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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: 830650-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was in a community hallway without staff persons’ (SP1 and SP2) knowledge or supervision for an unknown amount of time. The AV was found by a community person. Date of Incident(s): February 27, 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 March 13, 2024; from documentation at the facility; and through eight interviews conducted with the AV, the AV’s family members (FM1 and FM2), one community person (CP1), a facility supervisory staff person (P), and facility staff persons (SP1 and SP2). Another community person (CP2) was interviewed but did not provide information relevant to the incident. The facility was located in a L-shaped strip mall that also had other businesses including a Subway, hardware store, dental office, a bank, a grocery store etc. The strip mall had one main hallway with approximately six double doors that led from a main parking lot to the main hallway. The strip mall also had a smaller U-shaped hallway located in the corner of the L, and each ended with a single door to outside the back of the strip mall. The business entrances opened/connected to the hallways. The strip mall had a camera in the hallway, but at the time of the incident, it was not operational. The facility was located in the corner of the “L” in the “U” hallway. At one end of that hallway, was the entrance to the facility and at the other end was an exit door that led to a back parking lot and a mall service road. Also, in the hallway were two public restrooms. The preschool classroom had two doors, one that led into the facility and one that led to the U hallway. Located behind the strip mall was a playground adjacent to the facility, a parking lot, and a road. A toddler room had a door that opened onto the playground. Facility records showed the AV was three years old and enrolled in the preschool classroom at the time of the incident. The AV stated s/he was sad when s/he was left in the hallway. The AV did not provide further information about the incident. FM1 and FM2 provided the following information: · On the afternoon of February 27, 2024, the P called FM1 and told him/her that the AV had been left in the mall hallway for approximately one minute as the preschool class transitioned to the playground. · The AV was found crying in the hallway by CP1 who brought the AV to the P. The P brought the AV to the playground where s/he rejoined the group. The AV told FM1 that s/he was sad and that P1 made him/her “feel better.” · Prior to this incident, FM1 and FM2 had concerns regarding transitions because previously a child had been left on the playground when the group transitioned indoors. (See Investigation Memorandum 202208808 for further information.) CP1, who worked at the strip mall, could not recall the date but stated that on the day of the incident between 9:30 and 10 a.m., s/he was in the mall near the facility and heard a “hysterical” child “crying and yelling.” CP1 said s/he heard the child for a “couple of minutes,” so s/he walked to hallway that was in front of the facility main entrance door. CP1 looked down the hallway and saw the AV, “hollering and crying” at the door that led into the preschool classroom. CP1 told the AV that s/he would get someone and then rang the facility doorbell. The P came to the door and CP1 told him/her that the AV was in the hallway. The P walked down the hallway and got the AV and took him/her out the exit door. The P provided the following information: · On February 27, 2024, at approximately 10 a.m., the P was in the facility kitchen when s/he heard the facility doorbell. As the P walked out of the kitchen, through a window s/he saw the preschool children playing on the playground. · As the P walked to the facility front door, through a side window s/he saw CP1 “talking with someone” down the hallway. When the P opened the door, s/he looked down the hallway and saw the AV. The AV was “crying” and saying, “Mama.” CP1 then told the P that s/he had heard a child crying and saw the AV in the hallway. · The P walked down the hallway, picked up the AV, and hugged him/her. Then the P carried the AV and walked out the exit door to the playground, where they sat together between five and ten minutes. When the AV stopped crying, s/he went to play. · The P then talked with SP1 and told him/her where the AV had been found. SP1 “felt horrible.” Later in the day, the P talked with SP2, who told the P that s/he “felt bad and remorseful.” The P stated that SP1 and SP2 told him/her that they counted the children when they left the classroom but did not complete another count when the children entered the playground. SP1 and SP2 “thought” they were outside on the playground “less than five minutes” before the P came out with the AV. · The P called FM1 and told him/her that the AV had been found in the hallway. “At the time,” the P did not think the AV was unsupervised for “that long” but the P did not know how long the AV was unsupervised. FM1 “seemed calm” and wanted to “make sure” the AV was “okay.” SP1 provided the following information: · SP1 could not recall the date or time but on the day of the incident, as the children lined up in the classroom by the door to the strip mall hallway to go outside, SP1 completed a name to face count by calling each child’s name and placing a check mark on an attendance sheet. There were 19 children present. SP1 could not recall where the AV was in line and the children were not in any specific order. Then, as the children stood at the door to the mall hallway, SP1 counted 19 children and then the group went into the hallway and lined up against the wall. · Then SP1 opened the mall door to go outside. SP1 said s/he “usually” counted the children as they walked out of the mall exit door but that day the children were “rushing,” and s/he did not count. SP1 walked backwards on a sidewalk to the playground until s/he could see SP2 at the end of the line. Then SP1 turned to face forward and walked to the gate. When s/he arrived at the gate, s/he opened it and let the children go in the playground without completing a name to face or count check. · After the group was on the playground, SP1 