|
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: 801684-CCC (Child Care Center) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV), who was nine months old, was unsupervised on the facility playground for approximately three minutes. Date of Incident(s): July 3, 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 July 18, 2024; from documentation at the facility; and through five interviews conducted with three facility staff persons (the SP, P1, and P3), a supervisory staff person (P2), and the AV’s family member (FM). The facility had multiple classrooms, including an older and younger infant room, which were separated by a half wall and half door. The facility also had three outdoor play areas, including one for infant and toddler children. The infant/toddler play area had a large grassy area, a small play structure, and toys. The infant/toddler play area was surrounded by a chain link and wrought iron fence with a gate that latched from the outside. The infant rooms accessed the infant/toddler play area by going through an exterior door in the older infant room. The facility was located between three roads. One road had a speed limit of 35 miles per hour, another with a speed limit of 40 miles per hour, and the other had a speed limit of 50 miles per hour. There were single and multi-family residences nearby, various businesses, and a wooded area behind the facility. The playground was visible to passersby on one road. The AV was approximately nine months old at the time of the incident and enrolled in the younger infant classroom. The AV enjoyed playing with other children and being outside. The facility Daily Attendance showed that on July 3, 2024, around 3:45 p.m., there were 11 children in the younger infant room, including the AV. The SP, P1, and another staff person (P4) worked in the younger infant classroom. P3 worked in the older infant room with four children. The Incident Report Form said that on July 3, 2024, at 3:44 p.m., the AV was left unsupervised in the fenced in infant/toddler play area for “just under three minutes” after the AV’s class transitioned inside. There were no injuries to the AV. P1 provided the following information: · On an unknown Wednesday in July 2024 (Note: P1 did not recall the specific date but it was later determined to be July 3, 2024), P1 worked in the younger infant room with the SP and P4. At some point prior to 3:45 p.m., the SP took four children from the younger infant classroom, including the AV, outside to the play area. P3 also took four children from the older infant classroom to the play area. During this time, P1 and P4 remained inside the younger infant room with the remaining seven children. · At 3:45 p.m., the SP and P3 began bringing the children inside while P1 started getting snack ready for the children. During this time, P1 looked to ensure “everyone was inside” but did not see the AV. P1 then looked in the older infant room to ensure the AV was not “still sitting over there” after returning inside but P1 did not see the AV. P1 asked the SP where the AV was and rather than respond to P1, the SP asked P3 about the AV. P3 told the SP that s/he “made sure” his/her four infants were inside but did not say anything about the AV. The SP then went outside and returned the AV to the classroom. The AV had been left outside on the playground unsupervised for “no more than two minutes.” The SP was “surprised” that the AV was outside. · There were no injuries to the AV as a result of the incident and the AV was not crying. Although the AV was not injured, risks to the AV being unsupervised included the weather as it was a “warmer day.” · When the younger and the older infant rooms went outside, the teacher(s) from each classroom were responsible for supervising the children in their assigned room. Each staff person had a list on an app (ProCare) on a classroom iPad for the children enrolled in their room and staff persons were to do name to face counts using that list. Although each staff was responsible for doing the name to face counts for their assigned classroom, staff persons assisted one another as needed. · Staff persons were trained to do a name to face count on the iPad as children were coming inside from the play area. When coming inside, the exterior classroom door, which was on the older infant side, was propped open and if there were infants who could not walk, the staff person(s) carried those children inside “one by one.” P1 did not know what happened on the date of the incident or how the AV was left outside but said there was “nothing out of the ordinary” that day. There were no prior concerns with the SP. · P1 said that had s/he not realized the AV was not in the classroom, the toddler classroom went outside at 3:45 p.m., “right after” the infant classrooms came in and would have noticed the AV in the play area unsupervised. P3 provided the following information: · On the afternoon of July 3, 2024, P3 worked in the older infant classroom with four children. At some point in the afternoon, P3 took his/her four children outside and when s/he got out to the playground, the SP was already outside with four children from the younger infant room, including the AV. · Around 3:42 p.m., P3 took his/her four children inside and did the name to face counts via the iPad for his/her classroom. P3 then began getting his/her children ready for snack. After approximately two minutes, the SP brought the children from his/her classroom in. (Note: