|
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: 1119051-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on the playground without staff person knowledge or supervision for approximately one minute. Date of Incident(s): March 14, 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 March 28, 2024; from documentation at the facility; and through seven interviews conducted with one supervisory staff person (P1) and six facility staff persons (SP1, SP2, P2, P3, P4, and P5). (Note: P5 was also the AV’s family member). This investigator arranged a time to speak with an additional staff person (P6), but P6 did not answer at the scheduled time. This investigator left a message and did not hear back from P6. The AV was two years old and enrolled in the Toddler One classroom at the time of the incident. The facility was a stand-alone building with ten classrooms serving infant through school aged children. The playground was enclosed with a wrought iron fence. Within the fenced area there were four doors leading inside (one door led to the Toddler Two classroom, one door led to the Toddler One classroom, one door led to the Waddler Classroom, and one door led to a hallway). The Toddler Two classroom door was set back slightly, and the other three doors were on the same exterior wall. The facility used Daily Connect (an application used to track attendance and communicate with family members). Daily Connect had a feature for a name to face procedure. Staff persons saw a picture of a child’s face along with their name to mark for initial attendance as well as at regular intervals during the day. SP1, SP2, P1, P2, P3, P4, and P5 all provided consistent information that on the day of the incident SP1, SP2, P2, and P3 were outside on the playground with the Toddler One and Toddler Two classrooms. P2 and P3 each stated that the Toddler Two classroom had 12 children and facility records showed that the Toddler One classroom had 10 children, for a total of 22 children on the playground. SP1, SP2, P2, and P3 all provided consistent information that SP2 went inside to use the restroom prior to the staff persons bringing the children inside. While SP2 was still inside, SP1, P2, and P3 brought the classrooms inside. P4 and P5 provided the following consistent information to the DHS investigator: · On March 14, 2024, P5 said the AV was having a “rough” day because SP1 was a new teacher in the AV’s classroom. P5 saw the AV outside and saw s/he was “upset,” so P5 opened up his/her door from the Waddler classroom and sat in the doorway and gave the AV a hug. · After giving the AV a hug, P5 gave the AV to P2 since the AV was familiar with P2, and closed the door to his/her classroom. The AV was outside on the playground with the staff persons for at least ten more minutes before the classrooms started lining up. By 11 a.m., the two classrooms were inside. · About five minutes later, P5 saw the AV standing outside the Waddler door by him/herself looking “confused.” P5 went outside to get the AV and saw there were no staff persons outside. P5 brought the AV inside and went to find P1. P5 stated s/he found P1 in the infant classroom and told him/her that the AV was found outside alone. P1 went and talked to SP1 and SP2 and they stated they thought the AV was with P5. P2, P3, SP1, and SP2 provided the following information to the DHS investigator and during the facility’s internal review: · SP2 said that between 10:55-11 a.m., SP2 went inside to the restroom while the Toddler One and Toddler Two classrooms were still outside. SP1 had asked SP2 if s/he would grab SP1 a soda from the break room on his/her way back. · P2 stated that SP2 had been gone to the restroom for “like 15 minutes” and it was time to bring the children inside for lunch. P2 and P3 lined up their children to go inside to the Toddler Two classroom. SP1 asked P2 for help to get one child (not the AV) inside. P2 brought that child to SP1 and SP1 told P2 s/he had all of his/her children. P2 went to the Toddler Two classroom and started helping children take off their jackets to get ready for lunch. About five minutes later, P2 heard the AV was left outside. P2 said it was a “nice” day outside. · P3 said that the AV was “emotional” by the [Waddler] door because s/he saw P5, so P5 opened the door for a minute or two to soothe and hug the AV. P5 went back inside to do his/her job but “never” brought the AV inside. · P3 said that when the children began going inside, SP2 had been gone for “about ten minutes” to the restroom, and P3 thought SP2 would be back inside to help SP1. P3 stood at the Toddler Two door getting children inside. P2 brought P3 a child and went to help SP1 with a child who did not want to go inside. · P3 said s/he and P2 were inside by 11:03 a.m. and were helping children take off their jackets. At 11:05 a.m., P3 heard a commotion and saw P5 had the AV on his/her hip. P3 asked P5 what happened, and P5 said the AV was outside on the playground alone. · P3 told P5 to go find P1 and let him/her know. P3 walked