|
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: 809621-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 in a community room for approximately 10 to 18 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 23, 2024; from documentation at the facility; and through seven interviews conducted with a supervisory staff person (P1), three facility staff persons (P2, SP1, and SP2), the AV’s family members (FM1 and FM2), and a community person (CP) who worked in the same building as the facility. According to the AV’s enrollment information, the AV was three years old and enrolled in the preschool room at the time of the incident. Consistent information was provided that SP1 and SP2 were working in the preschool room at the time of the incident. The facility was inside a community building. The community building had four halls in the shape of a square. In the middle of the square was a chapel. Along the east hall was the preschool room and along the west hall was a community room that the facility used for indoor play and activities. The building also contained a kitchen, library, offices, and bathrooms. P2 stated that on May 16, 2024, at 11:15 a.m., P2 saw SP1, SP2, and the preschool children walk by P2’s classroom towards the preschool room. At 11:33 a.m., SP1 came into P2’s classroom and said that s/he “lost” the AV. Another staff person came into P2’s classroom and SP1 and P2 went to look for the AV. SP1 told P2 that they had been in the community room so SP1 went one direction and P2 went the other direction toward the community room. P2 walked through the chapel and during that time, s/he texted P1 that the AV was missing. Before P2 got out of the chapel, s/he heard the AV crying and met SP1 in the hall and they went to the community room together. SP1 opened the door of the community room and the AV stood by the door crying but did not have any injuries. SP1 picked up the AV and brought the AV back to the preschool room. P1 stated that on May 16, 2024, at 11:35 a.m., s/he received a text message from P2 saying that the AV was left alone in the community room. P1 was at a different facility location so s/he went to the facility and arrived at approximately 11:45 a.m. P1 spoke to SP1 who said that it was “hectic” when SP1 and SP2 left the community room and they did not count the children prior to leaving nor once they got to the preschool room. P2 and SP1 went and looked for the AV and found the AV crying in the community room. P1 stayed in the preschool room while SP1 took a break. P1 saw the AV and s/he did not have any injuries. P1 then called FM1 and FM2 and let them know about the incident. P1 did not talk to SP2 about the incident. The CP stated on May 16, 2024, sometime between 11 a.m. and noon, s/he heard a child (later determined to have been the AV) crying in the community room. The AV cried for approximately ten minutes so the CP went to the community room to check on the AV and saw a staff person (later determined to have been SP1) with the AV. Shortly after, the CP saw SP1 and the AV walk past the CP’s door and the AV was no longer crying. SP1 provided the following information: · On the day of the incident, SP1 and another staff person (P3) worked in the preschool room. SP1 and P3 had approximately 18 preschool children including the AV in the community room. While in the community room, SP1 took approximately four children back to the preschool room to change diapers. During that time, P3 went on break so SP2 went into the community room. SP2 had not worked in the preschool room prior to this incident. · SP1 and the four children returned to the community room after diapering was completed. After one or two minutes, SP1 realized it was time to return to the preschool room for lunch so SP1 and SP2 had the children line up at the door. · SP1 did not count the children and two of the children who had lined up ran out the door and into the hall so SP2 went after them. SP2 brought the two children back into the community room and since they had all the children together, they left the community room. SP1 was at the front of the line and SP2 was at the back of the line and neither of them counted the children prior to leaving the community room nor once they got to the preschool room. SP1 knew s/he was supposed to count the children but had been “frazzled” by the two children running out of the room and s/he did not think to count. SP1 last remembered seeing the AV prior to leaving to change diapers. · Once inside the preschool room, the children got out toys to play while SP1 and SP2 prepared lunch. SP1 was passing out plates when s/he realized that the AV was not in the preschool room. Since the AV liked to hide, SP1 looked around the preschool room first. SP1 then went and told P2 that the AV was last seen in the community room and they went looking for the AV. SP1 went down the hall, opened the door to the community room, and saw the AV standing inside the door crying. SP1 picked up the AV and carried him/her back to the preschool room. The AV was alone for approximately ten minutes in the community room and was not injured. SP2 provided the following information: · On the day of the incident, SP2 arrived at the facility at approximately 11 a.m. SP2 went into the preschool room where SP1 was changing diapers and SP1 told SP2 to relieve P3 in the community room so P3 could take a break. SP2 went into the community room, P3 told SP2 how the morning went for the children, and then P3 left for his/her break. SP2 tried counting the children but they were all running around the room. SP2 was alone with approximately 14 to 15 children for approximately ten minutes prior to SP1 coming back with the other four children after diapering was completed. · SP1 and SP2 were in the community room for approximately eight minutes when they decided to return to the preschool room for lunch. The children were “pretty frustrated” when SP2 turned off the television and were “hardly cooperating” including running around. By the time SP1 and SP2 got the children in a “decent” line and opened the door, some of the children ran out into the hall. SP2 went and got the children back in line. One of the children refused to listen, so SP2 picked up the child and carried him/her. · SP1 was in the front of the line and SP2 was in the back of the line. SP2 looked around the front of the room where a few children were hiding but did not go back into the back of the room to check for children. SP2 did not count the children prior to leaving the community room or after entering the preschool room because s/he did not know “exactly” how many children there were supposed to be since it was SP2’s first day working in the preschool room. SP2 did not hear SP1 count the children out loud. · After getting back to the preschool room, a child threw toys so SP2 tried to get the child under control while SP1 began serving lunch. At one point, SP1 asked where the AV was at and SP2 did not know the AV’s name since it was the first time SP2 worked in the preschool room. They both looked around the room before SP1 left and another staff person (P4) came into the preschool room with SP2. · SP1 eventually returned to the preschool room with the AV who was not injured. The AV was alone for approximately 10 to 15 minutes. FM1 and FM2 were concerned about the amount of time the AV was left alone and that staff persons were not aware. FM1 and FM2 did not have prior concerns with the facility. According to the facility’s Risk Reduction Plan, children were supervised “at all times” including while transitioning from another space and in the halls. “Regular counts” of the children were made when transitioning from one classroom to another. According to the facility’s Child Supervision policy, children were supervised “at all times.” Facility documentation showed that all staff persons, including SP1 and SP2, received training on the Risk Reduction Plan, Child Supervision policy, 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 16, 2024, the AV was left alone in the community room 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. Neither SP1 nor SP2 counted the children before leaving the community room, or upon return to the preschool classroom. As a result, the AV was left in the community room without the knowledge or supervision of staff persons for approximately 10 to 18 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 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. 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 trained on the facility’s Risk Reduction Plan, Child Supervision policy, 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. SP1 and SP2 received verbal retraining on supervision and written warnings. The facility also added additional training on counting children that occurred at orientation. 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 26, 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.
|
