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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: 803970-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that five alleged victims (AV1, AV2, AV3, AV4, AV5) were outside of the facility without supervision for two to five minutes. Date of Incident(s): May 16, 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 30, 2024; from documentation at the facility; and through nine interviews conducted with six facility staff persons (P1, P2, SP1, SP2, SP3, SP4), AV3’s family member (FM2), AV4’s family member (FM3), and AV5’s family member (FM4). This investigator made attempts to contact AV1 and AV2’s family member (FM1) through phone and mail, but attempts were unsuccessful. The facility was located in a large building. In the back of the building was a fenced in preschool playground. Along the left side of the building was a fenced in toddler playground. On the right side of the preschool playground near the corner of the building was a gate that exited into another fenced area that ran along the right side of the building. This fenced in area had another gate that exited to a sidewalk that ran the length of the front of the building. The other end of the sidewalk bordered the toddler playground on the left side of the building. Both of the gates had a U-shaped lever that pulled down to secure the gate and pushed up to open the gate. The gate that ran along the sidewalk had an alarm that sounded when the gate was open. AV1, AV2, and AV4 were each three years old at the time of the incident and enrolled in the Preschool B classroom. AV3 was four years old at the time of the incident and enrolled in the PreK classroom. AV5 was 33 months old at the time of the incident and enrolled in the Preschool B classroom. P1 provided the following information: · On the date of the incident, at approximately 4:15-4:30 p.m., P1 was outside on the toddler playground. P1 saw AV1 and AV2 at the gate of the toddler playground that bordered the front sidewalk. This was not uncommon as sometimes AV1 and AV2 came to the gate when they left the facility with FM1. They said hello and then ran away. · Approximately 30 seconds later, AV1 and AV2 were back at the gate along with AV3, AV4, and AV5. P1 said, “What are you doing?” One of the children said, “We escaped the gate.” P1 went out of the gate and the children started running down the sidewalk back toward the gate on the other side of the building (preschool playground gate). · P1 followed the children down the sidewalk and heard SP1 yelling for them. By the time that P1 got to the preschool gate the children were back inside and P1 was at the gate. P1 and SP1 closed the gate and P1 returned inside through the front entrance and told P2 what had happened. · P1 said that there was an alarm on the toddler gate, but s/he was not sure if the preschool gate had an alarm on it. The alarm was activated as soon as the gate was open and did not stop until a button was pushed on the gate. P2 provided the following information: · On the date of the incident, P2 saw P1 in the hallway and P1 said that some preschool children had opened the gate and gone outside. P1 said that they needed to order locks for the gate. P1 ordered some locks for the gate that day. · P2 did not have any concerns with any of the staff persons. The gate from the fenced area along the side of the building to the sidewalk did have an alarm that went off when opened. A button on the top needed to be pressed to turn off the alarm. The gate from the playground to the fenced area along the side of the building did not have an alarm. On the day of the incident, P2 was not sure if the staff persons were able to hear the alarm on the exterior gate. SP1-SP4 provided the following information: · SP1 and SP2 went outside to the playground with the PreK classroom sometime in the afternoon after snack time (likely after 4 p.m.). SP3 and SP4 came out outside later with the Preschool B classroom. All staff persons were spread out monitoring the children throughout the playground. · SP1 said that approximately 10 minutes after the PreK classroom came outside, s/he was walking around when s/he noticed that the gate to the side fenced in area was open. When SP1 walked to the gate s/he saw children in the gated area and the gate to the sidewalk was open. · SP1 walked down to the sidewalk gate and met P1 at the gate. P1 had a couple children with him/her. There were five children in total. There were some children from each classroom. SP1 talked with the children about the importance of staying inside the playground area and then brought them back to the playground. Staff persons counted the children to make sure all children were accounted for. P1 was not sure how the children were able to leave the playground without staff persons noticing. · SP2 was near the toddler playground interacting with children when s/he heard some shouting and was told that some children had left the playground through the gate. SP2 had never had any children try to open or go out of the playground gate before. The gate had a pull-down lever on it and SP2 was unsure how the children got it open. · SP3 said that “almost right away” within “just a few minutes” some children