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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: 1106266-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that two alleged victims (AV1 and AV2) were left alone on the playground for approximately two minutes. Date of Incident(s): April 1, 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 11, 2024; from documentation and video footage at the facility; and through six interviews conducted with a supervisory staff person (P1), four facility staff persons (P2 and SP1-SP3), and AV1’s family member (FM1). Attempts were made via telephone and mail to contact AV2’s family member (FM2), but FM2 did not respond to the requests. According to AV1’s and AV2’s enrollment information, AV1 was two years and seven months old and AV2 was two years and eight months old at the time of the incident. AV1 and AV2 were enrolled in the toddler B room. The facility had a toddler and a preschool playground that were separated by a chain link fence with a gate. The preschool playground went along the west side of the facility and the toddler playground went along the south side of the facility. The preschool playground was enclosed on the two other sides by a wooden fence and the third side was the facility. Along one of the wooden fences was a hill that dipped down toward the fence. The toddler playground included a sidewalk that went from the chain link fence gate to a door that staff persons used to enter and exit the facility. Inside the door was a stairwell and another door that led to a hall in the shape of a T and one side of the hall led to a playroom. Consistent information was provided that P2 worked in the preschool room; SP1 worked in the toddler A room; and SP2 and another staff person (P3) worked in the toddler B room on the day of the incident. Prior to going out to the playground, SP3 began helping SP2 supervise the toddler B room while P3 left the classroom to assist a child with an injury. Consistent information was provided that the toddler A and toddler B rooms were combined outside on the preschool playground at the time of the incident. P2 stated on the day of the incident, when going outside with the preschool children, SP1-SP3 already had the toddler children outside on the preschool playground. When SP1-SP3 and the toddler children left the playground, P2 brought the preschool children over to the preschool playground. Once inside the preschool playground, P2 did a name to face of the preschool children and then saw AV1 and AV2 stand up on the hill. P2 texted P1 that AV1 and AV2 were on the preschool playground. Right before P1 came out the door, SP3 came outside and got AV1 and AV2. P2 thought AV1 and AV2 were alone outside for between two and five minutes and neither of them had injuries. Video footage provided by the facility showed the gate between the toddler and preschool playground and approximately five feet of sidewalk on each side. On April 1, 2024, at 10:31:19 a.m., SP2 left the preschool playground and closed the gate. At 10:33:47 a.m., P2 opened the gate from the toddler playground and went into the preschool playground. P1 provided information that the video was eight minutes behind normal time. SP1 provided the following information: · On the day of the incident, at approximately 10:30 a.m., SP1 recalled seeing AV1 and AV2 near a slide. SP1-SP3 had the toddler children line up near the gate to go inside. SP1 was at the front of the line and counted ten children from the toddler A room (not including AV1 and AV2), did a name to face of the toddler A children, and documented the number of children in his/her cell phone on the facility app. SP3 was at the middle of the line making sure the toddlers did not stop at the toddler playground on the way inside and SP2 was at the back of the line and closed the gate. · SP1 led the line to the playroom where the children began taking off their coats. SP1 did another head count and name to face once inside the playroom. At that time, SP3 realized some of the children were missing so SP3 went back outside to the playground and brought AV1 and AV2 into the playroom. AV1 and AV2 did not have injuries. SP2 provided the following information: · SP2 did not recall how many children were on the preschool playground at the time of the incident but SP2 and SP3 had between 10 and 12 toddlers in the toddler B room on the day of the incident. SP1 also came outside to the preschool playground with seven toddlers from toddler A room and they combined toddler rooms. · After a while, SP1 decided the line up the toddlers from toddler A room first to go into the playroom. The children from toddler B room also wanted to go inside so started “crowding into” the toddler A room children making it “hard to separate” the two rooms so SP1-SP3 decided to have all the toddler children go into the playroom at the same time. · SP2 “forgot” to do name to face prior to bringing the children inside and SP2 was not sure if SP1 and/or SP3 did name to face. SP2 thought s/he remembered SP1 “trying to” do name to face while the children lined up but the area was “very crowded” when walking inside. SP2 was at the end of the line and “should have stayed back” on the preschool playground, walked around the playground, and made sure all the children were with the group. · SP2 tried counting the toddler children “as best” s/he could while walking inside but it was “chaotic.” Once inside the playroom, it was “very stressful” and the children began taking off their outside gear including coats when SP3 counted the children and realized some were missing. SP3 went back outside to the preschool playground while SP1 and SP2 stayed in the playroom and assisted the other children. After a minute, SP3 brought AV1 and AV2 into the playroom and they did not have injuries. SP3 provided the following information: · SP3 stated on the day of the incident, SP2 and SP3 bought the toddler B children to the playground. Since P3 was busy, SP3 went inside and assisted SP1 with getting the toddler A children ready and outside. At approximately 10:30 a.m., SP3 asked SP1 if s/he wanted to bring one room or both inside to the playroom and they decided to bring both rooms in together. SP1 went to the gate and some of the children started lining up while SP2 got a child from the sandbox and SP3 got a child from a rock climbing wall. SP3 asked SP1 to wait to open the gate until all the children were lined up. SP1 did not wait and opened the gate and walked along the sidewalk to the facility door. SP3 was not able to complete a name to face because once SP1 opened the gate, the children ran through it to the other door. · SP3 asked SP1 again to wait to open the door to inside and SP1 did not and opened that door also. Some of the children began mixing in with the preschool children and others began running upstairs. Since SP3 was in the middle of the line, s/he went up the stairs to bring those children back down. When all the children were inside, SP2 closed the outside door. · While SP1-SP3 and the children were near the stairs and before going inside the last door, SP3 asked SP1 if s/he counted the children. SP1 responded