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) left the facility without staff person’s (SP1 and SP2) knowledge or supervision and was gone approximately two minutes. The AV was found by a community person (CP) and returned to the facility unharmed. Date of Incident(s): Unknown date prior to November 14, 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 December 7, 2023; from documentation at the facility; and through five interviews conducted with the CP, a supervisory staff person (SP1), two staff persons (P1 and SP2), and the AV’s family member (FM). Due to the AV’s age, s/he was unable to provide any information about the incident. SP1 and SP2 have an interpersonal relationship. Facility documentation showed the AV was two years old and enrolled in the toddler classroom at the time of the incident. The facility was located at the corner of two streets with speed limits of 30 miles per hour. Surrounding the facility were churches, businesses, and single-family homes. Inside the facility were five classrooms, including the toddler classroom. The toddler classroom was a large open space with several doors. One door was an interior door that led to SP1’s office. Another door in the back of the classroom was a push bar exit door to the outside. On December 7, 2023, there was an alarm on the exit door. Outside the exit door was an unfenced area and a sidewalk that was parallel to the back wall of the facility. At one end of the sidewalk was a parking lot and a street and at the other end of the sidewalk was a building where the CP worked. That building had a cement patio surrounded by shrubs. Information regarding the date of the incident was inconsistent so the actual date could not be determined. According to www.wunderground.com, the temperature outside on November 10, 13, and 14, 2023, between 10 and 11 a.m. averaged approximately 48 degrees Fahrenheit. FM1 stated that on the afternoon of the day of the incident, as s/he picked up the AV from the facility, s/he was told the AV had opened one of the exit doors and was outside and then found by the CP. Prior to this incident, the FM did not have concerns regarding the facility. The CP provided the following information: · On the day of the incident, the CP was working in the back part of the building that was located behind the facility. As the CP was working s/he saw and watched the AV walk through the shrubs lining the patio and then stand on the patio. The CP went outside and picked up the AV. The AV was calm and did not say anything to the CP. The AV was dressed in a tee shirt, diaper, and pants and was barefoot. · The CP carried the AV to the facility door nearest the patio and knocked on a window. The CP could see two staff persons in the classroom but neither responded so the CP knocked again. Then one of the staff persons turned around and saw the CP at the window. The staff person opened the door and said, “What in the world?” The CP told the staff person that the AV had walked through the shrubs, and the CP “assumed” s/he belonged at the facility. · The staff person called the AV by name and took him/her from the CP. The AV went into the classroom and did not seem upset. Then the CP left and went back to his/her building. After approximately ten minutes, s/he called the facility and asked to speak with SP1. The CP asked SP1 if s/he was aware that the CP had brought back the AV. SP1 told the CP that a staff person had told him/her about the incident, and s/he was “frustrated” because s/he could not lock or block the door to prevent children from opening it and getting out. The CP told SP1 that it was “disconcerting” that s/he found the AV on the patio and was glad that it was not “really” cold. The CP and SP1 then ended the telephone conversation. SP2 provided the following information: · SP2 could not recall the date when a child “snuck” out the back door of the toddler classroom. On the day of the incident, between 10:20 and 10:40 a.m., SP1 and SP2 were in the classroom cleaning the room for lunch when the CP knocked on a classroom window to get SP1’s and SP2’s attention. The CP had the AV in his/her arms. SP2 opened the door and was given the AV. SP2 did not recall what the AV was wearing but did remember that the AV was barefoot when the CP returned him/her to the facility. The AV did not seem upset and was not crying. · SP2 could not recall whether SP1 left the classroom and was in the office before the AV was returned. SP2 did not hear the AV open or close the exit door and did not think the AV was gone long because s/he had just “interacted” with him/her “shortly” before the CP brought the AV back to the facility. · Prior to the incident, SP2 had not seen the AV open the back classroom exit door. The door was not heavy, and the AV could reach the push bar to open the door. · While the AV was unsupervised outside, s/he could have left the area and gotten lost or “picked up” by someone else. · SP2 could not recall how s/he was trained on supervision but stated s/he knew that s/he was “always” to be watching the children and playing with them. P1 stated that on the day of the incident, at approximately 10:15 a.m., s/he was in the kitchen making lunch. SP1 came and told him/her the AV had opened the back classroom exit door, gone outside, and was found by the CP. The CP then brought the AV to the back classroom door and SP1 opened the door and let the AV back into the facility. SP1 told P1 that the AV had not been out “long.” SP1 provided the following information: · Initially during the interview, SP1 could not recall the date of the incident and stated s/he would need to know the “exact date” of the incident to know which staff persons were in the toddler classroom. SP1 knew “almost immediately” of the incident because s/he was in his/her office, stepped out to the toddler classroom, and was “actually in the room” when the CP knocked on the classroom back exit door. SP1 said to SP2, “What the heck?” and SP2 opened the classroom door for the CP and the AV. SP1 thanked the CP and took the AV back into the classroom and the CP left. · Then during a follow up interview after this investigator obtained additional information, SP1 stated that s/he was the other staff person in the classroom at the time of the incident. SP1 stated that s/he “couldn’t even think of the day” and “didn’t even know that s/he was in the classroom the whole day,” and then recalled that s/he and SP2 were working in the classroom. SP1 was in the toddler classroom between 9:22 a.m. and 4:11 p.m. SP1 acknowledged leaving the classroom and SP2 out of ratio at the time of the incident. SP1 stated that on the day of the incident there were thirteen toddlers present in the classroom. · SP1 stated that “just before lunch,” s/he and SP2 were in the classroom when SP1 handed the AV his/her water cup and then went into the office “for less than a minute to put some things away.” When SP1 stepped back into the classroom, s/he was picking up blocks when the CP knocked on the classroom back exit door.