went out the gate. SP3 was on the other side of the playground but heard some other staff persons talking and saw the children coming back through the gate. SP3 did not think the children could open the gates. · SP4 said that approximately five minutes after they came outside, SP1 or SP2 came over and informed SP4 that some children had left through the gate. SP4 was documenting snack time on the iPad application and did not see the incident. At times the children might try to open the gate that connected to the toddler playground. Staff persons walked around the playground to make sure no child was opening any gates. According to www.wunderground.com, the outdoor condition at the facility, on May 16, 2024, at the time of the incident, was “mostly cloudy” with a temperature of between 67-68 degrees Fahrenheit (°F) and wind speed of 10-13 miles per hour (mph). The Individual Child Care Program Plan for AV1 dated March 4, 2024, indicated that AV1 attempted to leave the classroom by opening the door or going through a door that is opened by other families. Staff persons increased monitoring and tracking of AV1 for physical safety including affixing visual stop signs to doors and/or child safety handle mechanisms on all applicable doors. The Individual Child Care Program Plan for AV2 dated March 4, 2024, indicated that AV2 might leave the immediately supervised environment by quietly eloping into the adjoining classroom, usually through a connected bathroom. Staff persons increased monitoring and tracking of AV2 especially around the bathroom for physical safety including affixing visual stop signs to doors and/or child safety handle mechanisms on all applicable doors. The Individual Child Care Program Plan for AV4 dated March 15, 2024, indicated that A4 attempted to leave the classroom by opening the door or going through a door that is opened by other families. Staff persons increased monitoring and tracking of AV2 for physical safety including affixing visual stop signs to doors and/or child safety handle mechanisms on all applicable doors. The Individual Child Care Program Plan for AV5 indicated that s/he needed to refrain from opening all classroom and building doors. Accommodations needed were to affix stop signs to all doors in AV5’s environment. The Child Care Center Risk Assessment and Risk Reduction Plan stated that both playgrounds could be accessed through the exterior classroom doors. There were two gates that faced the parking lot that remained locked. On the playground staff persons were evenly distributed and rotated to monitor children’s activities.
The School Employee Handbook stated that all children were within sight and sound at all times. Facility documentation showed that all staff persons were trained on the facilities policies including the Child Care Center 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 16, 2024, AV1, AV2, AV3, AV4, and AV5 left the gated playground without the knowledge or supervision of a staff person for likely less than five minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1, SP2, SP3, and SP4 were each not aware that AV1, AV2, AV3, AV4, and AV5 opened two gates to leave the playground going out onto the sidewalk of the facility, 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. Given that AV1, AV2, AV3, AV4, and AV5 who were all between 33 months and four years old, left the facility and were in the community in a location that could expose AV1, AV2, AV3, AV4, and/or AV5 to community dangers, and that staff persons were not with AV1, AV2, AV3, AV4, and AV5 to intervene in the event of an emergency, there was a preponderance of the evidence that there was a failure to supply the AVs with necessary care and a failure to protect the AVs from conditions or actions that seriously endangered the Avs’ 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. The SP1, SP2, SP3, and SP4 each worked in AV1, AV2, AV3, AV4, and/or AV5’s classroom and were responsible for supervision of the two classrooms at the time of the incident. SP1, SP2, SP3, and SP4 were trained on the facility’s policies including the Child Care Center Risk Assessment and Risk Reduction Plan, the School Employee Handbook, and the Reporting of Maltreatment of Minors Act prior to the incident. SP1, SP2, SP3, and SP4 were responsible for maltreatment of AV1, AV2, AV3, AV4, and AV5. 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, SP3, and SP4 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and AV1, AV2, AV3, AV4, and AV5 were 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. Additional security measures were added to the gate. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, SP3, SP4, and SP5 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1, SP2, SP3, SP4, and SP5 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, SP3, SP4, and SP5 were each responsible for maltreatment is subject to appeal. On July 24, 2024, the facility was issued a Correction Order for the violation outlined in this report. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. On July 24, 2024, the license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal. 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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