entered the facility via the toddler classroom playground door and from the doorway, saw the P come to the playground with the AV. · The P and the AV sat on a picnic table and the AV looked “sad.” Then the AV “shook it off” and played on the playground. · SP1 “speculated” that the AV was unsupervised a “couple of minutes,” because they had entered the playground and the P brought the AV out. · SP1 made and “error” and “was not visibly watching” the AV. SP1 did not know where s/he made the error, but s/he “did not have eyes” on the AV. SP2 provided the following information: · SP2 did not recall the day of the incident but stated that at approximately 10 a.m., the preschool class got ready to go outside. SP2 helped children put on jackets and when everyone was ready, the children sat on the floor in a circle. · SP1 then called the children’s names in the order they appeared on the attendance sheet. When a child’s name was called, they stood up and walked to line up at the door that led into the mall hallway. Once everyone was in line, SP1 completed a name to face count again and there were 19 children present. The AV was in the middle of the line. Then the group went out the door and into the hallway with SP1 at the front and SP2 at the back of the line. · In the hallway, the children lined up along the wall near the mall bathrooms before going outside. SP1 was at the front of the line but SP2 stepped in front of SP1 to hold the mall exit door open as the children walked through. SP2 did not recall if SP1 completed another count in the hallway before the group went out the exit door. SP2 stated that “sometimes” children like to “hide” behind a door frame in the hallway but did not “remember” seeing the AV when s/he looked in the hallway before s/he walked out. · The group walked along the sidewalk to the gate of the playground. SP2 stated that s/he “thought” s/he “heard” SP1 count the children as they walked through the gate. · When the group was on the playground, SP1 did not say anything to SP2 and went inside the building. After approximately “two to five minutes,” SP1, the P, and the AV came out to the playground. At this time, the P told SP2 that the AV had been left in the hallway and “someone” had brought him/her to the door. SP2 had a lot of “emotions” after the incident happened and “froze up.” The facility’s Name to Face policy showed that staff persons used name to face attendance “any time the class…transitions to any location outside of the classroom.” At the top of the name to face form “under T”, staff persons wrote the code for the transition destination. Then the staff person read the child’s name, visually located the child, and checked off his/her name on the form. After completing the name to face check, staff persons counted the check marks, verified the correct total and if the numbers matched, initialed the form. If the number did not match, staff persons corrected the total and/or retook name to face attendance. If the name to face count was accurate, staff persons proceeded to their destination, and upon arrival, counted to be sure all children were accounted for. The Name to Face attendance sheet for the preschool classroom dated February 27, 2024, had 18 children’s names typed into the sheet. The AV’s first name was handwritten on the 19th line. It showed there were 19 children in attendance at 10 a.m. All children there that day had two transition check marks. There was no code written on the sheet to indicate the transition destinations and there were no initials to indicate what staff person completed the sheet. The facility’s Supervision of Children policy showed that “all children will be within sight and hearing of a staff member at all times.” Facility documentation showed that the P, SP1, and SP2 were each trained on the facility’s Supervision of Children and Name to Face Policies and the Reporting of Maltreatment of Minors 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. Conclusion: A. Maltreatment: Information was consistent that on February 27, 2024, the AV was in the mall hallway without the knowledge or supervision of a staff person for an unknown amount of time, but likely two to five minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 and SP2 both stated that a name to face count was completed in the classroom before the group transitioned into the mall hallway. SP1 stated that in the hallway s/he did not complete a count of the children because the children rushed through the exit door and walked outside to the playground. Once the group walked to the gate, SP1 stated s/he did not complete a count of the children and SP2 stated s/he “thought” SP1 completed a count. SP2 did not complete a count because s/he felt rushed. While the group was on the playground, CP1 notified the P that the AV was in the mall hallway. The P then got the AV in the hallway and took him/her to the playground to join his/her class. Given that the AV, who was three years old, was in the mall hallway without the knowledge or supervision of staff person and was found by a community person, that the hallway was open to businesses and accessible to the public and was near an exit door that led to the mall parking lot and road, and that staff persons would be unable to intervene if the AV injured him/herself or in the event of an emergency or other hazards, there was a preponderance of the evidence that there was a failure to supply the AV with the necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV’s 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/or 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 facility’s Supervision of Children and Name to Face Policies and the Reporting of Maltreatment of Minors before the incident. SP1 and SP2 were responsible for the supervision of the AV at the time of the incident. SP1 and SP2 were 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 and SP2 were each responsible did not meet statutory criteria to be determined as recurring because it 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 but not followed by SP1 and SP2. SP1 and SP2 each received additional “Name to Face” training. 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 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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