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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: 1083442-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised for approximately thirteen minutes on the playground. Date of Incident(s): May 23, 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 June 6, 2024; from documentation at the facility; and through six interviews conducted with five facility staff persons (SP1, SP2, SP3, P1, P2), and the AV’s family member (FM). The facility was a two-level building. On the second floor of the building were four preschool classrooms. On the lower level were the infant and toddler classrooms. At the back of the building were fenced playgrounds for each age level. The infant playground was a fenced area directly behind the building. Through a gate was the fenced preschool playground which contained a large plastic play structure. The AV was 33 months old at the time of the incident and enrolled in the Preschool 4 classroom. P1 provided the following information: · On the date of the incident at approximately 4:50 p.m., P1 brought his/her last child to a different classroom then came back to clean up his/her classroom. On the way back to his/her classroom P1 glanced out the window and saw the AV standing on the preschool playground by the gate to the infant playground. P1 went outside and got the AV. · The AV was quiet and did not say anything. P1 brought the AV to the front desk to inform a supervisor then changed the AV’s diaper and brought him/her to his/her classroom. SP1 provided the following information: · On the date of the incident at approximately 3:30-4 p.m., SP1 was outside with another staff person when that staff person left for the day, SP1 was responsible for the Preschool 4 classroom. When that staff person left, SP1 thought that two children moved over to Preschool 1, but s/he could not remember which ones. When it was time to go inside, SP1 lined up the children and counted ten. SP1 “felt” like s/he was missing “more” but was not sure. SP1 took his/her ten children inside to the Preschool 1 classroom where they combined at the end of the day. SP1 counted ten children when s/he returned inside. · Sometime later, P1 brought the AV up to the classroom and SP1 recognized the AV as “mine.” SP1 thought the AV was outside for “ten minutes or so.” · SP1 said that staff persons used the iPad or paper to keep track of the children that they had. On that occasion, SP1 did not have an iPad or paper and was not able to keep track in his/her head. SP2 and SP3 provided the following information: · On the date of the incident, SP2 and SP3 were outside with the Preschool 1 classroom. SP2 and SP3 decided to go inside so they started lining up the children along a fence. They previously had taken two children from Preschool 4 so SP1 would stay within ratio. · SP1 also decided to go inside and started to line up his/her children along another fence. The two children from Preschool 4 that were put in Preschool 1 lined up with the Preschool 4 class. SP2 asked SP1 about it and SP1 said that those children were in his/her classroom. As families were picking up children, from the playground SP1 was taking back his/her children from Preschool 1 so SP2 and SP3 did not take those children and left them with SP1. · SP2 and SP3 counted their children and went back to the classroom. When SP2 was lining up the children s/he went over to the play structure and did a sweep as sometimes children hid underneath the structure. SP2 did not see the AV but only looked underneath the structure. SP2 and SP3 went inside the facility while SP1 continued lining up and counting his/her children. · SP2 left for the day shortly after they returned inside and SP3 remained in the Preschool 1 classroom. Approximately 10 minutes later SP1 joined SP3 in the Preschool 1 classroom with his/her children. After that P1 brought the AV to the Preschool 1 classroom and said that the AV had been left outside. P2 did not have any previous concern with SP1, SP2, and SP3. Staff persons were to use a phone application to complete counts, but the staff persons had not been bringing the i-pads outside. Going forward, staff person used a clipboard with a paper list of children to complete counts. The FM said that that the AV told the FM that the AV “got locked out” and was “sacred.” Video footage showed that on May 23, 2024, at 4:42 p.m., SP1 lined up children along a fence and could be seen pointing his/her finger at each child. SP2 and SP3 lined up children along a different fence and took them into the infant playground and then inside the facility through the door. SP1 then took ten children into the infant playground and inside the building at 4:45 p.m. It appeared the AV was hiding in a tunnel on the play structure. The camera which was motion activated turned off and later turned back on. At that time the AV was at the gate to the infant playground. At 5:14 p.m. (this time is likely not correct as the facility said the camera is motion activated and often it takes a period for the time to sync correctly), P1 opened the door from the infant classroom and came out and got the AV. P1 carried the AV inside. The Time Card Detail showed that P1 moved his/her last infant to the new classroom at 4:58 p.m. and the child was picked up at 5:22 p.m. According to www.wunderground.com, the outdoor condition at the facility, on May 23, 2024, at the time of the incident, was “fair” with a temperature of 77 degrees Fahrenheit (°F) and wind speed of 12 miles per hour (mph). The Risk Reduction Plan stated that when children were transitioned from one area to another, one staff person led the group with the second staff person following the group at the end. All children were counted when leaving point A and again when arriving at point B. Facility documentation showed that staff persons were trained on the facilities policies including the Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states 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: Information was consistent that on May 23, 2024, the AV was left on the facility’s playground without the knowledge or supervision of a staff person for approximately thirteen minutes (time the children left playground until time P1 dropped his/her last child off), which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1, SP2, and SP3 were each not aware that the AV was still on the playground when they took the other children back to the classroom, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Although the playground was fenced, the AV, who was 33 months old, was unsupervised for thirteen minutes with no staff person available to intervene if the AV attempted to do something dangerous, injured him/herself, or in the event of an emergency. 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, and SP3 were each trained on the facility’s policies including the Risk Reduction Plan and the Reporting of Maltreatment of Minors Act prior to the incident. At the time of the incident, SP1, SP2, and SP3 were on the playground. SP1 had ten children including the AV in his/her classroom. SP2 and SP3 had a number of other children that they were supervising from their classroom. Information was consistent that two children went from SP1’s classroom to SP2’s and SP3’s classroom to remain within ratio when another staff person left for the day. When SP1 lined up his/her classroom to take the children inside, SP1 took back those children likely throwing off the count of children that s/he had and leading to the AV not being in the count of children. Given that SP1 was responsible for knowing who s/he had in his/her classroom including the AV, that SP2 and SP3 left the playground with their classroom prior to SP1 leaving with his/her classroom, and that SP2 and SP3 were not responsible for the AV’s supervision at the time of the incident or any time before the incident, SP2 and SP3’s responsibility was mitigated and SP1 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 SP1 was responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV was not injured. 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 were adequate and followed when staff persons counted the children. All staff persons were retrained on the importance of child numbers and not letting children go between preschool classrooms while coming from outside in order to ensure an accurate count. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. On July 17, 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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