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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: 1099968-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on a playground without staff person knowledge or supervision for over five minutes. Date of Incident(s): May 29, 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 June 5, 2024; from documentation at the facility; and through five interviews conducted with a supervisory staff person (P1) and four facility staff persons (P2, SP1, SP2, and SP3). This investigator met the AV, but s/he did not provide any details to this investigator. The AV was 3 years old and enrolled in the Pre-K One (preschool) classroom at the time of the incident. The facility was a stand-alone building with two levels. The Pre-K One classroom was located on the upper level along with two other classrooms and a kitchen. There was a hallway that ran the length of the building with a staircase that led down to an exterior door on the front corner of the building for closer access to the playgrounds. The playgrounds were located off of the front corner of the building next to the parking lot with an entrance gate approximately eight feet from the exterior door which led into the toddler playground. The preschool playground was accessed by passing through the toddler playground and through a second gate in a four-foot-high fence that separated the toddler and preschool playgrounds. Both playgrounds were surrounded by a six-foot-high chain link fence. The facility’s Incident Report stated that on May 29, 2024, at 11:50 a.m., the AV was left unattended on the toddler playground when the class entered the building. The FM was made aware of the incident but did not feel s/he received a lot of information as to how it happened, or how long the AV was on the playground. The FM had no prior concerns. During his/her interview, P2 said that on the day of the incident, around noon, P2 returned to the facility from his/her scheduled break. When s/he approached the main door to enter the facility, s/he saw the AV running on the toddler playground. The AV went to the toddler playground gate and motioned for P2 to open the gate. P2 “froze” for a moment, then as s/he walked toward the AV, SP2 came out the exterior door by the playgrounds, opened the gate and hugged the AV. P2 went into the facility to find P1 and let him/her know what happened. P2 was trained to perform a name to face count when leaving a classroom and at any gate or checkpoint. SP1, SP2, and SP3 each provided consistent information that on the day of the incident, they were on the preschool playground with a group of children including the AV. When it was time to go inside, all the children from the Pre-K One classroom lined up near the gate between the preschool playground and the toddler playground. SP3 was at the front of the line, SP1 was in the middle of the line, and SP2 was at the end of the line. When the class got inside the classroom, they started to wash hands to get ready for lunch, and at that time they noticed the AV was not in the classroom. They looked to see if the AV was hiding in the classroom, and then SP2 went into the hallway and then back outside where s/he found the AV. SP2 brought the AV back into the classroom and the AV had been crying, but was unharmed. The AV washed his/her hands and sat down for lunch. SP1, SP2, and SP3 provided the following additional information: · SP1 stated that the AV did not want to line up initially when they were outside, but when the AV did, s/he was the last in line. SP3 said the children lined up by the gate between the preschool playground and the toddler playground and SP3 counted the children, and s/he had the correct number of children, including the AV who was closer to the end of the line, but SP3 stated s/he did not perform a name to face count. SP2 said the staff persons counted and they had all 22 children they were supposed to have. SP1 stated as the children went from the preschool playground to the toddler playground, SP1 performed a name to face, and the AV moved from one playground to the next. SP1 stated that during transitions, s/he “usually” performed the name to face, and the other staff persons counted. · SP3 stated that SP1 was initially supposed to be at the end of the line and SP2 was supposed to be in the middle, but they switched on the toddler playground. SP3 said s/he started bringing the children inside the exterior doors and then had a couple children help hold the exterior door, while s/he went up to open the door upstairs. Once SP3 saw SP1 was in the middle of the staircase SP3 brought the children through the door at the top of the stairs. SP1 said when s/he got to the exterior door, s/he faced inside the exterior door toward the stairs, SP3 was already going up the stairs with the children, and SP2 was still coming inside with some children, so SP1 did not see the AV after that point. SP2 stated that s/he was the last staff person to come off of the playground. · SP3 said s/he entered the classroom and had the children sit on the carpet, then SP1 came in and started to pass out soap for the children to go and wash their hands to prepare to eat. SP3 then went over by the tables to set up name cards and when SP2 entered the classroom, s/he went over by SP3 to assist. SP1 said once they were all upstairs in the classroom, the children started washing their hands to get ready for lunch, and when the children sat down at tables, the staff persons noticed that the AV was not at his/her name card. SP2 said s/he was the last staff person to enter the classroom and noticed “almost immediately” that the AV was not with the class. SP2 asked SP1 and SP3 if they saw the AV. · SP3 said s/he checked the bathroom, and then SP2 went out into the hallway to see if the AV was out there. SP1 said the staff persons looked in the classroom and in the hallway for the AV, and then SP2 went outside to look for the AV. SP2 stated that the staff persons looked to see if the AV was hiding in the classroom, and then SP2 sprinted down the hallway and found the AV outside by the gate by the door. SP2 said the AV was crying, so SP2 comforted the AV and told the AV s/he was “okay.” · SP3 said that when SP2 returned with the AV, SP2 told SP1 and SP3 that