Video footage showed that the SP and P3 brought their children in at the same time.) P3 said s/he did not hear the SP do the name to face counts. The SP then returned his/her children to the younger infant room. · During this time, P1 was in the younger infant classroom getting the children ready for snack when P3 heard P1 ask the SP where the AV was. The SP then asked P3 if the AV was in the older infant classroom. P3 looked in his/her room but did not see the AV and told the SP that the AV was “not there.” The SP stated that the AV “must be outside” and then the SP went outside to the infant/toddler play area where s/he found the AV by “[him/her] self.” When the SP brought the AV inside, the AV was not crying and was uninjured. The AV was unsupervised for approximately two minutes. · Although the AV was not injured, risks to the AV being unsupervised included that the AV could have climbed on something and fell. · The SP felt “horrible” about the incident and there were no similar incidents with the SP. · P3 said it was not busy or hectic while going inside and described it as a “normal day.” · Staff persons were trained to do name to face counts via the classroom iPad including when going inside and outside. On the date of the incident, while outside, the SP did not have the classroom iPad with him/her. P3 knew this because the iPad was “very big” and P3 did not see the SP outside with it. P2 provided the following information: · Staff persons were trained to do name to face counts “every time” they went outside and when they returned inside. Staff persons did this via an app on a classroom iPad and documented when they did so. Each classroom had a list of the children enrolled on their iPad. · P2 was not at the facility when the incident occurred. However, on July 5, 2024, P2 spoke to the SP about the incident. The SP told P2 that s/he did not do the name to face count as s/he was trained to do and “did not know why” s/he did not do so. The SP said that s/he “may have been distracted.” P2 had no prior concerns with the SP and staff persons “adored” the SP. · P2 reviewed video footage from the incident which showed that the AV was unsupervised for approximately two minutes and fifty seconds. The SP provided the following information: · On the date of the incident, which the SP thought was July 8, 2024, (but was later determined to be July 3, 2024), the SP worked in the young infant room which included the AV. At some point prior to lunch (Note: All other information showed that the incident occurred in the afternoon), the SP took four children, including the AV, outside to play in the infant/toddler play area. During this time, P3 was also outside with some older infants. Around 11:30 or 11:40 a.m., (later determined to be around 3:45 p.m.), the SP brought his/her children inside. As the SP entered the classroom, P1, who had remained inside with some of the other children, asked the SP where the AV was. The SP did not see the AV in the classroom, so the SP “hurried” outside and found the AV “smiling” and sitting in a “grassy area” of the play area. The AV was not hurt and was not crying. The SP then brought the AV inside. · Prior to coming inside, the SP last recalled seeing the AV in the same grassy area s/he found the AV in. · The AV did not yet walk but crawled. Although the AV was not injured from the incident, potential risks to the AV included the AV crawling to another area within the play area and injuring him/herself. The AV could not have exited the play area due to the height of the latch on the gate but someone outside the gate could open the gate via the latch and access the AV. · Following the incident, the SP was told that supervisory staff persons watched video footage of the incident which showed that the AV was unsupervised for approximately one minute. The SP “felt so bad” about the incident and said nothing similar had happened prior. The SP “could not believe [s/he] left [the AV] outside.” The SP thought the incident occurred because s/he got “so busy” as s/he was coming inside, because the older infant room came in at the same time. The SP did not do a “name to face count” prior to returning inside. The SP said s/he was “normally pretty good” at doing name to face counts, but on the date of the incident, s/he “rushed” and did not “focus” on the name to face counts. · The SP also typically did a head count after s/he returned inside and thought s/he would have realized the AV was missing “right away” after getting inside and doing a “head count.” However, the SP did not get to doing a head count once inside because P1 had already notified him/her that the AV was not present. The FM said that P2 notified him/her of the incident. The FM had concerns regarding “how” the SP could leave an “infant outside.” The FM was “upset” the incident happened but was “glad” the facility told him/her and that they “did not brush it off.” The FM also had concerns that “anything could [have] happened” while the AV was outside including that on the date of the incident, it was “gross and muggy” outside. However, there were no injuries to the AV and the AV was “happy” when the FM later picked the AV up following the incident. A ProCare document showed that on July 3, 2024, at 3:08 p.m., the AV was playing outside. At 3:13 p.m., a staff person (who was not identified), did a “spot check” on the AV while outside and a photo showed the AV sitting outside wearing a short-sleeved onesie and socks. Video footage from