that s/he had counted the toddler A children. SP3 asked SP1 to wait on opening the door to the hall while SP2 and SP3 counted all the children. SP1 did not wait and opened the door and the children went to the playroom. · SP3 went to the playroom and SP1 and some of the children were already inside the playroom. SP1 was setting items down, SP2 came in and assisted some children with getting their outside clothes off, and SP3 tried counting the children and noticed not all the children were inside. SP3 remembered seeing AV1 and AV2 on top of the hill so s/he ran outside to get them. SP3 told P1 about AV1 and AV2 while outside and then brought AV1 and AV2 inside to the playroom. AV1 and AV2 did not have injuries and were alone outside for approximately two to three minutes. P1 stated right after s/he received the text from P2, s/he went outside and saw SP3 walking back towards the facility with AV1 and AV2. AV1 and AV2 did not have any injuries. FM1 stated s/he received an email from the facility on the day of the incident explaining what happened. FM1 did not have other concerns with the facility. According to the facility’s Supervision policy, staff persons “must” supervise children within sight and hearing and have the ability to intervene “at all times.” According to the facility’s Risk Reduction Plan, children were supervised “at all times.” Staff persons completed head counts and name to face attendance before and after every room transition to account for all children and double check that they had the correct children. There was an app or attendance form that staff persons completed to document these checks. Facility documentation showed that all staff persons, including SP1-SP3, received training on the Supervision policy, the Risk Reduction Plan, 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 was 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: Consistent information was provided that on April 1, 2024, at approximately 10:30 a.m., AV1 and AV2 were left alone on the preschool playground for approximately two and a half minutes without the knowledge or supervision of a staff person which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. After SP1-SP3 left the preschool playground, P2 brought his/her children to the playground and saw AV1 and AV2 stand up on a hill. P2 texted P1 that AV1 and AV2 were on the preschool playground. Right before P1 came out the door, SP3 came outside and got AV1 and AV2. Minnesota Statutes, section 260E. 30, subdivision 3, stated that rather than making a determination of substantiated maltreatment by an individual, the commissioner of human services shall determine that a nonmaltreatment mistake was made by the individual. A nonmaltreatment mistake occurs when: (1) at the time of the incident, the individual was performing duties identified in the center's child care program plan required under Minnesota Rules, part 9503.0045; (2) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; (4) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; and (5) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing requirements relevant to the incident. Regarding SP1 and SP2: Consistent information was provided that at the time of the incident, SP1-SP3 and the children left the preschool playground and went inside to the playroom, leaving AV1 and AV2 unsupervised on the preschool playground. SP1’s and SP2’s actions or conduct were determined to be a nonmaltreatment mistake for the following reasons: (1) Supervision was defined in the facility’s Supervision policy and Risk Reduction Plan. SP1 stated s/he counted the seven children from toddler A room prior to leaving the playground. Although SP1 did not count all the children from both toddler rooms upon entering the facility, SP1 completed tasks within his/her job related duties while assisting the children. SP2 said s/he tried counting the children in the hall but the area was “very crowded.” (2) SP1 and SP2 had not previously been found responsible for a similar incident that resulted in a finding of maltreatment or a nonmaltreatment mistake in the past. (3) SP1 and SP2 had not previously been found responsible for a similar incident that resulted in a finding of a nonmaltreatment mistake in the past. (4) AV1 and AV2 were uninjured and did not require medical care after the incident. (5) Outside of this incident, the facility, SP1, and SP2 were in compliance with all relevant licensing requirements. The nonmaltreatment mistake to AV1 and AV2 by SP1 and SP2 was not maltreatment. Regarding SP3:
A. Maltreatment:
Although SP3 was performing job related duties at the time of the incident, AV1 and AV2 were not injured, and the facility and SP3 were in compliance with all licensing requirements relevant to the incident, SP3 had been determined responsible for a similar incident that resulted in a finding of a nonmaltreatment mistake. Therefore, SP3 was not able to be considered under a nonmaltreatment mistake for this report.
Given that AV1 and AV2 were unsupervised without staff persons’ knowledge, and when AV1 and AV2 were found, they were outside on the preschool playground and staff persons were not able to intervene if necessary, there was a preponderance of the evidence that there was a failure to supply AV1 and AV2 with necessary care and a failure to protect AV1 and AV2 from conditions or actions that seriously endangered his/her physical or mental health. 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. SP3 was trained on the facility’s Supervision policy, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. SP1-SP3 were responsible for AV1’s and AV2’s supervision at the time of the incident. However, given SP1’s and SP2’s conduct met the requirements for a non-maltreatment mistake, SP1 and SP2 were not responsible for maltreatment of AV1 and AV2.
SP3 did not meet the requirements for a non-maltreatment mistake, therefore SP3 was responsible for the maltreatment of AV1 and AV2.
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 SP3 was responsible in this report was not serious or recurring maltreatment because it was a single incident and AV1 and AV2 did not sustain an injury. 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. SP1-SP3 received additional training on the Risk Reduction Plan and policies. P2 also conducted another meeting with SP1-SP3 about policies and procedures. Action Taken by Department of Human Services, Office of Inspector General: SP3 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP3 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 SP3. The determination that SP3 was responsible for maltreatment is subject to appeal. SP1 and SP2 were not determined as a perpetrator of maltreatment of AV1 and AV2 because the Department of Human Services found that the incident for which SP1 and SP2 were responsible met the criteria to be determined a nonmaltreatment mistake. SP1 and SP2 were notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP1 and SP2 are responsible might not be considered a non-maltreatment mistake. On June 20, 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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