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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: 1088066-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left in a toddler classroom without staff persons’ (SP1, SP2, and SP3) knowledge or supervision for approximately five minutes. Date of Incident(s): March 12, 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 20, 2024; from documentation at the facility; and through six interviews conducted with the AV’s family member (FM), a community person (CP), a facility supervisory staff person (P), and three staff persons (SP1, SP2, and SP3). The facility consisted of eight classrooms. There were two toddler classrooms (Dolphins and Starfish) for children 16 to 24 months. The Dolphin and Starfish classrooms were across a hallway from each other, and each had large windows that looked into the hallway. The Starfish classroom was a square room with a bathroom and an exit door to their playground. In the Starfish classroom, near the door to the playground, was a coat rack and a large, oval, “ocean” carpet. There were also several tables in the classroom. There was a video camera in the hallway between the Starfish and Dolphin classrooms and one on the playground above the Starfish classroom playground door. The facility used a mobile application (app) platform to communicate with families and streamline administrative functions. The AV’s enrollment form showed that at the time of the incident, the AV was two years old and was enrolled in the toddler “Starfish” classroom. FM1 stated that s/he received a phone call from the P “right after” the incident happened. The P told the FM that the AV had been left “alone” in the classroom for “about” five minutes when his/her class went outside. “Someone” noticed the AV and s/he was brought to his/her group outside. The FM stated the AV was “fine” and s/he has not noticed any changes in his/her behavior since the incident. The FM stated that this was the second incident involving the AV at the facility, but they had sent an older sibling to the facility and they “love it” and “support” the facility. The CP stated that on March 12, 2024, s/he was at the facility between 10 a.m. and 12 p.m., observing another child in the Dolphin classroom, which was across the hall from the AV’s classroom. As s/he walked out of the Dolphin room, s/he looked in the Starfish classroom and saw the AV standing by a table with his/her coat on. The CP entered the Starfish classroom and looked to see if there was a staff person inside the bathroom. There was not, so the CP walked to the window that looked out to the playground and saw a group outside. The CP walked to the door to the playground, opened it, and told the unknown staff persons on the playground, “I think you forgot someone.” The staff persons looked at each other and then told the CP that they had completed a “face to face” check as they went out and the AV was the first one out. The CP gave one of the staff persons the AV and the AV went outside. Then the CP walked to the front of the facility and told the P what happened. The facility provided two video segments of the incident one from the playground and one from the hallway. The videos did not contain audio. The videos provided the following information: o At 11:28:31 a.m., SP2 walked out of the classroom playground door and onto the playground followed by SP3. The door remained open and then the children entered the playground. o At 11:29:48 a.m., SP1 entered the playground and the playground door shut. o At 11:32:50 a.m., the CP walked out of the Dolphin classroom door and into the hallway. The CP walked past the Starfish hallway window and then walked back to it. o At 11:33:15 a.m., the CP entered the Starfish classroom. o At 11:33:43 a.m., the playground door opened and SP2 walked to the door. The AV walked out onto the playground and was picked up by SP2 and s/he walked away. o At 11:34:10 a.m., the CP exited the Starfish classroom. The P, SP1, SP2, SP3, and facility documents provided the following consistent information: · On March 12, 2024, just after 11 a.m., SP1, SP2, and SP3 were in the Starfish classroom and were getting the toddler children ready to go outside to the playground. SP1 stated that they put coats on children with short sleeves but children with long sleeves did not need a coat or sweatshirt. When children were dressed and ready, they sat on the “ocean” carpet near the door to the playground. · SP3 stated that “usually” there were three staff persons in the Starfish classroom and when they transitioned to the playground, one staff person “grabbed” the iPad, one staff person went out to the playground, and one staff person stayed with the children on the carpet. Initially, SP3 stated s/he went out first so SP2 should have stayed on the carpet. After viewing the video footage, SP3 stated that SP2 went out to the playground first and SP3 “should have” stayed inside with the children on the carpet. · SP1 stated s/he “grabbed” the iPad and stood at the open door to the playground and SP2 and SP3 walked out to the playground. SP1 called the children to the playground in “alphabetical order by first name” and did “name to face” in the app on an iPad as each child walked out the door. The AV attempted to go through the door before his/her name was called and SP2 sent him/her back to the ocean carpet. SP1 stated s/he did “not remember” but “must have accidentally” clicked on the AV’s name in the app at that time to move him/her to the playground. · When SP1 finished calling the children through the door and moving them from the classroom to the playground in the app, s/he noticed that two children, neither of which were the AV, had not been moved to the playground in the app and there were no children sitting on the carpet. SP1 asked SP2 if those two children were on the playground and SP2 told SP1, “Yes.” · SP1 again looked at the carpet and did not see any children so she went through the playground door and shut it. After approximately five minutes, the CP opened the door and asked if the AV was “supposed to be” out with the group. SP2 told the CP that the AV did belong outside and took the AV from him/her. The AV did not seem “upset” and was not “crying.” After the AV was outside, SP2 played “ball” with him/her. · The P was in the kitchen “prepping lunch” and walked out of the kitchen and walked to the front of the facility. There s/he met the CP who told him/her that s/he had found the AV alone in his/her classroom and that s/he took him/her outside. The P completed lunch and that afternoon, talked with SP1, SP2, and SP3 abut the incident. Then the P watched video footage. · SP2 stated that the only “blind spots” in the classroom were behind the coat rack and behind the diaper changing table. · SP1 stated that there were coats on the coat rack, and s/he could not see behind it and s/he failed to “double check the blind spots in the classroom.” · On March 12, 2024, the facility Attendance Sheet for Starfish showed there were 17 children present at the time of the incident. The facility’s Educational Program Plan showed that “all children are supervised” by staff persons “at all times.” The facility’s Risk Reduction Plan showed that staff persons “carry a binder and/or tablet when children transition which allows for name to face checks at each transition.” Facility documentation showed that the P, SP1, SP2, and SP3 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including the Risk Reduction Plan and Educational Program Plan prior to the incident. 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: Information was consistent that on March 12, 2024, the AV was in the Starfish classroom for approximately five minutes without the knowledge or supervision of SP1, SP2, and SP3, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was in a classroom designed for children who were the AV’s age, the AV was unsupervised for approximately five minutes prior to being found by the CP. Given that the AV was two years old, it was unlikely that the AV would be able to provide for him/herself in an emergency and staff persons were not aware that the AV was in the room in the event of any emergency. Therefore, 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 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, SP2, and SP3 were trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including the Risk Reduction Plan and Educational Program Plan. At the time of the incident, SP1, SP2, and SP3 were working in the Starfish classroom. Although SP1 completed the name to face count, SP1, SP2, and SP3 were each responsible for the care and supervision of all the children in the classroom, including the AV, and responsible for ensuring all the children were present after transition from the classroom to the playground. SP1, SP2, and SP3 were each 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 SP1, SP2, and SP3 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not sustain an injury that required the care of a physician. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were inadequate. The facility added a “final visual check” of the classroom to their supervision policy. Staff persons were retrained on the new supervision policy. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1, SP2, and SP3 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 disqualification. The determination that SP1, SP2 and SP3 were each responsible for maltreatment is subject to appeal. On May 22, 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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