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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: 1075412-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 facility classroom without staff persons’ (P3 and the SP) knowledge or supervision for approximately 20 minutes before being found by a community person. Date of Incident(s): March 19, 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 10, 2024; from documentation at the facility; and through seven interviews conducted with the AV, the AV’s family member (FM), a community person (CP), a supervisory staff person (P1), and staff persons (P2, P3, and the SP). The facility was located in a community church in a rural area surrounded by farm fields and sporadic single family homes and farms. The facility shared space inside the church and consisted of seven classrooms including three preschool rooms (Preschool 1, Preschool 2, and Preschool 3), and a “gym” area. The preschool rooms and gym area were connected by a hallway and there were two restrooms down the hallway from the preschool rooms and near the gym. The Preschool 2 and Preschool 3 rooms were on the same side of the hallway with doors next to each other approximately six inches apart. The Preschool 2 room was a small, open, rectangular room with tables and shelving. The facility used ProCare [a mobile application (app) platform used to communicate with families and streamline administrative functions]. Family members were responsible for using the app to sign their child in and out each day. On March 19, 2024, the app showed that the AV was signed in at 8:15 a.m. and the CP’s child was not signed in that morning. A facility Daily Attendance sheet was completed by staff persons and showed that on March 19, 2023, the AV was not on the Preschool 2 or Preschool 3 sheet for the morning, but the AV was on the Preschool 3 Daily Attendance sheet for the afternoon. Facility documentation showed the AV was three and a half years old at the time of the incident and enrolled in the Preschool 2 classroom. The AV stated s/he “sometimes” liked to eat in the Preschool 3 room. After breakfast, s/he went back to the Preschool 2 room and was alone. The AV was “going to run” to a staff person but s/he “forgot.” Then P2 found the AV and s/he went with him/her to the gym. The FM provided the following information: · On March 19, 2024, at 8:14 a.m., the FM and the AV arrived at the facility. They went to the Preschool 2 classroom where P3 was and dropped off the AV’s things. Then the FM took the AV to Preschool 3 where the SP was, because that is where the AV liked to eat breakfast. · The following day when the FM dropped off the AV in the morning, a supervisory staff person “caught” him/her and told him/her that the AV had been found alone in the classroom the previous day and s/he would “circle back” when s/he had all the information. · On April 3, 2024, the supervisory staff person “caught” the FM when s/he was at the facility and told the FM what P1 learned about the incident. The FM was told that the AV had finished eating breakfast and at 8:35 a.m., the SP sent the AV back to Preschool 2. The AV went “right around the door” to Preschool 2 but there was no one in there. The “normal” Preschool 2 teacher, who knew the routine, was not in that day and P3, was a “substitute” staff person in that room. P3 and the Preschool 2 children had “already left” the room when the SP sent the AV to Preschool 2. The AV stayed in the Preschool 2 room alone and at 8:50 a.m., the CP entered the room to drop off his/her child and found the AV. · The AV was “perfectly normal” since the incident. · Prior to this incident, the FM did not have concerns with the facility. The CP provided the following information: · On March 19, 2024, the CP arrived at the facility with his/her child at an unknown time in the morning. They walked down the hallway, past the gym, and toward the Preschool 2 classroom. When they arrived at the classroom, the lights were off. The CP turned on the lights and noticed the AV “hiding” in a corner of the room. · The CP told the AV that s/he should not be in the room “alone” and s/he needed to “come with” them to the gym. The AV “slowly” walked toward the Preschool 2 classroom door as the CP and his/her child exited the classroom and walked toward the gym. At this point, the CP thought the AV was following the CP, but the AV was not. · When the CP arrived at the gym s/he saw the SP and P2 sitting on the floor. The CP told the SP that there was a child alone in the Preschool 2 classroom and the CP’s child told the SP the child’s name. The SP said, “Oh my God, why is [s/he] there?” The SP then told the CP that the AV had just gotten dropped off by the FM and did not “realize” the FM left. The SP left the gym area and walked down the hallway toward the Preschool 2 classroom while the CP walked down the hallway in the opposite direction and left the facility. · The CP stated s/he “felt safe” sending his/her children to the facility. P2 provided the following information: · P2 could not recall the date, but at approximately 9:50 a.m., P2 was in the facility hallway, walking with the Preschool 1 group from the bathrooms to the gym, when s/he saw the AV “poke” his/her head out of the Preschool 2 classroom. (Information from the investigation showed this was likely at approximately 8:50 a.m.) P2 “thought” the AV was being dropped off by his/her family member and said, “Hi,” to him/her and then the group went into the gym and the AV went back inside the room. The door to the Preschool 2 classroom was open. · When P2 arrived in the gym, the Preschool 2 children, Preschool 3 children, P3, and the SP were already there. P2 “mentioned” that the AV was being dropped off but did not know if P3 and the SP heard him/her because of “all the children” in the gym. Neither P3 nor the SP responded to P2. · Approximately ten minutes later, the CP came into the gym and told P2 that the AV was alone in the Preschool 2 classroom. P2 told P3 and the SP that s/he was going to get the AV and they “looked confused.” 