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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: 1109590-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was in a facility vehicle and parking lot without staff persons’ (SP1 and SP2) knowledge or supervision for approximately seven minutes. Date of Incident(s): April 19, 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 25, 2024; from documentation at the facility; and through six interviews conducted with the AV, two facility supervisory staff persons (P1 and P2), and facility staff persons (P3, SP1, and SP2). Several attempts were made via telephone and US mail to contact the AV’s family member, but the AV’s family member did not respond to the requests. The facility provided care for preschool-aged children in two classrooms. One of the rooms was named the Blue Preschool classroom and the other room was the Yellow Preschool classroom. There was an exit door from the Blue Preschool classroom to a playground. The playground was to the side of the facility and was surrounded by a seven-foot-high chain link fence with a gate. The gate was secure and opened with a keycard. Near the playground was a facility side door used as a staff entrance. This door was secure, had a doorbell, and opened with a key card. At the front of the building there was an unlocked entrance door. There was a sidewalk that ran from the playground to the front of the facility. Adjacent to the playground and the facility was a parking lot. The parking lot had marked spaces for cars to park and spaces with diagonal lines for facility buses. The facility was surrounded by businesses, had residential homes behind it, and in front of the facility was a four-lane street with a speed limit of 30 miles per hour. A Metro light rail line ran in between the lanes of traffic in front of the facility and traveled between 20 and 50 miles per hour. The facility provided transportation for the children to and from their homes in a 14-passenger bus. The bus had a driver’s side door, a side manual folding door, and a rear exit door. The manual folding door had a secured lever handle. Once released, the lever needed to be pushed away to open the door. The exit door had a slide lock to secure it and a handle that needed to be lifted to open. On the bus, each child had an assigned seat with a car seat with buckles. There was a Bus Tracking sheet on a clipboard on the bus that indicated the driver, the mileage of the bus, children’s names, and times the children were picked up and dropped off from their homes. The facility had cameras that recorded the parking lot. According to weatherunderground.com, the temperature on April 19, 2024, at 9 a.m., was 36 degrees Fahrenheit with a wind of 20 miles per hour. Using a windchill calculator, the temperature felt like 25 degrees Fahrenheit. Facility documentation showed the AV was five years old and enrolled in the Blue Preschool classroom at the time of the incident. The AV stated that s/he fell asleep and “they all got off the bus.” The AV “lifted up the red thing” and went out the back bus door because the “front door was locked.” Then the AV went to the gate and “kicked it” because s/he thought it would open the gate. P3 came outside to get him/her. The AV was “kind of” scared when s/he was on the bus alone and cried. The facility provided two video segments of the incident. Both videos were from cameras that showed the parking lot of the facility. The videos did not contain audio. The videos provided the following information: o At 8:52 a.m., a facility bus entered the parking lot and backed into a parking spot outside the playground. The driver of the bus exited the bus through the driver’s side door and walked around to the folding door. Two children exited the bus, and the driver held each child’s hand as they walked to the playground gate. Another child exited the bus and ran behind the driver and the two children. A staff person exited the bus and walked to the gate. The driver opened the gate, and the three children ran into the playground. Then the driver and the staff person entered the playground, and the last staff person pulled the push bar to shut the gate behind him/her. o At 8:57 a.m., a second facility bus entered the parking lot and pulled into a designated bus parking spot across from the playground. o At 8:59 a.m., the folding bus doors opened, and three children exited the bus. Two of the children ran across two empty parking spots to the gate while the third child turned and faced the folding doors. A fourth child exited the bus and walked toward the gate. When s/he arrived at the gate, one of the children already at the gate began to pull on his/her jacket while a fifth child exited the bus. o At 8:59:35 a.m., another child exited the bus followed by SP1 and they walked toward the