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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: 830575-CCC (Child Care Center) Investigator(s): Lindsay Arth/Alice Percy 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was found unsupervised in the facility’s parking lot. Date of Incident(s): December 20, 2023 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 January 4, 2024; from documentation at the facility; and through six interviews conducted with a facility administrative staff person (P1), four staff persons (SP1, SP2, SP3, and P2), and the AV’s family member (FM). The AV was two years old and enrolled in the preschool classroom at the time of the incident. The facility was located next to a two-lane road with a change in speed limit of 45 and 50 miles per hour depending on the driving direction. A narrow grassy area separated the facility parking lot from the road and the parking lot was located in the front and along one side of the facility. A sidewalk ran along the front and the side of the building where the parking lot was located. A fire station was located on one side of the facility and a small strip mall was located on the other side of the facility. One entrance door to the facility was located in the middle of the front of the building. A second entrance door that was typically used by the staff persons and the children’s family members was located along the side of the building next to the side parking lot. A glass entrance door opened into a small vestibule and a second glass door opened into the lobby of the facility. The door to the administrative staff office also opened into the lobby area. At the far side of the lobby from the glass entrance door was a wood door, which opened into a hallway that led to the classrooms. Information obtained showed that on the day of the incident, prior to the AV leaving the facility, s/he was in a large preschool classroom which had a half-door opening to the hallway that led to the lobby. The large preschool classroom contained several tables and chairs as well as several low bookcases that containing books and toys. Once outside the facility, the AV walked along the side of the facility and was found in the parking lot in front of the facility that also bordered the street. P1, P2, SP1, SP2, SP3, and the facility’s documentation provided the following information: · On December 20, 2023, SP1, SP2, SP3, and P2 worked in the large preschool classroom with 27 children from three different preschool classrooms. The three groups typically were combined in the morning and that day they were working on a holiday art project. Each staff person worked on the art project with the children from their respective classroom. The AV was enrolled in SP2’s classroom. At approximately 8:50 a.m., SP1, SP2, and SP3 each sat at tables assisting the children with their art projects and each stated that their attention was on the art projects the children were working on. P2 was in the classroom and also assisting children with their art projects. Children who were not working on an art project played around the classroom. Shortly before 9 a.m., P2 left the classroom to take some children to the entrance at the front of the facility to wait for the school bus, which typically arrived at 9:05 a.m. P2 and the children waited inside the entrance door for the bus to arrive. · SP1 stated that the AV recently transitioned into SP2’s preschool classroom and “hadn’t gotten used to” staff persons and other children. SP2 stated that the AV was “very independent” and often played on his/her own. SP1 last noticed the AV standing near the classroom door leading out to the hallway; SP2 last noticed the AV playing in the “housekeeping area;” and SP3 saw the AV approach another staff person and ask them to help put on his/her shoe. SP1, SP2, and SP3 each stated that the half-door to the classroom was open. SP2 stated that in the mornings, the half-door was propped open with a chair because family members were dropping off their children and the toddler class had recently left the preschool classroom to walk to the toddler classroom. P1 stated that the door leading to the lobby was also open and the doorknob cover that was typically on the front lobby door was not on the knob at the time of the incident. · At approximately 9:15 a.m., P1 went to the large preschool classroom to get his/her keys and then walked out of the classroom to his/her office to put on his/her boots. While in the office, P1 heard the doorbell ring. P1 looked out of his/her office, but did not see anyone enter or exit the facility. P1 believed the other door to the facility had been opened causing the doorbell to ring. P1 left his/her office, picked up a car seat from the lobby, and took it outside through the side entrance door to his/her vehicle, which was parked near the front of the building. At that time, P1 saw the AV walking on the sidewalk in front of the facility. P1 went to the AV and picked him/her up taking the AV back into the facility. P1 told the staff persons that s/he found the AV unsupervised outside in front of the facility. SP2 stated that the AV “was a little upset” when P1 brought the AV back to the preschool classroom, but s/he was not crying. The AV did not sustain any injury during the incident. SP1, SP2, and SP3 were not aware that the AV left the classroom until P1 returned the AV to the classroom. · P1 believed that the AV followed P1 out of the large preschool classroom when s/he got his/her keys and that when P1 entered his/her office, the AV opened the wood lobby door and the glass entrance doors to access the outside of the facility. None of the staff persons saw the AV follow P1 out of the classroom. P1 believed that the AV was unsupervised for two to three minutes. P1 telephoned the AV’s family member (FM2) to tell him/her about the incident. · P2 stated that after the school-age children got on the bus, s/he walked by the toddler and infant classrooms and put his/her coat in his/her classroom. While there, s/he checked on an art project the children in his/her classroom made and then returned to the large preschool classroom shortly before P1 entered the large preschool classroom with the AV. P2 stated that s/he did not see the AV or P1 as s/he walked through the hallway. · P2, SP1, SP2, and SP3 each stated that when the three preschool classrooms were combined, all of the staff persons supervised all of the children. There was typically another staff person in the large preschool classroom in the morning, but that staff person was not there that day. SP1 believed that at approximately 9:30 a.m., the staff persons would have counted the children and realized the AV was not part of the group. SP2 stated s/he would have counted the children within 5 to 10 minutes when s/he took his/her group of children to their regular classroom. SP2 stated that in the past, the AV sometimes attempted to follow FM1 or FM2 out of the classroom when the AV was dropped off at the facility but had not previously left the classroom on his/her own. · After the incident, the staff persons ensured that the classroom and lobby doors were kept closed and that the doorknob covers were kept on the doorknobs so that the children could not open the doors. P1 stated that the facility’s video recordings on the day of the incident did not show everything that the AV did after leaving the preschool classroom because the AV was too small to show up on the recording. When the AV opened the outside entrance door, the staff persons in the infant classroom also heard the doorbell ring, but when they looked at the video camera monitor, which was located in the infant classroom, they did not see the AV on the monitor. FM1 stated that after the incident, the facility installed new handle locks on the doors. FM1 had no concerns about the care the AV received at the facility. A video camera was located in the lobby and provided a partial view of the lobby and the vestibule. A review of two video recordings of what occurred in the lobby of the facility on December 20, 2023, showed that at 9:14:19 a.m., the AV walked through the hallway door into the lobby and then walked across the lobby to the glass entrance door. Between 9:14:25 a.m. and 9:14:40 a.m., the AV opened the glass door from the lobby and then stood in the vestibule for approximately 15 seconds before opening the outside door and walking outside to the side parking lot. According to the facility’s Risk Reduction Plan, all of the children were to be under the direct supervision of a staff person at all times so that a staff person would be able to intervene if needed to protect the health and safety of all the children. The staff persons were trained to do face-to-name counts frequently and to also do head counts to ensure all the children were present. According to Weather Underground Fort Snelling, MN Weather History, on December 20, 2023, at 8:53 a.m., it was 29 degrees Fahrenheit (F). Information obtained showed that when the AV went outside, s/he was wearing pants, a long-sleeved shirt, and shoes, but was not wearing a coat. Facility documentation showed that SP1, SP2, SP3, P1, and P2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, state 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 December 20, 2023, the AV left the facility without staff persons knowledge or supervision and was found in the parking lot by P1. This was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Video recordings of the lobby showed that at 9:14:19 a.m., the AV walked through the hallway door into the lobby and then walked across the lobby to the glass entrance door. Between 9:14:25 a.m. and 9:14:40 a.m., the AV opened the glass door from the lobby and then stood in the vestibule for approximately 15 seconds before opening the outside door and walking outside to the side parking lot. P1 believed that the AV was unsupervised for two to three minutes. Given that the AV was two years old, left the facility unsupervised and was in the facility’s parking lot, the AV was exposed to community dangers including traffic and unknown community persons. In addition, staff persons would not have been able to intervene in the event of an emergency or to protect the AV from harm. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with 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. SP1, SP2, SP3, and P2 were each responsible for the supervision of the AV at the time of the incident and were trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including those regarding the supervision of children, prior to the incident. Shortly before 9 a.m., P2 left the classroom with other children to wait for the bus and returned to the large preschool classroom shortly before P1 brought the AV back to the classroom after finding the AV outside the facility. Therefore, it was most likely that the AV left while P2 was out of the classroom. Therefore, P2’s responsibility was mitigated and SP1, SP2, and SP3 were 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 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 any 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 the facility’s policies were adequate, but were not followed by the staff person. After the incident, all of the staff persons reviewed the facility’s supervision policies. 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 June 14, 2024, the facility was issued a Correction Order for the violation outlined in this report and for failing to report maltreatment as required. 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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