2 then “immediately” left the gym to get the AV. When P2 entered the Preschool 2 classroom, the AV was standing in a corner and the AV “ran” to P2 and “started to cry.” P2 brought the AV to the gym and told P3 and the SP that the AV had been alone. Then P2 brought the AV to the bathroom. When they returned to the gym, the AV stayed by P2’s side for about ten minutes and then got up and played like “nothing ever happened.” · P2 was trained that when a group transitioned from one area to another, staff persons should complete name to face attendance and count the children. · P2 estimated the time that the AV was alone to be between 20 and 25 minutes but did not know how much longer s/he been in the classroom alone before P2 saw him/her as P2 went into the gym. P3 provided the following information: · P3 could not recall the date but was at the facility and was a staff person in the Preschool 2 classroom. The morning was “hectic” because other staff persons were sick. When P3 arrived, P2 and the SP were in the Preschool 2 classroom with all of the preschoolers. P2 and the SP took their children to their classrooms and P3 stayed in the Preschool 2 classroom. · When s/he was in the room, sometime before 8:30 a.m., the FM and the AV came to the room. P3 said, “Hello,” and then they walked out of the room. Then they came back and P3 saw the FM and the AV in the hallway and instead of walking into the Preschool 2 classroom, the AV walked into the Preschool 3 classroom. P3 did not add the AV to his/her Daily Attendance sheet because the AV did not remain in the Preschool 2 classroom “at that time.” · P3 then “popped” his/her head around the corner of the classroom door and saw that the AV eating breakfast in Preschool 3. P3 told the SP, “Send [the AV] over [after s/he finished eating] and let me know.” P3 did not recall if the SP responded to him/her but it was “pretty quiet” in the classroom, so s/he did not think it was possible that the SP did not hear him/her. · After the Preschool 2 children were finished eating breakfast, P3 got them ready to walk down the hallway to use the bathrooms before playing in the gym. The AV was not yet back in the room at this time. At approximately 8:15 a.m., P3 and the children left the classroom and walked past the Preschool 3 classroom which had the door open and did a “freeze” in the hallway. P3 counted the children and proceeded to walk down the hallway to the bathrooms. · At approximately 8:30 a.m., the Preschool 2 group transitioned from the bathrooms to the gym. When the Preschool 2 group entered the gym there were no other groups present. P3 did not recall when, but later, other groups, including Preschool 3, entered the gym. Shortly after, P3 left the gym to use the restroom. · Approximately two minutes later, P3 returned and P2 asked him/her if s/he “forgot something.” P3 responded, “No.” P2 pointed to the AV and then P3 asked P2 what had happened. P2 told P3 that the AV was in the Preschool 2 classroom and “poked” his/her head out of the room, and s/he saw the AV and brought him/her to the gym. P3 was “shocked” and was not sure what to do next. · P3 tried to talk with the SP but the SP was “sick” and “half asleep” and was lying on the floor. · P3 stated that the AV could not have entered the Preschool 2 room while the group was still in the room because the children would not have let him/her be alone. P3 did not know how long the AV was unsupervised. When the AV was brought to the gym, s/he did not “seem bothered” and played with children. The SP provided the following information: · On March 19, 2024, in the morning, the preschool children were combined in the Preschool 2 classroom. As more staff persons and children arrived, the group split. There were three Daily Attendance sheets for the preschool rooms, one for each Preschool room. · The AV “dropped” his/her jacket off in the Preschool 2 classroom and then came into the Preschool 3 classroom to eat breakfast. The SP stated s/he did not add the AV to his/her attendance log because the AV was not “going to be in” the room “that long.” The SP stated the AV “should” have been on the Preschool 2 log, because that is the classroom the AV was enrolled in. · At 8:34 a.m., the SP sat at a “circle” table “doing something on the iPad,” the door to the classroom was “open” and the SP told the AV to go to the Preschool 2 classroom and the AV left the Preschool 3 room. · “Normally” the SP and the staff person from the Preschool 2 classroom stood at the doorway and watched the AV go between the rooms. The SP did not “know” why s/he did it differently that day and thought that it was because s/he was “trying” to get the children ready to go to the gym. The SP stated that s/he “should have” stood in the doorway as the AV walked to Preschool 2. · The SP was “facing” the door and did not “see” P3 or the Preschool 2 children in the hallway before s/he sent the AV to the Preschool 2 classroom. · After the SP sent the AV to Preschool 2, s/he and the children in the Preschool 3 classroom left the room and lined up in the hallway, where the SP completed a name to face count of the children. Then the group walked down the hallway to the bathrooms. · After the group was done in the bathrooms, they transitioned into the gym. When the SP arrived at the gym, P3 and the Preschool 2 group were already there. · At approximately 9 a.m., the CP entered the gym and told the SP and P2 that the AV was “hiding” in the corner of the Preschool 2 classroom. The SP left the gym and walked “straight” toward the Preschool 