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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: 1044125-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on a playground without staff person knowledge or supervision for a minute and a half. Date of Incident(s): March 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 March 27, 2024; from documentation at the facility; and through six interviews conducted with a supervisory staff person (P1), four facility staff persons (SP1, SP2, P2, and P3), and the AV’s family member (FM). The AV was four years old and enrolled in the Eagle classroom (pre-kindergarten) at the time of the incident. The AV was not at the facility the day of the site visit, so s/he was not interviewed for this investigation. The facility shared a building with a community outreach program. The building was surrounded by other community outreach buildings, a public park, a church, and residences. The building was located on a one-way street with parking on both sides of the street, and there was a sidewalk in front of the building. The speed limit on the street was 20 miles per hour. The facility’s playground was on the side of the building and divided into a younger and older side for play, and each side had play structures appropriate for the ages of the children. The sides were separated by a four-foot-high chain link fence. There was an exterior four-foot-high chain link fence that partially enclosed the playground. There was an opening with stairs leading up from the sidewalk on the corner of the playground, and a smaller sidewalk that led from the sidewalk to an entrance of the building. Along this smaller sidewalk was an opening in the fence for a wheelchair ramp. Through the entrance to the building there was a vestibule and another set of doors into the building. Through those doors there were five steps up to the first floor of the building. There was a staircase to the second floor with ten steps, a landing, and then an additional ten steps. The Eagle classroom was the first door on the left at the top of the stairs on the second floor. P2 stated that s/he arrived for his/her shift at the facility around noon on the day of the incident (P2 stated March 4, 2024, but based on video of the incident, the date was most likely March 11, 2024). P2 was walking on the sidewalk when s/he saw the AV on the playground under a slide. When the AV saw P2 s/he ran around the fence to P2. P2 asked the AV what s/he was doing out there, and the AV said s/he ran down there, and that his/her class was upstairs. P2 told the AV that was not safe and asked the AV if s/he could bring the AV back inside. P2 brought the AV upstairs into his/her classroom as there was no one in the hallway. P2 brought the AV into the classroom and told “the main staff person” (likely SP1) that the AV was left outside. P2 stated that the other children were at tables doing an activity when s/he brought the AV into the classroom and that SP1 was helping those children. P2 did not see another staff person in the classroom. P2 said SP1 did not know the AV was missing and then P2 brought the AV to P1 and let P1 handle the situation from there. P2 said the AV seemed “fine” when s/he found him/her and that it was “nice” out that day. P2 did not know how long the AV was outside without supervision. SP1 said that on March 11, 2024, around noon, SP1 was outside with a group of ten children and SP2. SP1 stated it was time to go inside, so the children walked along the ramp and started to line up next to the wall of the building. At that point two other children started walking toward the sidewalk, so SP1 told SP2 to take the rest of the children inside and SP1 would bring in those two children. SP1 said when s/he and those two children got inside the vestibule area there was no one else in there and when they went into the building to the stairs, SP1 saw the last child from the other group running up the stairs. When SP1 got upstairs, SP2 was just outside of the classroom with some children. SP1 opened the classroom door and said to the rest of the children “Let’s wash up,” and when s/he turned around, P2 was walking up the stairs with the AV. P2 said the AV was outside on the playground. SP1 asked P3, who was also walking in the hallway, to let P1 know what had happened. SP1 said the AV was smiling, so SP1 told the AV to take off his/her jacket and wash up to get ready for lunch. SP1 thought the AV was without supervision for a minute or two. SP1 stated s/he was trained to do a headcount when leaving and coming from an area and once they got into the classroom. SP1 stated that s/he did not count on the way inside that day. SP1 stated that s/he was devasted that this happened and worried about what could have happened to the AV if P2 had not walked by. SP1 stated that s/he now stops at the entryway even if children are having a difficult time to recount the children. SP2 did not remember the date of the incident but stated that s/he and SP1 were outside on the playground with ten children, and it was a nice spring day. It was time to bring the children inside so SP1 told the children to line up. SP2 went to gather a child who was on one side of the playground. As SP2 walked back to where the children were lined up, SP1 was helping two other children who were not lining up. SP2 brought the children who were lined up into the facility and upstairs. The children took off their jackets, and then they went into the classroom to wash hands to get ready for lunch. SP2 was not aware of when P2 brought the AV back to the group, but stated the AV was there when lunch was served. When SP2 heard that they had left the AV outside, s/he could not believe it, and was glad that P2 walked by at that time. SP2 stated that s/he and SP1 separated during the transition from the outdoor play area to the classroom because there were children who were struggling, but that was not what they usually did. SP2 said his/her memory of the incident was “fuzzy,” but s/he thought they counted the children when they returned to the classroom. P1 said that on March 11, 2024, around noon, P3 told P1 that s/he needed to talk to the Eagle classroom staff persons as the AV was just left outside on the playground. P1 said s/he went and quickly talked to the staff persons. SP2 told P1 that the AV had come inside, and then SP1 stated that the AV hid under the playground structure when the rest of the children came