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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: 1092878-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left alone on the playground for approximately five to ten minutes. Date of Incident(s): May 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 May 15, 2024; from documentation at the facility; and through four interviews conducted with a supervisory staff person (P), two facility staff persons (SP1 and SP2), and the AV’s family member (FM). Two community persons (CP1 and CP2) who worked in the same building as the facility provided initial information but follow up phone calls were not returned. According to the AV’s enrollment information, the AV was 2 years and 11 months old and enrolled in the preschool room. SP1 and SP2 worked in the preschool room on the day of the incident. The facility was inside a building with two other early childhood facilities that shared an open gym space. Along one side of the gym was the door to the playground, another side had two doors that led to the two other facilities, and a third had a hall that led to the facility and preschool room. The facilities shared a playground that was fully enclosed with a chain link fence and near the playground was an elementary school, woods, a road, and a parking lot. CP1 stated on May 8, 2024, at 11 a.m., CP1 found a child later identified as the AV alone on the playground for “over ten minutes.” CP1 went inside the facility and notified SP1 and SP2 who had “no idea” that the AV was missing. CP2 stated on May 8, 2024, s/he was in a common area of the building when s/he saw a staff person later identified as SP1 carry the AV inside from the playground. CP2 overheard “bits and pieces” of SP1 talking about head counts and that the AV was left outside. CP2 went outside and did a full playground safety check and spoke to CP1. CP2 then went and spoke to SP1 and SP2 who said that they did leave the AV outside alone and they felt “awful.” CP2 stated that the incident lasted between five to ten minutes. The DHS investigator reached out to CP1 and CP2 in attempt to clarify how each knew the incident lasted “over ten minutes” or “between five to ten minutes,” but neither responded. The P provided the following information: · On May 8, 2024, SP1 called the P and provided the following information: o Earlier when s/he was on the playground with SP2, when lining up to go back inside the facility, the AV was left on the playground. SP1 said s/he did a head count of 15 children but another child (C) had joined the group on the playground which meant they actually had 16 children. SP1 “assumed” 15 was correct since that was the number of children they brought outside. o SP1 and SP2 brought the preschool children inside to the preschool room and “a couple minutes later” CP1 came to the preschool room and asked if they were missing a child. SP1 looked around the room and realized that the AV was not there so s/he went back outside to the playground and got the AV. SP1 said that the AV was “fine” and did not have injuries. · Within a few hours, the P spoke to SP2 on the phone and SP2 provided consistent information as to SP1 about the incident. SP2 said that while SP1 did a head count, another child was “acting out” so SP2 was dealing with him/her during that time. SP1 and SP2 provided the following information: · SP1 and SP2 had 15 children including the AV on the playground. At some point while on the playground, the C came back from his/her preschool program and joined them, making their total 16 children. At approximately 11 a.m., SP1 and SP2 had the children line up to go back inside and SP1 remembered seeing the AV by the gate at that time. SP2 did not remember when s/he last saw the AV outside. · SP1 knew s/he was supposed to do a name to face but they were “rushing” to get inside for lunch and there were three children who were not listening and running around. SP2 was a newer staff person and was not aware that they needed to do name to face so s/he only counted the children. SP1 counted 15 children and SP1 was in the front of the line and SP2 was in the back of the line carrying a child who was not listening. SP1 and SP2 did not look around the playground prior to going inside. They did two additional head counts along the way and each time counted 15 children including immediately after they got into the preschool room. SP1 and SP2 each said they knew the C was with the class but did not think to include the C in the counts. · Once in the room, after counting 15 children present, SP2 assisted a child who pulled a bucket of toys off a shelf and SP1 was getting ready for lunch. After approximately five minutes, CP1 came into the preschool room and asked if they were missing a child. Right around that time, SP1 realized that the AV was not in the room. SP1 went outside to the playground and saw the AV standing on the sidewalk “a little upset” but unharmed. SP1 brought the AV back to the preschool room and notified the P about the incident. SP2 stated that the AV was alone on the playground for five to eight minutes and did not have injuries. The FM was notified the day of the incident and did not see injuries on the AV. The FM did not have previous concerns with the facility. According to wunderground.com, on May 8, 2024, at 11 a.m., it was 45 degrees Fahrenheit in Montrose. According to the facility’s Risk Reduction Plan, staff persons were trained to do a head count and name to face while on the playground prior to going indoors, and after they entered the facility. While in the halls, children were lined up and supervised “at all times.” Facility documentation showed that all staff persons, including SP1 and SP2, received training on 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: A. Maltreatment: Consistent information was provided that on May 8, 2024, the AV was left alone on the playground unsupervised without staff persons knowledge or supervision, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although SP1 and SP2 each counted the children in their care multiple times during the transition from the playground to the classroom, both failed to notice the AV’s absence. The AV was left outside without the knowledge or supervision of a staff person for approximately five to ten minutes and was exposed to community dangers, including community persons. 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 each responsible for the care and supervision of the AV and were each trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. SP1 and SP2 were each 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 each responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the AV 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. The facility implemented an app to use for head counts. All staff persons received retraining on head count procedures and transitions. SP1 and SP2 received a “notice of accountability” for the incident. 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 July 17, 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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