gate. SP2 then exited the bus through the folding doors and pushed the doors shut. As SP2 walked across the parking lot, one child fell. SP2 picked up that child and carried him/her to the gate. o At 8:59:50 a.m., SP1 opened the gate and the six children and SP2 walk through. SP1 used then pulled the gate shut behind him/her. The group walked into the playground and off camera. o At 9:02:03 a.m., inside the second bus, the AV walked to the front near the folding doors. o At 9:02:46 a.m., the AV opened a bus window, stuck his/her head partially out of the window, and then went back in the bus. Then the AV walked to the back exit door and was visible through the exit door window. o At 9:03 a.m., the bus back exit door opened, the AV exited the bus, and then pushed the exit door shut. The AV then opened the door again and stood between the door and the bus and moved the door handle. o At 9:03:45 a.m., the AV shut the bus door again and ran across the parking lot to the playground gate. The AV wore a jacket with the hood up, pants, and shoes. The AV hit the gate with his/her right hand and bent down to look through the gate below the push bar. Then the AV stood upright and banged and knocked on the gate with his/her left hand. o At 9:04:05 a.m., the AV turned and walked approximately 19 feet down the sidewalk toward the road in front of the facility. Then the AV turned, walked back to the gate, and kicked it six times with his/her right foot. o At 9:04:27 a.m., the AV walked to the playground fence to the left of the gate, pounded on the fence with both hands, and then kicked the fence. Then the AV stopped and turned and ran back across the parking lot to the bus. o At 9:04:49 a.m., the AV opened the back exit door of the bus and jumped and pulled him/herself back into the bus. The AV stood up, pulled the door, sat down on the bus floor, and then exited the bus. The AV shut the exit door and moved the door handle again. o At 9:05:38 a.m., the AV ran across the parking lot to the playground gate and banged on it with both fists and kicked it nine times. Snow began to fall. The AV attempted to pull the gate open, backed up and ran to the fence to the left of the gate. The AV held the fence with both hands. Then the AV kicked the fence numerous times and removed his/her hood from his/her head. o At 9:06:59, the AV pounded on the fence with his/her right hand and appeared to be yelling. o At 9:07:37 a.m., P3 appeared on camera, opened the gate, and the AV walked into the playground. P3 pulled the gate shut and hugged the AV. Then the video ended. P1, P2, and P3 provided the following consistent information: · On April 19, 2024, at approximately 9:10 a.m., P1 and P2 were in a meeting at the facility and P3 was in the Blue Preschool classroom “prepping things” for the children. P3 stated s/he did not see the buses pull into the parking lot but saw four staff persons walk through the playground at the same time. P3 opened the classroom door to let children and four staff persons into the Blue classroom. Then the group “went on” with their normal routine of washing hands, eating breakfast, and playing. · Approximately five to eight minutes later, P3 heard “high pitched” screaming outside. P3 opened the classroom door to the playground and saw the AV standing at the fence near the gate. The AV held the fence with his/her hands as s/he cried. P3 “ran” to the gate, opened it, and let the AV inside the playground area. The AV told P3, “They left me. I was on the bus, and they left me.” P3 then hugged the AV and “tried” to comfort him/her. SP2 joined them on the playground and told the AV that s/he was sorry. Both P3 and SP2 told the AV that they were proud of him/her for “finding a safe way to get out of the bus.” · P3, SP2, and the AV went inside the classroom. P3 “went back to attending” to the children while SP2 sat with the AV in the “calming corner.” After about 30 minutes, the AV was calm and joined in play with his/her friends. · At approximately 10:45 a.m., P3 left the classroom and told P1 that the AV had been left on the facility bus. P3 told P1 that s/he had heard the AV “screaming” on the playground, “poked” his/her head outside, and saw the AV “screaming and crying” at the gate. P1 then talked with SP1 and SP2 about the incident. · SP2 told P1 that first s/he unbuckled one row of children and those children “congregated” on the bus steps while SP1 documented the mileage and shut the bus off. The AV had fallen asleep and when SP2 unbuckled the AV, s/he stirred so SP2 thought the AV woke up. Then SP2 unbuckled another child and was at the back of the bus. SP1 opened the bus door and four children “rushed off” the bus. SP1 then got off the bus and held a child’s hand as they walked to the gate where children were fighting. SP2 then got off the bus, shut the door, and