inside. P1 called the FM to let him/her know about the incident. P1 tried to talk to the AV, but the AV just smiled at P1 when P1 asked what happened. P2 documented the incident and told P1 that the AV did not seem “scared.” SP1 told P1 the class was lining up to come inside, and there were a few children struggling, so SP1 had SP2 bring in the rest of the group while SP1 brought in the children who were struggling. SP1 told P1 that s/he was still in the hallway with these children when P2 brought the AV upstairs. P1 reviewed video footage and stated the AV was without supervision for approximately 90 seconds. P1 said the policy was to do a name to face count before coming in, and then to count again once back in the classroom. P1 had no prior concerns with SP1 or SP2. P1 stated that on the day of the incident, the weather was “nice” out and that some children had their jackets tied around their waist. P3 said s/he did not remember the date of the incident but at “about noon” s/he was walking down the hallway and saw SP1 in the hallway with “about” five children who were taking off their jackets. P2 and the AV were standing next to SP1 at that time. SP1 asked P3 to find P1 and tell him/her that the AV was left on the playground when the class came inside and P2 found the AV. P3 did not see SP2 in the hallway. The FM said s/he was aware of the incident. SP1 told the FM that s/he did not count the children when coming inside and that there was a lot going on, but SP1 thought the AV was with them. SP1 asked the FM to talk to the AV about hiding from staff persons, and the FM thought it was “weird” that SP1 said that. The FM said that the AV did not seem bothered by the incident. According to www.wunderground.com, the temperature in Minneapolis on March 11, 2024, at 11:53 a.m. was 55 degrees Fahrenheit (F°). This investigator reviewed video footage and noted the following: · On March 11, 2024, at 11:49:23 a.m., SP1 was on the play structure with some children and SP2 was with a child on the other end of the playground. The children and SP1 got off the play structure and started to walk toward the entrance door which was not in the camera’s view. During this the AV laid down on the ground under the play structure. SP2 and the child s/he was with started walking toward the entrance door as well. · At 11:49:46 a.m., SP2 and the other child stopped by the play structure, and the AV moved slightly underneath it. As SP2 and the other child walked down the ramp leading toward the smaller sidewalk the AV got up into a crawling position and crawled about three feet in the direction of SP2, while still under the play structure. At 11:50:07 a.m., SP2 and the other child were no longer in the camera’s view. Eleven seconds later the AV stood up and moved behind a slide where s/he was out of view of the camera. · At 11:51:59 a.m., the AV ran out from behind the slide and toward the sidewalk and P2 was seen walking on the sidewalk. The AV ran down the ramp toward P2 and out of view of the camera. The facility’s Risk Reduction Plan stated that children will be adequately supervised at all times and that on stairways, one staff person proceeds before the children, and one staff person remains behind the children when walking. The Risk Reduction Plan also referenced a policy/procedure in the Staff Orientation Handbook: Procedure for Tracking Children’s Whereabouts, that was developed and implemented to address supervision risks. This policy stated that, “While on the playground or fieldtrips, [staff persons] will bring along the sign in clipboards. Prior to leaving [staff persons] will count the children to endure that all children are present and accounted for.” Facility records showed that SP1, SP2, P1, P2, and P3 were each trained on the facility’s Risk Reduction Plan and 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: On March 11, 2024, SP1 and SP2 were outside with a group of ten children including the AV when it was time to line up to go inside. SP1 stated that the children started lining up along the wall of the building when two other children started to walk toward the sidewalk. SP1 went to gather those two children and had SP2 bring in the remaining children. While SP2 brought most of the children upstairs, SP1 brought in the two children s/he had gathered. P2 stated that when s/he arrived at the facility, s/he saw the AV hiding under the play structure on the playground. The AV ran out to P2 and P2 brought the AV inside. Information from P2, P3, SP1, and SP2 was conflicting as to what was happening when P2 brought the AV back to his/her class. However, video footage showed that based on when SP2 was no longer visible in the camera view to when P2 arrived on the playground, the AV was on the playground without the knowledge or supervision of a staff person for between one to two minutes, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and the 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. Being unsupervised at a playground that was not fully fenced in and was visible and accessible to passersby, gave the AV access to community dangers including unknown community persons, streets, homes, and community buildings. SP1 said that s/he was trained to complete a headcount of children before and after transitioning away from one area and into another. However, SP1 acknowledged that s/he did not count the children prior to transitioning into the facility after playing outdoors on March 11, 2024, and SP2 acknowledged that the group separated before a count could be completed. As a result, the AV's absence from the group went undetected and the AV was unsupervised outdoors until P2 saw him/her one to two minutes later. 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 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. 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 AV’s supervision at the time of the incident, and they were each trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. SP1 and SP2 were 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 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV did not sustain any injuries. 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 retrained the staff persons on supervision. 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 disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal. On June 12, 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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