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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: 1104835-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that three alleged victims (AV1, AV2, AV3) left the classroom and were found by a community person. Date of Incident(s): April 11, 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 April 24, 2024; from documentation at the facility; and through ten interviews conducted with seven facility staff persons (SP1, SP2, SP3, SP4, SP5, P1, P2), AV1’s family member (FM1), AV2’s family member (FM2), and AV3’s family member (FM3). Due to their ages AV1, AV2, and AV3 were not able to provide any information about the incident. The facility was located in a large building with a hallway running along the center. There were classrooms located along each side of the hallway. The Toddler classroom was a large open room with a door along the outside wall that exited to the outside. There was a carpeted area in the back of the classroom and a vinyl type flooring with tables in the front of the classroom. Along the right wall of the classroom was a bathroom and diaper changing area. Directly outside of the outside door was a sidewalk that ran the length of the building. The sidewalk led to the back corner of the building. In the back of the building was a detached fenced in playground and additional paved areas. Around the corner along the back of the building were the infant classrooms. At the time of the incident, AV1 and AV2 were 30 months old and AV3 was 25 months old, and each were enrolled in the Toddler 1 classroom. P1 provided the following information: · On the date of the incident, P1 worked in the Infant 2 classroom. A community person knocked on the emergency door leading outside and told P1 that there were two children outside. P1 immediately went outside and saw AV2 and AV3 picking up sticks and wandering around. AV2 and AV3 were a “little further” than the playground going back towards some pine trees. · P1 and another staff person took AV2 and AV3 along the side of the building towards the Toddler 1 classroom. As they were getting close to the door, SP5 came out of the door and looked “surprised” to see P1 and the children. P1 and the other staff person gave AV2 and AV3 to SP5 and returned to their classroom. P1 then text another staff person about what had happened (determined to be 10:38 a.m.). P1 did not see AV1 outside. P2 provided the following information: · On the date of the incident, P2 was informed that AV1, AV2, and AV3 had gone outside when the outside door in the Toddler 1 classroom was propped open. P2 found that the classroom had their snack at 10:17 a.m. which lasted approximately 15 minutes. P1 sent a text at 10:38 a.m. reporting the incident, which was one to two minutes after s/he brought the children back to the classroom. P2 thought the children were outside for approximately three to five minutes. · There was no policy on having a door propped open, but after the incident, the policies were changed to indicate that doors would not be propped open. SP1-SP5 and the Internal Investigation provided the following information: · On April 11, 2024, SP1, SP2, SP4, and SP5 worked in the classroom with 20 children. Sometime before snack, SP1 opened the outside door and put a small piece of wood in the door to prop it open. SP1 sat by the door with his/her legs propped against the wall blocking the door. At some point before snack time SP3 arrived in the classroom so that SP1 could leave to finish some training. SP1 left the classroom.
· At approximately 10:17 a.m., the Toddler 1 classroom sat down for a snack. Snack time lasted for approximately 15 minutes and all children were accounted for as the number of snacks given out matched up to the number of children in attendance. · At approximately 10:22 a.m., SP5 took a few children to the diaper changing area. SP4 started to assist some children into their outside clothing. SP2 was sitting down with some children at group time and SP3 started cleaning the tables. SP5 remembered having both AV1 and AV3 use the bathroom during this time. · At approximately 10:35 a.m., SP5 asked for AV2 to come to the diaper changing area but SP5 could not see AV2. SP5 looked around the classroom for AV2 and noticed that the outside door was propped open. · SP5 ran out of the classroom and saw AV1 right outside the door, “maybe two to three steps out.” Then SP5 noticed P1 and another staff person walking towards SP5 holding AV2 and AV3. SP5 brought the children back inside and did a name to face count to make sure all the children were in the classroom and then informed his/her supervisor. · SP1 said that s/he sat by the door to make sure no children left but s/he was called out to do training and “lost focus” on the door and it did not get shut. SP1 said when s/he got up the children were following him/her and SP5 was “more worried” about that. · SP2 said that s/he saw SP1 put a piece of wood in the door to prop it open and sit by the door. SP2 looked at his/her watch and noticed in was 9:52 a.m., so s/he started his/her group time with some of the children on a rug. SP1 left a while later and was relieved by SP3. SP2 did not know the door was still open. · SP3 came into the classroom so that SP1 could leave and go finish his/her training. When SP3 came into the classroom, s/he started cleaning up and sweeping after snack time. SP3 did not know the outside door was open. · SP4 said that s/he went to the bathroom during snack time and when s/he returned s/he started getting some children ready to go outside. SP4 remembered seeing SP1 at the back door but SP4 did not know the door was open. · SP5 said that sometime that morning, SP1 had propped open the door with a piece of wood and sat by the door with his/her legs blocking the door. SP3 came into the classroom and relived SP1. SP5 did not know the door was still propped open after SP1 left the classroom. FM1, FM2, and FM3 each had no prior concerns. According to www.wunderground.com, the outdoor condition at the facility, on April 11, 2024, at the time of the incident, was “partly cloudy” with a temperature of between 54-56 degrees Fahrenheit (°F) and wind speed of 13-14 miles per hour (mph). The Employee Handbook stated that staff persons were required to provide adequate supervision of students at all times. The Supervision/Accounting For Children Policy stated that all children were supervised within sight and hearing of staff persons and accounted for at all times. The Risk Reduction Plan for Licensed Child Care Centers stated that staff persons were required to supervise children at all times and maintain accountability of all children in the facility’s care. Facility documentation showed that SP1-SP5 were trained on the facilities policies including the Employee Handbook and the Risk Reduction Plan for Licensed Child Care Centers and on the Reporting of Maltreatment of Minors Act. 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: Information was consistent that on April 11, 2024, AV1, AV2, and AV3 each left the classroom without the knowledge or supervision of a staff person for likely three 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. SP2, SP3, SP4, and SP5 were each not aware that AV1, AV2, and AV3 left the classroom after SP1 propped the classroom door open, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Given that AV1, AV2, or AV3, who were all between 25-30 months old, left the facility and were in the community, in a location that could expose AV1, AV2, and AV3 to community dangers, and that staff persons were not with AV1, AV2, and AV3 to intervene in the event of an injury or emergency, 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 AV1, AV2, and AV3 from conditions or actions that seriously endangered AV1’s, AV2’s, and AV3’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, SP2, SP3, SP4, and SP5 were each trained on the facility’s policies including the Employee Handbook and the Risk Reduction Plan for Licensed Child Care Centers and the Reporting of Maltreatment of Minors Act prior to the incident. At the time of the incident, SP2, SP3, SP4, and SP5 were supervising the children in the classroom. SP1 had left the classroom before the incident occurred but propped the outside door open prior to leaving. SP3 and SP4 said they each did not know the outside door was open. SP2 and SP5 said they each saw SP1 open and sit near the outside door but did not know SP1 did not shut the door before s/he left the classroom. Although SP2, SP3, SP4, and SP5 were in the classroom at the time of the incident, given that SP1 was the one who opened and sat near the door and failed to close the door when s/he left the classroom, and that SP2, SP3, SP4, and SP5 continued to participate in classroom activities with the children while AV1, AV2, and AV3 left the classroom, SP2, SP3, SP4, and SP5’s responsibility was mitigated and SP1 was responsible for the maltreatment of AV1, AV2, and 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. 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 was responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident and AV1, AV2, and/or AV3 were not injured. 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 policies and procedures were followed but the door was not shut after the active supervision stopped. A section was added to the risk reduction plan about propping doors open and all staff persons were retrained. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. On May 24, 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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