held a child’s hand as they walked to the gate. SP2 opened the gate and went into the playground. Then once all the children were inside the playground, SP1 shut the gate. · SP1 told P1 that s/he parked the bus and finished “paperwork” while SP2 unbuckled the children. As SP2 unbuckled the children, they got up and started to move down the bus isle to the stairs. SP1 tried to unbuckle a child seated behind him/her but that child hit SP1’s hand away. SP1 then told the children on the bus that a staff person needed to be at the front of the line and the children did not move. SP1 opened the door but rather than waiting, the children “rushed off” the bus. SP1 got off the bus behind them and then SP2 got off the bus and closed the door. SP1 said when s/he got to the gate, two children were fighting so s/he separated them as SP2 unlocked the gate and they all went into the playground. Once everyone was inside the playground, SP1 closed the gate. · P1 said the AV was unsupervised for seven minutes. Hazards present to the AV while unsupervised were vehicles, community persons, the street, hurting him/herself, the weather, and the emotional impact of being left on the bus alone. · P1 and P2 stated that when staff persons and children arrive to the facility by bus, they are to get the children off the bus and hold hands as they walk to the playground. If there were too many children and not enough staff persons to hold hands, children should hold the hands of a peer that was holding a staff person’s hand. Another staff person in the facility was to come out and meet the children at the playground gate and check children in. On the day of the incident, one bus had already arrived, so staff persons were inside with those children. · P1 stated that on the day of the incident, SP1 should have exited the bus on the driver’s side and walked to the folding doors to let the children off the bus while SP2 checked the seats to ensure all the children were off the bus. Then SP1 and SP2 should have held children’s hands and walked to the playground gate. As children entered the facility, a staff person should have taken attendance. · P2 stated that on the day of the incident, either SP1 or SP2 could have taken two children off the bus and walked them to the facility while the others waited on the bus. A face to name attendance should have been taken when the children entered the facility and a final “check” of the bus completed to ensure everyone was off. SP1 and SP2 provided the following information: · On April 19, 2024, SP1 and SP2 were on the facility bus doing the “morning bus route.” It was SP1’s first time driving the facility bus in the morning and SP2 helped the children on and off the bus. SP2 stated that the AV was carried onto the bus by his/her family member and slept the “whole route.” When the bus arrived at the facility, SP2 began unbuckling children. SP2 stated that when s/he unbuckled the AV, the AV “opened” his/her eyes or “said something” so SP2 “thought” the AV knew s/he was at the facility. · SP1 stated that while SP2 unbuckled the children, s/he “finished paperwork,” “shut off the bus,” and “took the keys out.” SP1 stated s/he did not tell SP2 that s/he was going to open the bus door. · SP2 completed unbuckling the children in one row and was at the back of the bus when s/he noticed one child did not want SP1 to unbuckle them. SP2 walked to the front of the bus and unbuckled that child and was unbuckling other children when SP1 opened the bus door. At that time, a “few” kids ran off the bus without a staff person. SP2 told SP1 that children need to be with a staff person and “rushed” to get other children off the bus. · SP1 stated that the children lined up in the bus as they were unbuckled. Two children were “getting upset with one another” and when SP1 opened the bus door, they “darted” off the bus so SP1 could not get off the bus before them. Then other children ran off the bus and toward the gate. SP1 got off the bus with the remaining children followed by SP2. SP1 said that s/he and SP2 “missed the count” they would “normally” do as children got off the bus. SP1 stated there was not a form to take attendance when children exited the bus, but the Bus Tracking form could have been used to take attendance. · SP2 stated that when children ran off the bus it “distracted” from the normal routine. SP1 and SP2 made sure the children who ran off the bus were “okay and supervised.” Then they walked to the gate, entered the playground, and went inside the classroom. SP2 took some children to the Yellow classroom and helped them with their jackets and SP1 stayed with the children in the Blue classroom. Then about two or three minutes later SP2 went back into the Blue classroom. · SP1, SP2, and P3 were getting breakfast ready when they heard the AV “screaming.” SP1 stayed