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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: 801660-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that a staff person (SP) opened an exterior door and an alleged victim (AV) went out the door and into a parking lot unsupervised. Date of Incident(s): April 8, 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 15, 2024; from video footage and documentation at the facility; and through four interviews conducted with a supervisory staff person (P1), two facility staff persons (P2 and the SP), and the AV’s family member (FM1). This investigator contacted a family member (FM2) of another child who attended the facility and arranged a time to interview FM2 via telephone. FM2 did not answer the telephone at the scheduled time and did not respond to a voicemail left for FM2 to contact this investigator. According to the AV’s enrollment information, the AV was 11 months old and enrolled in the infant room at the time of the incident. Consistent information was provided that P2 and the SP were working with approximately four to five infants in the infant A room at the time of the incident. The facility was in a strip mall along with other businesses. The infant room and entrance/lobby were in the front of the building and each had windows and an exterior door that led to a sidewalk and a community parking lot. Along two sides of the parking lot were Humbolt Avenue, which had four lanes of traffic and a speed limit of 30 miles per hour; and 69th Avenue. Video footage from the facility showed the following: · On April 8, 2024, at 4:11 p.m., P2 and the SP were in the infant room with approximately four children including the AV. The SP waved to a person later identified as FM2 out the front of the building. The SP walked to the exterior door and at 4:11:41 p.m., the SP opened the door. The AV walked across the room and while the SP held the door open, at 4:11:57 p.m., the AV walked outside and out of view of the camera. At 4:12:10 p.m., the SP closed the door and walked back into the infant room. During that time, P2 sat on the floor playing with two to three infants. · The SP then walked quickly to the other side of the room and touched an item on the wall. The SP blew his/her nose and walked around the room while motioning with his/her hands and appeared to talk to P2, then leaned against a cabinet and continued talking to P2. At 4:14:06, FM2 walked to the exterior door carrying the AV and the SP ran across the room and opened the door. Six seconds later, the SP held the AV in his/her arms. P2 stated on the day of the incident, FM2 left the facility and walked outside along the sidewalk. The SP walked over, opened the exterior door, and said goodbye to FM2 and his/her family. P2 did not see the AV leave the facility because s/he was sitting on the floor with other infants and a shelf was between P2 and the door. The SP closed the door, walked back over to the counter area and checked the computer app on the wall. A minute or two later, FM2 came back to the exterior door carrying the AV who was not harmed. P2 was not aware the AV left the room prior to that.
P1 stated s/he was in the staff office when FM2 came inside the lobby front door and told P1 that the AV had been outside. At the same time, the SP came into the office upset and told P1 that it was his/her “fault” that the AV walked out the exterior door of the infant room. P1 tried to “calm” the SP, then called an administrative staff person for advice on the next steps to take. By that time, FM1 had already picked up the AV so P1 called FM1 and explained the incident. There were previous occasions when a mail person delivering mail used the door to the infant room but otherwise the door was not used. The SP stated on the day of the incident, the SP and P2 had approximately five children in the infant room. At one point, FM2 walked past the windows and waved. The SP went to the exterior door, opened it, and spoke to FM2 with the door held open. During that time, the SP did not look down and when s/he was done talking to FM2, the SP closed the door. The SP walked to the counter, looked around, walked “directly” back to the door, and saw FM2 holding the AV outside the door. The SP took the AV who did not have any injuries. The AV was alone outside for approximately one and a half minutes. Prior to this incident, there were a few times when the SP opened the door for the mail person but otherwise the door stayed closed. Since the incident, the SP “refuse[d]” to open the exterior door. FM1 stated that on the day of the incident, when s/he picked up the AV, the SP told FM1 about the incident. The SP was crying. FM1 said that the AV getting outside was a “mistake” and s/he did not have previous concerns with the facility. According to the facility’s Supervision of Children policy and employee handbook, the safety and well being of the children were the “utmost importance” to staff persons and their first responsibility. All children were supposed to be within sight and sound “at all times.” According to the facility’s Risk Reduction Plan, all staff persons were trained to be aware of “any activity in close proximity to doors.” It was staff persons responsibility to “increase their level of supervision at these times.” Facility documentation showed that staff persons, including the SP and P2, were trained on the facility’s Supervision of Children policy, the Risk Reduction Plan, the employee handbook, and the Reporting of Maltreatment of Minors Act 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, stated that a child must have supervision at all times and that supervision was 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: Consistent information was provided that on April 8, 2024, at approximately 4:11 p.m., while the SP held the exterior door open, the AV left the facility unsupervised. Video footage showed that the AV was outside for approximately two minutes and nine seconds without the SP’s knowledge or supervision and was found by FM2. The SP was not aware that the AV left until s/he saw FM2 walking and carrying the AV. A child leaving the facility without staff persons knowledge or supervision was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, the Supervision of Children policy, and the facility’s Risk Reduction Plan; and was also a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. When the 11 month old AV left the facility without the knowledge and supervision of the SP, the AV was exposed to dangers outside the facility including parking lot and street traffic. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health when reasonable 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 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 626.556, subdivision 10e, paragraph (i): 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. The SP and P2 were responsible for the care and supervision of the AV at the time of the incident and were trained on the Supervision of Children policy, the Risk Reduction Plan, the employee handbook, and the Reporting of Maltreatment of Minors Act. At the time of the incident, P2 was across the room on the floor interacting and supervising a group of children when the SP opened the door. The SP opened the exterior door failing to ensure that no children left and which allowed the AV to leave the facility. Therefore, P2’s responsibility was mitigated and the SP was 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. The substantiated maltreatment for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the AV did not sustain an 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 policies and procedures were adequate but not followed. The facility “immediately” put up a sign on the door for emergency use only. Staff persons received additional at a staff meeting. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP 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 the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On May 31, 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.
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