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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: 1113648-CCC (Child Care Center) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) left an alleged victim (AV) unsupervised in a classroom for sixteen minutes. 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 19, 2024; from documentation at the facility; and through five interviews conducted with a facility staff person (P1), an administrative staff person (P2), SP1, SP2, and the AV’s family member (FM). The AV was 31 months old and enrolled in the older toddler classroom at the time of the incident. The older toddler classroom was a large room with several tables and short bookshelves placed around the classroom. A door on the outside wall led to a playground. An alarm sounded if the door was opened. A half-wall with a half-door separated the classroom from the toddler bathroom. Consistent information was provided that the door to the bathroom was kept closed. A third door opened onto the main hallway of the facility. A large window was located next to the door. P1, P2, SP1, SP2, and the facility’s documentation provided the following information: · On the afternoon of April 8, 2024, SP1 and SP2 worked in the older classroom with 13 children. SP1 stated that at approximately 3:35 p.m., the children finished eating their snack and SP1 and SP2 cleaned up the classroom and lined the children up at the door. SP1 stood by the door as the children lined up and saw the AV “sitting there and crying” because s/he was having a “hard day.” SP1 said that s/he told the AV they were going to the gym and told SP2 that the AV needed help walking to the gym. SP2 stated that some of the children had a hard time lining up, so SP2 helped them join the other children, but s/he did not recall SP1 specifically telling him/her to assist the AV. One of the other children was “emotional” and SP2 held his/her hand and focused on leading him/her to the gym. SP2 stated that because of his/her focus on the child, s/he did not look back and check the classroom for children as s/he normally would when s/he left the classroom. · SP1 stated that s/he asked SP2 if all the children were in the line and SP2 told SP1 that all the children were in the line. SP2 stated that s/he did not hear SP1 count the children or ask SP2 if all the children were in line. SP1 led the group to the gym door and began to count them as they entered the gym. SP1 stated that SP2 did not walk at the end of the line as s/he usually did and entered the gym before all the children entered the gym. SP2 then went to talk to other staff persons who were already in the gym with the younger toddler children. SP1 stated that two more children entered the gym after SP2 walked in. SP1 believed that s/he miscounted the children because of the delay of all the children entering the gym. SP2 stated that s/he did not hear SP1 count the children as they entered the gym. · At approximately 3:55 p.m., P1 entered the older toddler classroom to clean. The classroom door was open and the lights were off. As P1 was getting the classroom laundry, s/he heard a child crying and found the AV sitting in a corner of the classroom behind a table. P1 looked in the bathroom to ensure that another staff person was not present and then took the AV to P2 and told him/her that s/he found the AV unsupervised in the toddler classroom. P2 stated that s/he was in the hallway when P1 brought the AV to him/her. P2 took the AV to the gym and told SP1 and SP2 that they left the AV unsupervised in the classroom. SP1 stated that the AV was quiet and “teary eyed.” · P2 then went to his/her office and reviewed the facility’s video recordings, which showed that at 3:35 p.m., SP1 and SP2 lined the children up at the classroom door to go to the gym. SP1 led the group out of the door and SP2 walked out of the room before all of the children were out of the classroom. The AV remained in the classroom standing by a table. SP2 did not look back to ensure that all of the children were out of the classroom. The AV sat down on the floor. At one point, a parent sent a child into the classroom to get his/her water bottle. The child looked at the AV, but did not say anything to the AV before s/he left the classroom. At 3:51 p.m., P1 entered the classroom and found the AV. After reviewing the video recording, P2 talked to SP1 and SP2 about what occurred. Neither SP1 nor SP2 were aware that the AV was left unsupervised in the classroom. · P2 stated that although there was a door in the toddler classroom that gave access to the outside of the facility, an alarm sounded if the door was opened. At the time of the incident, the door to the classroom bathroom was closed, but not locked. · SP1 stated that the staff persons used a Brightwheels app to keep track of things like the number of the children in the classroom, their activities, and meals. The staff persons also had a paper attendance sheet that they used to write down which children were present each day. Staff persons were trained to count the children each time the group transitioned from one area to another. The staff persons lined the children up at the door and counted them out loud. One staff person led the group and the other staff person walked at the end of the line and ensured that all of the children remained in line and were present. When they arrived at their destination, they again counted the children. P1 stated that the staff person at the end of the line was supposed to ensure that all of the children were lined up and that no child was left in the classroom. The two staff persons were trained to communicate with each other as to how many children were present at the time and whether all of the children were in line. · SP2 did not recall having any training on counting children and when to count children during transitions. The FM stated that P2 told the FM that the AV was left in the toddler classroom when the staff persons took the other children to the gym and was found approximately ten minutes later by another staff person. The AV did not provide any information about the incident to the FM. Prior to the incident, the FM did not have any concerns about the care the AV received at the facility. The facility provided the video for the investigation but due to technical difficulties the video was not able to be viewed. According to the facility’s Risk Reduction Plan, when transitioning groups of children from one area to another, it was required that one staff person led the group and a second staff person remained at the back of the group. All children were to be within sight and sound at all times. The children were to be counted before and after transitioning. Facility documentation showed that SP1, SP2, 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 April 8, 2024, SP1 and SP2 worked in the toddler classroom with 13 children. At approximately 3:35 p.m., SP1 and SP2 lined the children up at the classroom door and then took the children to the gym. SP1 stated that when they arrived at the gym, s/he counted the children, but believed that s/he somehow miscounted them. SP2 did not hear SP1 count the children and did not count them him/herself. At approximately 3:51 p.m., P1 entered the toddler classroom and saw the AV sitting on the floor unsupervised. P1 took the AV to P2, who then took the AV to the gym and told SP1 and SP2 that the AV was found unsupervised in the classroom. Neither SP1 nor SP2 realized the AV was not with the group until P2 told them the AV was found alone in the classroom. Leaving the AV unsupervised in the classroom for approximately 16 minutes was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart1, item A, and of the facility’s policies. The AV did not sustain any injury while s/he was unsupervised. Although the AV was not injured, given that SP1 and SP2 each failed to ensure that all of the children were in the gym once the group had completed its transition from the classroom, and that the AV, who was 31 months old, was left alone in the classroom for approximately 16 minutes without any staff person’s knowledge which did not allow for a staff person’s intervention in the event of any emergency, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care required for his/her physical or mental health and a failure to protect the AV from conditions 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 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 and SP2 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. SP1 and SP2 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 and SP2 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 persons. After the incident, the facility updated its supervision policies and trained the staff persons on the new policies. SP2 no longer worked at the facility. 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 26, 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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