the infant classrooms did not have sound and there were no cameras outside. On July 3, 2024, at 3:42:48 p.m., the exterior door in the older infant room opened (Note: Due to the camera angle, it was not able to be determined who opened the door. The view did not show past the doorframe or outside) and two children walked into the room as the SP carried a third child in and set this child near the open exterior doorway. Based on shadows near the door, the SP appeared to remain near the doorway. During this time, P1 and P4 were in the adjoining younger infant room attending to other children. At 3:43:34 p.m., the SP held a fourth child’s hand and walked the child into the classroom and then returned outside. At 3:43:56 p.m., a fifth child walked into the classroom. At 3:44:09, P3 walked into the classroom via the exterior playground door carrying a sixth child and an iPad. At 3:44:35 p.m., the SP carried a seventh child into the room and shut the exterior door. The SP did not have an iPad with him/her. The SP then began bringing three of the children to the younger infant side while P3 removed his/her shoes and put items s/he had outside, such as a bag, away in the older infant room. P3 also began cleaning up the room and getting a child seated at a table. At 3:47:02 p.m., P1 appeared to be looking for something in the younger infant room. P1 then went to the half door separating the younger and older infant rooms and looked in the older infant classroom. P1 then appeared to speak to the SP and P3. At 3:47:24 p.m., the SP then walked to the older infant room and at 3:47:32, went outside via the exterior door. At 3:47:50 p.m., the SP returned carrying the AV. The AV was not crying. According to www.wunderground.com, on July 3, 2024, at the time of the incident, the temperature outside was 86 degrees Fahrenheit with a heat index of 85 degrees Fahrenheit. The New Horizon Academy Safety and Supervision Policies said that staff persons were to “never” leave a child unattended for “any reason.” Staff persons were to be within “sight and sound” of children at all times. Staff persons were to “always know the exact number” of children they were responsible for and where they were at “all times.” Children were to “always” be supervised on the playground. The Child Care Center Risk Assessment and Risk Reduction Plan said that children were supervised by “qualified staff” while on the playground. Additionally, ratios were maintained on the playground. The playgrounds were fenced in and gates were “secured with latches out of a child’s reach.” The facility was located “on a busy road.” Facility documentation showed that the SP, P1, P2, and P3, received training on the facility’s Risk Reduction Plan, the Safety and Supervision Policy, and the Reporting of Maltreatment of Minor’s Act prior to the incident. Relevant Rules and/or 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 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: On July 3, 2024, the AV was left outside within the enclosed infant/toddler play area, unsupervised and without a staff person’s knowledge, for approximately three minutes which was inconsistent with the facility’s Risk Reduction Plan and the Safety and Supervision Policies, and a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. When P1 realized the AV was not in the classroom and asked the SP where the AV was. The SP then found the AV within the enclosed play area. The AV was uninjured and was not crying when the SP found him/her within the play area. Although the AV was in a fenced in playground, given that the AV was approximately nine months old and that the playground was visible to passersby and therefore the AV had access to potential community dangers, which placed the AV at an increased risk of harm, there was a preponderance of the evidence that leaving the AV unsupervised outside in an area which was accessible to community dangers 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. 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. Although P3 was also on the playground and returned inside at the same time as the SP and the children, information was consistent that the SP and P3 were each responsible for the children from their own groups. Therefore, the SP was responsible for the care and supervision of the AV at the time of the incident. The SP received training the facility’s Risk Reduction Plan, the Safety and Supervision Policies, and the Reporting of Maltreatment of Minors Act. The SP was 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 the SP was responsible did not meet statutory criteria to be determined as recurring or serious. The SP’s actions were a single incident of maltreatment and the AV did not sustain a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought. 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 because not “every” child was within sight and sound at all times. Additionally, staff persons did not “ensure” they did a name to face count when “moving children from place to place.” There were no similar incidents. The facility updated their risk reduction plan and used the incident as a “teachable experience” for staff persons. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP 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 the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On August 21, 2024, the facility was issued a Correction Order for the violation outlined above. 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.
|
