|
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: 1037325-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that three alleged victims (AV1, AV2, AV3) left an unfenced area and walked across a street to one of their homes without staff persons’ (SP1 and SP2) supervision or knowledge. Date of Incident(s): February 6, 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 27, 2024; from documentation at the facility; and through ten interviews conducted with a facility supervisory staff person (P), facility staff persons (SP1 and SP2), a community person (CP) who provided care for AV1 at AV1’s house, AV1, AV2, AV3, and AV1’s-AV3’s family members (FM1, FM2, and FM3 respectively). Facility enrollment records showed that at the time of the incident, AV1 was five years old and AV2 and AV3 were four years old, and each were enrolled in the facility’s preschool program. The facility was located on a square plot of land in a primarily residential area. Two buildings were on the plot of land, the facility, and a community cultural center institute. The facility was in the Northeast corner; the institute was in the Southeast corner; a fenced in playground was in the Northwest corner; and a grassy area with trees, shrubs, and a concrete patio was in the Southwest corner. In the middle of the square was a parking lot. The entry into the parking lot was located between the playground and the grassy area. The plot of land was boarded on three sides by streets and on the fourth side was a home. The street to the north was a single lane of traffic and was like an alley. The other two streets had sidewalks. One street, on the south side, had a speed limit of 25 miles per hour and the other street, on the west, had a speed limit of 20 miles per hour. Across the intersection nearest the corner of the playground was AV1’s home. AV1, AV2, and AV3 provided consistent information that they walked to AV1’s house where the CP and FM1 were. They walked inside and took off their shoes and coats. Then SP1 came to the house and walked AV1, AV2, and AV3 back to the facility, where they joined the rest of the class and went inside. AV2 and AV3 each also stated that one time, before the incident, each had been to AV1’s house visiting AV1. FM1 stated that on the morning of February 6, 2024, AV1, AV2, and AV3 walked across the street and rang the doorbell to his/her home. The CP and FM1 opened the door and AV1, AV2, and AV3 walked into the house. FM1 talked with them right away and about “five seconds later” SP1 came “dashing” across the street and took them back to the facility. Prior to this incident, FM1 did not have concerns about the facility. FM1 stated the incident occurred because their house was across the street from the facility and the “excitement” of AV1, AV2, and AV3. FM2 stated that s/he was notified of the incident on the day it happened, but s/he could not recall the date. Staff persons at the facility sent a message to him/her online that stated AV1, AV2, and AV3 were playing in the lawn when they decided to go to AV1’s house. They took off their shoes and entered the house and when they were coming back out of the house, SP1 crossed the street to get them. FM2 was not sure how long AV1, AV2, and AV3 were without supervision. The day before the incident, FM2 and AV2 had been at AV1’s home. Prior to this incident, FM2 did not have concerns about the facility. FM3 stated that on February 6, 2024, staff persons told him/her that AV3 and AV2 went with AV1 to his/her home. It was not noticed “right away” and when staff persons did notice, they got them before they went inside the house. FM3 did not think AV1, AV2, and AV3 were gone “very long.” One week before the incident, AV3 played at AV1’s home. Prior to this incident, FM3 did not have concerns about the facility. The CP stated that on February 6, 2024, before noon, the doorbell rang several times. The CP opened the door and AV1, AV2, and AV3 were standing there. AV1 took off his/her shoes but AV2 and AV3 did not. They came inside and the CP asked them what they were doing at the house and told them that they should not have crossed the street. FM1 heard the CP say AV1’s name and came to the entry. FM1 told the CP to take AV1, AV2, and AV3 back to the facility. AV1 and the CP put on their shoes, and they all went out to the front of the house. About a “minute later,” SP1 “ran” across the street and met them at the front of the house. SP1 apologized to the CP and then talked with AV1, AV2, and AV3 as they walked back to the facility. The CP returned to the house. The P stated that on February 6, 2024, s/he was not at the facility. On February 7, 2024, s/he talked with SP1 and SP2 and learned that the previous day, at approximately 11:15 a.m., the preschool group was outside playing. At the end of play time, one of the staff persons rang a bell and gathered the children. They counted the children and “discovered” that AV1, AV2, and AV3 were missing. SP2 stayed with the group of children while SP1 “ran” to the trees at the corner of the lawn and noticed AV1, AV2, and AV3 across the street. SP1 went across the street and had a “quick verbal exchange” with the CP and then “brought the kids back to the group.” The P stated that the staff persons routinely let the children play in the unfenced grassy area. SP1 and SP2 provided the following consistent information: · On February 6, 2024, at approximately 10:15 a.m., SP1 and SP2 took the preschool children outside to play on the grassy area. At some point, SP1 was near AV1, AV2, and AV3 at the northwest corner of the grassy area, near the entry to the parking lot, and then moved to assist another child who was hurt and crying. SP2 