· SP1 then talked with SP2. SP2 told SP1 that “they” had been cleaning up and did not hear the back classroom door, and there “was no way” the AV was outside more than “two minutes.” The AV must have gone directly from the door to the patio. SP1 stated the patio was approximately ten feet from the door. · When the FM picked up the AV that day, SP1 told the FM that the AV had left the facility. · On the day of the incident, the AV was dressed in a long sleeve shirt and sweatpants. The AV could have been barefoot because s/he like to take off his/her shoes. · After the AV left the facility s/he could have “went anywhere” including the highway. · The facility’s supervision policy stated that children must be always within sight and hearing. When children were indoors, staff persons counted children approximately every 45 minutes. Those counts were not documented on paper or electronically. Staff persons used an APP on an iPad or phone to know how many children were in attendance. At the time of the incident, there were thirteen toddlers present. The facility’s handbook stated that staff persons protected the safety of the children by creating a safe environment through staff person proximity in the classroom and on the playground. The facility’s Risk Reduction Plan stated that children were not allowed to leave the facility without supervision. Facility documentation showed that prior to the incident, P1, SP1, and SP2 received training on the facility’s Risk Reduction Plan, the facility’s handbook, and the Reporting of Maltreatment of Minors Act. Relevant Rules and/or Statutes: 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. Minnesota Rules, part 9503.0040, subpart 1, states that the minimum staff to child ratio for the toddler age category is one staff person to seven children. Conclusion: A. Maltreatment: On an unknown date, the AV left the facility for approximately two minutes without the knowledge or supervision of SP1 and SP2, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV walked through the shrubs and onto a patio at the building next door approximately ten feet away from the facility. The CP saw the AV and returned the AV to the facility. At some point during the time that SP1 and SP2 were in the classroom working, SP1 left the classroom leaving SP2 with 13 children which was a violation of Minnesota Rules, part 9503.0040, subpart 1. Although the AV was unsupervised for approximately two minutes and returned to the facility by the CP unharmed, the conduct of allowing the AV, who was two-years old to leave the facility and go outside without staff persons’ knowledge or supervision exposed to community hazards including unknown persons and did not allow for staff persons’ intervention 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 could seriously endanger the AV’s physical 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. SP1 and SP2 each received training on the Reporting Maltreatment of Minors Act, facility’s Risk Reduction Plan, and the facility’s handbook. SP1 and SP2 were responsible for the supervision of the AV at the time of the incident. SP1 and SP2 were each trained on the Reporting of Maltreatment of Minors Act prior to the incident. SP1 and SP2 were each of responsible for the maltreatment of the AV. Given that SP1 had significant administrative and supervisory authority over the operation of the facility and ensuring that the facility maintained compliance with Minnesota Rules and Statutes, the facility was also 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. The Office of Inspector General is also required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 the facility were each responsible did not meet statutory criteria to be determined as recurring because this was a single incident and was not serious because the AV did not sustain a serious injury that reasonably required the care of a physician. 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 conducted an internal review and determined that their policies and procedures were adequate and followed. The facility installed alarms that sounded when classroom exit doors were opened. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 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 the disqualification of SP1 and SP2. The determination that SP1 and SP2 were responsible for maltreatment is subject to appeal. On April 3, 2024, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which the facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. During the course of the investigation, it was determined that a supervisory staff person provided false and/or misleading information. On April 3, 2024, the facility was issued a $200 fine for providing false and/or misleading information. The Order to Forfeit a Fine is subject to appeal. 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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