the AV was outside on the toddler playground. SP3 stated the AV’s eyes were “a little watery” when s/he returned to the classroom. SP1 stated that when SP2 returned with the AV, the AV looked like s/he had been crying. SP1 and SP3 said the AV then washed up and got ready for lunch. When things settled down in the classroom, SP1 went to find P1 to tell him/her about what happened. · SP3 said SP1 “usually” performed a name to face count once all the children were back in the classroom or when s/he handed out the soap, but SP3 did not remember if SP2 was back in the class with the remaining children yet when SP1 started to pass out the soap. SP3 was trained to do a name to face count by saying a child’s name and looking at them when the children lined up on the fence, when passing through a door, and then once again in the classroom. SP1 was trained to do a name to face count at every door the class went through. SP2 was trained to do name to face and count at every doorway. · SP3 said the AV liked to go under tables and “ran away” when it was time to sit down for circle time. SP1 said the AV like to hide in spots in the classroom where s/he thought the staff persons could not see him/her. The FM told SP1 that the AV liked to hide “all the time” and the FM was not “surprised” that the AV did that. SP2 stated the AV had tried to hide in a toy shelf before. · SP1 thought the AV was on the playground for more than five minutes without supervision. SP2 thought the AV was alone for less than five minutes. On May 29, 2024, around 11:55 a.m., P1 was in the kitchen getting lunch ready for the children when P2 found him/her and told P1 that P2 saw the AV on the playground when s/he returned from break. P1 went into the classroom and saw the AV eating lunch so s/he did not say anything to the staff persons in the classroom at that time. P1 left the classroom and called his/her supervisor. Around 12:15 p.m., P1 was giving another staff person a break and SP1 found P1 to tell him/her what had happened with the AV. P1 was told that the staff persons conducted a name to face at a gate, and then had one staff person in the front of the line, one in the middle of the line, and one at the end of the line. Once they were upstairs, the children sat on the rug and were starting to wash hands when they realized the AV was not there. The staff persons thought the AV might be hiding, so they looked in the classroom and then SP2 went in the hallway and then downstairs and found the AV outside. P1 thought the AV was outside for “no more than five minutes.” P1 said staff persons were trained to do name to face at every doorway. This investigator reviewed video footage from May 29, 2024, from the staircase and it was five minutes from when the exterior door closed behind SP2 as the group entered the facility to when SP2 pushed open the exterior door, after running down the stairs to find the AV. The facility’s Supervision Policy stated, “When going inside, a visual rollcall (or name to face check) should be taken on the playground before leaving, one when coming inside the building, and then once more after getting to the classroom.” The facility’s Risk Reduction Plan stated, “When using the hallways with a group of children, you must have sight and sound supervision of all the children in our group. When moving an entire class, you must stay together as a group. See Supervision Policy for more details.” Facility documentation showed that P1, P2, SP1, SP2, and SP3 each received training on the facility’s 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 29, 2024, the AV was outside on the playground with SP1, SP2, and SP3. When it was time to go inside, the children including the AV lined up at the fence, and the staff persons confirmed they had all the children. As they transitioned from the preschool playground to the toddler playground the AV was with them as SP3 led the line of children, SP1 was in the middle of the line, and SP2 was at the back of the line. Although the facility’s Supervision Policy stated that staff persons should account for children when entering the building and again after returning to the classroom, there was no information that SP1, SP2, or SP3 accounted for each child when entering the exterior door, nor upon return to the classroom. Once the class arrived at the classroom, SP3 had the children sit on the carpet. SP1 then started to pass out soap for the children to start washing hands before lunch. SP2 stated s/he was the last staff person to enter the classroom and noticed “almost immediately” that the AV was not with the rest of the class. However, SP1 said the staff persons did not notice the AV’s absence until the children sat down at tables and they noticed the AV was not at his/her name card. The staff persons looked around the classroom and then SP2 went down the hallway and back outside and found the AV on the toddler playground. When SP2 and the AV returned to the classroom, SP1 and SP3 stated the AV looked as if s/he had been crying. P1, SP1, SP2, and video footage showed the AV was out of staff person supervision for approximately five minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules part 9503.0045, subpart 1, item A. As a result, the AV was exposed to community dangers. 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, SP2, and SP3 were each responsible for the AV’s supervision at the time of the incident, each was trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act, and each failed to account for the AV at all times as trained. SP1, SP2, and SP3 were 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 SP1, SP2, and SP3 were 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 by SP1, SP2, and SP3. All staff persons were retrained on the name to face protocol and supervision of children. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1, SP2, and SP3 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, and SP3 were each responsible for maltreatment is subject to appeal. On August 30, 2024, the facility was issued a Correction Order for the violations outlined in this report and for not completing an Individual Child Care Program Plan as required. 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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