2 classroom and found the AV in the hallway near the bathrooms. The SP “grabbed” the AV’s hand and told him/her, “Let’s go to the gym.” The SP and the AV walked into the gym and up to P2 and hugged him/her and then P2 took the AV to the bathroom. · The SP stated s/he did not have a “clue” how long the AV was unsupervised. The SP believed s/he found the AV near the bathrooms between 8:50 and 9 a.m. P1 provided the following information: · The facility had a policy that staff persons supervised children by “sight and sound at all times” and trained staff persons on that policy upon hire during orientation and then every January and August. · The SP “should have handed” the AV to another teacher and not let the AV go unsupervised. The SP told P1 that the “normal” staff person in the Preschool 2 classroom would stand at the Preschool 2 classroom door and ask the SP if the AV was done eating breakfast and when the AV was done, the SP would stand at the door to the Preschool 3 classroom and send the AV to the staff person in the Preschool 2 classroom. The classrooms were “one step away from each other.” · P1 stated that s/he did not know how long the AV was unsupervised because of the different information provided by P2, P3, and the SP. P1 estimated that the AV was found by the CP between 8:50 and 9:10 a.m. · When family members arrived at the facility, they used an electronic device to “check in” their child. There was a “minute or two lag” from the time the family checked their child into the app and the time the child appeared on the roster in the app. Staff persons used “paper” attendance rosters because they had not yet been trained on the process in the app. When classrooms transitioned from one location to another, staff persons used the paper attendance roster with the names of children that were present in the classroom. Staff persons then did a “name to face” by calling the child’s name and giving them a “high five” and did a head count before leaving an area and upon arriving at the destination. The facility’s Program Plan showed that “all children must be supervised at all times. This includes but not limited to: classroom, hallways, and playground areas.” The facility’s Risk Reduction Plan showed that “supervision” was required “each time children are within the common areas and hallways” of the church. “Children will be supervised at all times and never left alone. A name to face check will be completed at every transition and logged into Procare.” When transitioning, children “lined up” and a staff person faced “each line of their classroom children.” “A head count and name to face” was completed before leaving the classroom and again upon arriving at the new destination. Facility documentation showed that prior to the incident P1, P2, P3, and the SP each received training on the Reporting of Maltreatment of Minors Act and on the facility’s Program Plan and Risk Reduction Plan. 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 19, 2024, the AV was in the Preschool 2 classroom without the knowledge or supervision of a staff person for an unknown amount of time, but likely between 20 and 40 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV was found by the CP who had come to the facility to drop off his/her child. The CP notified staff persons who were in the gym. Then either the SP or P2 left the gym, found the AV either in the hallway or the classroom, and returned him/her to the group unharmed. Given that the AV who was three years old, was in the classroom and a shared facility hallway without the knowledge or supervision of staff persons for between 20 to 40 minutes and was found by a community person, 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. The SP and P3 received training on the Reporting of Maltreatment of Minors Act and the facility’s Program Plan and Risk Reduction Plan before the incident. On the day of the incident, P3 worked in the Preschool 2 classroom and the SP worked in the Preschool 3 classroom. The AV routinely attended the Preschool classroom but like to eat breakfast in the Preschool 3 classroom and did so that day. P3 stated that at 8:15 a.m., s/he and the children left the Preschool 2 classroom to use the bathroom and then go to the gym. The SP said that at approximately 8:34 a.m., the AV finished eating breakfast and the SP sent the AV back to the Preschool 2 classroom. The SP was near the Preschool 3 door but did not watch the AV as s/he walked to the Preschool 2 classroom or tell P3 that the AV was returning to the classroom. The SP then transitioned his/her classroom to the bathroom and then the gym. Between 8:50 and 9:10 a.m., the CP came into the gym and told the SP and P2 that the AV in the classroom alone. The SP was responsible for the care and supervision of the AV when the AV was in the Preschool 2 classroom and was responsible for ensuring the AV remained under the supervision of a staff person. The SP sent the AV back to the Preschool 3 classroom without ensuring the AV was supervised or that a staff person was in the classroom prepared to take over supervision of the AV. In fact, based on P3’s account, the classroom had been empty for approximately 20 minutes prior to the SP sending the AV to the classroom unsupervised. The SP was 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 the SP was 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 an injury that 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 their policies were adequate but not followed. The facility implemented an additional name to face count in the app and staff persons were retrained on the facility’s policies. 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 June 12, 2024, 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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