by the Toddler One classroom and SP1 did not realize the AV was “missing.” P3 went to find SP2 as s/he was still not back in the classroom at that point. P3 found SP2 in the break room and told him/her the AV was left outside. P3 said it was “warm” outside that day. · SP2 said s/he stopped at the break room to grab the soda and was talking with another staff person when P3 came in at 11:03 a.m. and told SP2 that the AV had been “missing” and that SP2 should go back to the Toddler One classroom. · SP2 thought SP1 would wait for him/her to get back outside before bringing the children inside. SP2 did not think s/he was inside more than five minutes. SP2 said it was sunny outside that day. · SP1 said it was his/her third or fourth day working at the facility. The AV was upset so P5 sat in his/her classroom doorway with the AV right before the classrooms went inside. SP1 said P5 gave the AV to P2 but the AV had a “hard time” when P5 went back into his/her classroom. · SP1 said that around 11 a.m., P2 and P3 went to bring their classroom inside, and even though SP2 was inside using the restroom, SP1 decided to bring his/her class inside too. SP1 brought the children inside and was “pretty sure” s/he had all the children from the Toddler One classroom, though SP1 stated s/he did not count the children at that time. · SP1 said that “within a minute” of returning to the Toddler One classroom, P1 came in and told SP1 that the AV was left outside on the playground. SP1 stated that SP2 was not back in the classroom at that point. SP1 said it was “sunny and warm” that day. P1 provided the following information to the DHS investigator: · On March 14, 2024, around 11 a.m., P1 was in an infant classroom covering a staff person’s break when P5 came to the door holding the AV and said the AV was outside on the playground by him/herself. P1 had a staff person step in the infant classroom so that s/he could go speak with SP1 and SP2. · P1 went to the Toddler One classroom and asked SP1 and SP2 if they were missing the AV. SP1 told P1 that P5 had opened the door to the Waddler room because the AV was crying and SP1 thought the AV was still with P5. P1 went back to P5 who told P1 that s/he did not take the AV off the playground. · P1 had SP1, SP2, P2, P3, and P5 write up statements about what happened and called into the corporate office to have someone pull video footage. P1 did not review the video footage. · Later that afternoon, P1 spoke with SP1 to see if s/he had been trained on the name to face feature on Daily Connect since it was SP1’s first week working at the facility. SP1 told P1 s/he had not been trained on that. P1 stated that staff persons were trained by another staff person on Daily Connect when they started in the classroom and said that SP2 “should have been aware of it from when [SP2] started.” P1 was not working at the facility when SP2 started, so s/he was not sure who trained SP2. SP2, P1, P2, P3, P4, and P5 all provided consistent information that the policy for transitions was to conduct a name to face count. SP2, P1, P2, P4, and P5 stated that should happen when going through a doorway. P1-P5 stated that there was an application on the tablet to assist with that. SP1 stated that prior to the incident, s/he did not see headcounts being done and had not been shown the name to face on the tablet. SP2 stated that P1 came in after the incident and showed him/her and SP1 the name to face on the tablet. The facility’s Risk Reduction Plan stated that, “Children will always be accompanied and escorted to/from the outdoor play area.” The facility’s Employee Handbook stated that direct supervision of every child was expected at all times. The facility’s Child Care Program Plan stated, “All children will be supervised at all times during the course of their day.” The facility’s Name to Face Procedure stated, “Name to face is the action taken by all [staff persons] during all physical transitions in order to ensure they know how many children, and which children, are in their care at all times.” This was required to be documented using Daily Connect. The facility’s Internal Review stated that after reviewing classroom camera footage from both the Toddler One and Waddler classrooms, the AV was brought into the Waddler classroom by P5 at the same time (11:03 a.m.) that children were walking into the Toddler One classroom with SP1. This investigator reviewed video footage from the Toddler One and Waddler classrooms and noted the following: · At 11:01 a.m., the Toddler One classroom camera angle showed some children in the classroom. The door to the outside and SP1 were not in the camera view at that time. At 11:01 AM, the AV was seen on the corner of the video frame within the classroom. S/he then moved in and out of the video frame. At 11:02 a.m., SP1 was heard saying, “We are going inside,” and, “Thank you.” SP1 then appeared in the camera view along with more children and SP1 said, “Alright, should we take our coats off?” SP1 walked across the classroom and out of view again