in the classroom while SP2 and P3 went outside and came back inside with the AV. P3 talked with the AV and then the AV went to the “calming corner” with SP2. SP1 did not see P3 take attendance during breakfast. · SP1 stated s/he should have “gotten off” the bus first and should have waited and done a “sweep” of the bus to make sure everyone was off. · SP2 stated that s/he should have been “more intentional” with how the children got off the bus and s/he “should have communicated” to SP1 that s/he was not ready for the door to open. · SP2 stated that normally “attendance” was taken as children get on the bus and then again as “children get into the classroom.” At the time of the incident, SP2 missed a “walk through” of the bus and did not “realize” the AV was still on the bus. SP2 stated s/he took children into the Yellow classroom and “did not know what happened with attendance” in the Blue classroom. The facility’s Bus Tracking showed that on April 19, 2024, the AV was checked onto the bus at 8:46 a.m. and the bus arrived at the facility at 8:57 a.m. The facility’s attendance sheet showed that on April 19, 2024, the AV had an “X” placed by his/her name, which showed the AV was in attendance. The facility’s Policy Handbook stated that the facility maintained a staff person to child ratio of 1:4 at all times. When children transitioned to and from the bus, staff held each child’s hand. The facility’s Child Care Program Plan showed that children are supervised at all times. “Children will be accompanied by a staff member during transitions to and from the school bus, and staff are required to always hold the child’s hand when leaving the building.” The facility’s Risk Reduction Plan showed that “staff will maintain a 1:2 or 1:1 ratio when transitioning children from the secured preschool area to the bus area.” “Children’s hands are always held while loading or unloading the bus.” Facility documentation showed that P1, P2, P3, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including the Policy Handbook, the Child Care Program Plan, and the Risk Reduction Plan 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, state that “supervision” means 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; and that children are required to be supervised at all times. Conclusion: A. Maltreatment: Information from all sources was consistent that on April 19, 2024, at approximately 9 a.m. the AV was left on the facility bus. The AV left the bus and was outside the facility with access to the community without the knowledge or supervision of SP1 and SP2 for approximately eight minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Being unsupervised on the facility’s bus and in the parking lot gave the AV access to dangers both on the bus and in the community including unknown community persons, traffic, the light rail line, businesses, and exposure to the weather. Although the AV returned to the classroom unharmed, given that the AV was five years old, it was unlikely that the AV would be able to provide for him/herself in an emergency. In addition, given that staff persons were not aware that the AV was outside the facility, they would not have been able to intervene to protect the AV in the event of an emergency. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with the necessary care and a failure to protect the AV from conditions or actions that could seriously endanger the AV’s 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. 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. Facility documentation showed that SP1 and SP2 received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies including the Policy Handbook, the Child Care Program Plan, and the Risk Reduction Plan prior to the incident. At the time of the incident, SP1 and SP2 were each responsible for the supervision of the children, including the AV, on the bus and the during the transition to the facility. Neither SP1 nor SP2 counted the children who got off the bus, as they entered the playground, or as they entered the facility. 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 of maltreatment for which the AV did not sustain and 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 their policies and procedures were not adequate and followed. The facility implemented additional safety procedures for bus transportation, including that the last staff person on the bus needed to double check that all children were off the bus before exiting. All staff persons were trained on the new procedures. 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 19, 2024, the facility was issued a Correction Order for the violation outlined in this report and for failing to ensure staff qualifications. 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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