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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: 1106057-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised in the facility’s front entry for 13 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 26, 2024; from documentation at the facility; and through five interviews conducted with four facility staff persons (SP1, SP2, P1, P2), and the AV’s family member (FM). The facility was located inside a church and had a separate entrance. The fenced playground was located a short distance from the main entrance door down a sidewalk. Through the main entrance door was an entryway that had a pew and a small bench. The entryway door was a locked double door with a long glass pane on each side that looked into the facility. Through the entryway door was a large main room. To the right of the main room down a short hall was the early preschool classroom. The AV was 34 months old and enrolled in the Early Preschool classroom at the time of the incident. P1 and P2 provided the following information: · On the date of the incident somewhere between 10-10:30 a.m., P1 and another staff person were on the playground with their classroom. The Early Preschool classroom had gone inside sometime earlier but P1 was not aware how much earlier. · P1 lined his/her children up and took them from the playground to the front entry door. The children were lined up along the glass window that looked into the entryway while P1 was doing a name to face count. P1 looked through the window and saw the AV sitting on a bench in the entryway. · P1 went in and entered the code to the door and P2 was close to the door. P1 gave the AV to P2 and continued to bring his/her children inside. · P2 said between 10:17 -10:24 a.m., s/he was in the main room with a classroom when s/he heard someone at the door and went over to assist. P1 was at the door with the AV and P1 said that the AV was in the entryway. P2 brought the AV back to the classroom and had SP1 and SP2 complete a name to face count at that time. · P2 watched the facility’s video cameras which showed SP1 and SP2 coming into the facility entryway with the classroom on a walking rope. There was a community person (CP) looking for the church and it appeared that SP1 tried to direct the CP. After the CP left, SP1 and SP2 continued with the class inside the facility. It appeared the AV let go of the walking rope when walking through the door and stood behind the door. The AV then had his/her face up to the door window, then sat on the bench in the entryway until P1 came inside. The AV was unsupervised in the entryway for 13 minutes. SP1 and SP2 provided the following information: · On the date of the incident, SP1 and SP2 were outside with the Early Preschool classroom. When it was time to go inside, they put the children on a walking rope and counted the children. Then they walked to the building and into the entryway and counted the children again. · The CP was in the entryway and SP1 and SP2 were trying to figure out what the CP wanted. SP1 grabbed another staff person that was in the main room and then the classroom walked inside and back to their classroom. · A while later, P2 brought the AV back to the classroom. SP1 was changing children’s diapers and SP2 was assisting other children. · SP1 said that they counted the children at the playground gate, but there were some distractions in the entryway including the CP and children crying and trying to leave the walking rope. · SP2 said that SP1 and SP2 did not complete as many name to face checks as they should have and although they counted the children at the playground gate and when coming in the entryway, they did not count the children when they returned to the classroom. · Normally when outside, staff person lined the children up at the gate and put them on a walking rope. A name to face count was done at the playground gate, at the main door, at the door in the entryway, and once the class was back in the classroom. The ProCare phone application was used for each name to face count. The FM had no previous concerns. The name to face counts on the ProCare application showed that on July 3, 2024, a name to face count was completed at 9:55 a.m., with a notation of “going outside.” Another name to face count was completed at 10:27 a.m. No other counts were documented until 3:55 p.m. This investigator was not able to view the facility’s video footage as P2 stated that it was only kept for a week and then automatically deleted. The Supervision Policy for Indoors and Outdoors stated that staff persons used name to face hourly checks to track the children throughout the day, including during transitions. Staff persons were required to know the names and the number of children in their care at all times, use name to face/hourly checks to account for the children in their care, conduct an additional headcount when transitioning to different areas, and log children in and out of ProCare Connect to ensure counts were always accurate. Facility documentation showed that staff persons were trained on the facilities policies 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 July 3, 2024, the AV was left in the facility’s front entryway without the knowledge or supervision of a staff person for approximately thirteen minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 and SP2 were each not aware that the AV remained in the entry way when they took the other children back to the classroom, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Although the entryway was inside the building, the door was not locked and the AV, who was three years old, was unsupervised for thirteen minutes with no staff person available to intervene if the AV attempted to do something dangerous, injured him/herself, or in the event of an emergency. 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 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. SP1, and SP2 were each trained on the facility’s policies and the Reporting of Maltreatment of Minors Act prior to the incident. Both SP1 and SP2 were working in the classroom at the time of the incident and in charge of the supervision of the classroom and both failed to count the children when they entered the facility from the entryway and/or when they returned to the classroom. SP1 and SP2 were 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 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV was not injured. 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 were adequate but not followed when staff persons did not do a name to face count using the ProCare application at each door frame they went through. Staff persons were retrained on supervision and name to face policies. 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 August 30, 2024, the facility was issued a Correction Order for the violation 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.
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