and the video stopped at that point. The AV was not visible on the video footage at that time. · The Waddler classroom video footage showed that at 11:03 a.m., P5 was standing by the counter in the classroom and one staff person was sitting on the floor with children. The door to the outside was not visible in the camera’s view. P5 pointed toward the door and then walked out of camera view. · The staff person on the floor got up and walked toward where P5 was and went out of view of the camera as well. A staff person was heard saying, “Did they forget [him/her]?” A third staff person who had been out of the cameras view previously walked into view and toward where P5 and the other staff person went. At 11:04 a.m., all three staff persons were visible in the camera’s view along with the AV. P5 took the AV from one of the staff persons and walked out of the classroom with him/her. The video stopped at that point. Facility records showed that SP1, SP2, P1, P2, P3, P4, and P5 were each trained on the facility’s Risk Reduction Plan, Child Care Program Plan, Employee Handbook, and the Reporting of Maltreatment of Minors Act. The facility did not supply documentation that showed whether staff persons were trained on the Name to Face Procedure. SP1’s personnel file showed that SP1 had 10,400 hours of previous experience working as a teacher in a child care center. According to www.wunderground.com, the temperature on March 14, 2024, at 10:53 a.m. was 49 degrees Fahrenheit (F°) in Saint Michael. Relevant Rules and/or 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: Consistent information was provided that on March 14, 2024, SP1, SP2, P2, and P3 were on the playground with the Toddler One and Toddler Two classrooms including the AV. SP1, P3, P4, and P5 stated that the AV was having a hard time so prior to the classrooms lining up to go inside, P5 sat in the Waddler doorway to outside and gave the AV a hug. P5 handed the AV back to P2. SP2 went inside to use the restroom before the classrooms lined up. Around 11 a.m., P2 and P3 lined up the Toddler Two classroom to go inside. SP1 decided to bring in the Toddler One classroom at that time as well, even though SP2 was not back outside with the class yet. P2 helped SP1 get one of the Toddler One children (not the AV) inside and SP1 told P2 that s/he had all of the Toddler One children. SP1 did not do a headcount at that time but thought s/he had all of the children. P5 saw the AV standing outside the Waddler classroom door looking “confused” and went to get him/her. P5 stated there were no staff persons outside with the AV. P5 brought the AV inside and went to find P1. When P1 asked SP1 and SP2 if they were missing the AV, SP1 stated that s/he thought the AV was with P5. Video footage showed the AV was in the Toddler One classroom at 11:01 a.m. but had moved out of the video frame by 11:02 a.m., and more likely than not the AV went back outside before SP1 was seen inside the Toddler One classroom after closing the Toddler One door to outside. At 11:03 a.m., P5 saw the AV unsupervised outside the Waddler classroom. The AV was outside without staff person knowledge or supervision for approximately one minute which was a violation of Minnesota Statutes, section 245A.02, subdivision 18 and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was not injured or in distress when s/he was found by P5, given the AV’s age of two years old, that the design of the fence meant the AV was visible to community persons, and that SP1 did not perform a name to face or a headcount once in the classroom, 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. SP2’s responsibility was mitigated because s/he was not with the AV’s group when the transition occurred. Although SP1 was not trained on the facility’s name to face feature on Daily Connect, SP1’s responsibility was not mitigated because SP1 was responsible for the supervision of the AV. SP1 did not count the children at the time of transition and assumed that the AV was with P5 without verifying whether this was accurate. SP1 had previous childcare experience, acknowledged awareness that children should be counted at transitions, and had received training on the facility’s Risk Reduction Plan. Therefore, SP1 was determined 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 did not sustain any injuries. 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 found their policies and procedures were adequate but were not followed because no name to face was completed at the time of transition. After the incident, SP1 and SP2 were trained on using the tablet to complete name to face. 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 August 9, 2024, the facility was issued a Correction Order for the violations outlined in this report. In addition, it was determined that facility mandated reporters including one mandated reporter in a management role had knowledge of the alleged incidents and did not report the incidents as required. 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.
|