was on the opposite side of the grassy area and moving around “a lot.” · At approximately 11:25 a.m., it was time to clean up to go back inside. SP1 rang a bell that indicated to the children that it was time to clean up and go back inside. The children lined up on the concrete patio and SP1 counted them and SP2 counted to “double check” the number. · SP1 “quickly realized” that “some” children were missing. SP1 began looking including “behind bushes and trees” that bordered the grassy area while SP2 stayed with the children in line. SP1 then looked across the street and saw AV1, AV2, AV3, and the CP standing in front of AV1’s house. SP2 stayed with the group of children and SP1 “ran” across the street and brought AV1, AV2, and AV3 back as “quickly as possible.” SP1 asked AV1, AV2, and AV3 why they went to AV1’s house but they did not “really” give an answer. AV2 told SP1 they had “looked both ways” before they crossed the street. · SP1 stated that the preschoolers played on the grassy area “pretty often.” SP1 could not recall specific training regarding supervision while on the grassy area but stated that a “general rule” was that there were two staff persons on the grass, and they tried to stay “far away” from each other to be able to “see all the kids.” SP1 stated the children liked “hiding” in the bushes that were “right up against the sidewalk.” · SP2 stated that s/he had been trained to have “active supervision” on the grass. Staff persons were not assigned “specific zones” but talked about where they would “put themselves” and then walked around to monitor the children. · SP1 thought AV1, AV2, and AV3 were gone for approximately ten minutes and SP2 thought they were gone 10 and 15 minutes. The facility’s Outdoor Activity Area/Playground Safety policy stated that staff persons positioned themselves so that they could see children on all areas of the playground and the playground was enclosed if it was located adjacent to traffic. The facility’s Program Plan stated that children will be supervised at all times. The P, SP1, and SP2 each received training on the facility’s Outdoor Activity Area/Playground Safety policy, the facility’s Program Plan, and the Reporting of Maltreatment of Minors Act before the incident. Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0045, subpart 1, item A, stated that children are required to have supervision at all times. Minnesota Statute section 245A.02, subdivision 18, states that supervision means 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 9503.0155, subpart 5, item C, stated that an outdoor activity area must be enclosed if it is located adjacent to traffic, rail, water, machinery, or other environmental hazards, unless the area is a public park or playground. Conclusion: A. Maltreatment: Information from all sources was consistent that on February 6, 2024, AV1, AV2, and AV3 left the group playing on the grassy area, walked across the street to AV1’s house and went inside where they talked with the CP and FM1. The CP, AV1, AV2, and AV3 then went outside so the CP could take them back to the facility when SP1 came running over to get them. SP1 and SP2 each stated they did not know AV1, AV2, or AV3 left which was inconsistent with the facility’s Program Plan and was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. In addition, the P and SP1 each stated that the preschool children routinely played in the unfenced grassy area, which was a violation of Minnesota Rules, part 9503.0155, subpart 5, item C. At the time of the incident, SP1 and SP2 were supervising and engaging with children on the grassy area and did not see AV1, AV2, and AV3 leave. When it was time to clean up and go into the facility, SP1 and SP2 counted and realized that AV1, AV2, and AV3 were missing from the group. SP1 and SP2 each stated that AV1, AV2, and AV3 were gone for about 10 to 15 minutes. Given AV1’s, AV2’s, and AV3’s age; the amount of time that passed before SP1 and SP2 were aware that they were missing; that AV1, AV2, or AV3 left the group and walked across the street exposing each to community dangers including traffic and other hazards, there was a preponderance of the evidence that there was a failure to supply AV1, AV2, and AV3 with necessary care and a failure to protect each from conditions that seriously endanger their physical or mental health 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 and a 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 were responsible for the care and supervision of AV1, AV2, and AV3 at the time of the incident and were trained on the facility’s Program Plan and Outdoor Activity Area/Playground Safety policies and the Reporting of Maltreatment of Minors Act. Although the facility was issued a citation regarding children playing in an unfenced area directly next to traffic, this did not mitigate SP1’s and SP2’s responsibility to ensure they maintained supervision of all the children. Therefore, SP1 and SP2 were responsible for the maltreatment of AV1-AV3. 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 and SP2 were each responsible did not meet statutory criteria to be determined as recurring because this was a single incident that impacted three alleged victims and was not serious because AV1, AV2, and AV3 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 completed an internal review and determined that their policies and procedures were adequate but not followed. Staff persons were retrained on active supervision expectations and the facility discontinued use of the lawn for regular outdoor play. 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 May 8, 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.
|
