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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: 802778-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 preschool classroom without a staff person’s (SP) knowledge or supervision for approximately nine minutes before being found by a community person. Date of Incident(s): May 17, 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 4, 2024; from documentation at the facility; and through seven interviews conducted with the AV, the AV’s family members (FM1 and FM2), a community person (CP), a facility supervisory staff person (P1), and facility staff persons (P2 and the SP). Facility documentation showed the AV was four years old and enrolled in the facility’s Bluebird Preschool classroom. The facility was in a community fitness center with two levels. There were classrooms on the first and second levels which were accessible by a ramp and an elevator. On the second level was a hallway with staff offices, a kitchen, and classrooms including the Bluebird classroom. The door to the classrooms required a key fob to enter. Just inside the door, was a vestibule with children’s cubbies and a doorway with no door that led to a bathroom. The bathroom had three toilets separated by stall walls but no doors and three hand sinks. The Bluebird classroom was on the left, and there was another classroom on the right that were each separated from the vestibule by a half wall and a half door. The Bluebird classroom was a square open space with tables, chairs, and shelves with toys. Just inside the room and along a wall was a handwashing sink and a drinking fountain. The classroom had an open door to the other classroom. There were two playgrounds, one on the roof of the first level and one on the roof of the second level. There was a video camera in the hallway near the first level playground door. The AV stated that s/he was in the Bluebird classroom but sometimes went to other rooms. The AV enjoyed playing with his/her friends at the facility. The AV stated that s/he was “maybe” in the bathroom when the SP and the children left him/her. The AV stated that s/he “cried” when s/he was “forgotten” and was found near the cubbies by a friend’s family member. The AV stated that the SP made him/her laugh. FM1, FM2, P1, P2, the SP, and the CP provided the following consistent information: · On May 17, 2024, at approximately 5 p.m., the SP and the “Bluebird” classroom children, including the AV, were on the second level rooftop playground when the SP brought ten children, including the AV, inside to the Bluebird classroom for water and a bathroom break. The group stayed in the vestibule near the cubbies and the bathroom. The AV’s water bottle was empty, so the SP told the AV to get water from the drinking fountain in the classroom. · The SP stated that at that time, another child was picked up by his/her family member and a child was “emotional” and “crying” and “scratching” at the door to the hallway to keep it open because s/he did not want his/her friend to leave. The SP moved the child from the door, lined up the children, opened the door, and they left the classroom. The SP stated s/he tried “to get the kids to the playground before something else happened” and did not complete a name to face check as the group exited the classroom. As the group walked down the hallway to the first level playground, about half of them “ran to the door.” When the SP arrived at the door to the first level playground, s/he held it open and had the children walk through. The SP stated s/he did not “count at all.” At that time, P2 and his/her group of children were also on the first level playground. · The CP stated that at approximately 5:15 p.m., s/he walked into the Bluebird classroom and saw the AV crying on the floor near the cubbies. The AV told the CP that “they forgot” him/her. The CP walked the AV to the first level playground. · P2 stated that the CP came out onto the playground and said that the AV had been left inside the classroom. The SP had the AV sit on his/her lap and s/he “comforted” the AV. The SP apologized to the AV and gave him/her a Kleenex and some water. The AV then saw his/her sibling and ran off with him/her to play. When FM1 arrived that evening, the SP was engaged with a different child and did not talk with FM1. · The SP stated that s/he could not “come up with a reason” as to why s/he did not complete a name to face check at the playground. P2 stated that s/he did not see the SP complete a “count” or “mark off” children as they entered the playground. · FM1 stated that on May 17, 2024 (Friday), when s/he arrived at the facility, the AV and his/her sibling were playing together and the AV “seemed happy.” FM1 was not told at that time that the AV had been unsupervised. · On Monday, May 20, 2024, FM1 was told about the incident and that the AV had been unsupervised between seven and eight minutes. FM1 asked the AV about the incident and the AV told FM1 that s/he cried and missed FM1 and that s/he had been found by the CP. · The SP stated s/he had been adequately trained to use name to face sheets as children transitioned from one area to another. Prior to the incident, the SP did not always use the name to face sheets and since the incident, s/he was “getting better” at using them. · P1 stated that s/he reviewed video footage of the incident, and the AV was unsupervised for approximately nine minutes. The SP should have used the name to face log and counted all the children before leaving the classroom and when s/he arrived at the playground. The SP told P1 that s/he had “a lot” going on as s/he left the classroom and did not complete a name to face check and when s/he arrived at the playground, s/he “forgot” to complete a name to face check. The facility provided video footage of the incident that was 10 minutes and 29 seconds long. The video was not time stamped and did not have audio. The video provided the following information: o At the beginning of the video, seven children and the SP entered the facility hallway. Six children were in front of the SP and one child was behind the SP. One child arrived at the playground door and opened it, and four children went through the door before the SP arrived at the door. Then the SP held the door open, and three children went through it and the door shut. o After two minutes and ten seconds, the SP entered the hallway through the playground door and walked through a kitchen door next to the playground door. The kitchen door shut. o After one minute, the SP walked out of the kitchen, took a bite of a cheese stick, and walked through the playground door. o After approximately nine minutes, the CP walked off the elevator and into the hallway. The CP walked down the hallway toward the classroom and out of camera view. o After one minute, the CP and the AV walked into the hallway toward the playground door. Then the CP and the AV exited the hallway through the playground door and the video ended. The facility’s Center Administration Procedures for the Child Supervision Log showed that the Child Supervision Log must be used by “all classrooms” and name to face counts must be “conducted every hour and during transitions.” It also showed that “immediately before leaving an area with a group of children,” staff persons counted the “number of children present” and matched it to the “count log” before leaving the area. Then staff persons “called out” the child’s name and matched it to the child’s face. “When all children” were accounted for and the number of children matched the log, the group moved to another area. When they arrived at the new area, staff persons completed the process again. The facility’s Risk Reduction Plan showed that “all children must be supervised and accounted for at all times. At transitions from one space to another, staff must complete the name to face Child Supervision Log of the children as they leave and as they arrive at the new space to make sure that no children are missing.” Facility documentation showed that P1, P2, and the SP each received training on the Maltreatment of Minors Reporting Act and on the facility’s policies including the Center Administration Procedures for the Child Supervision Log and the Risk Reduction Plan.
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 was consistent that on May 17, 2024, between 5 and 5:15 p.m., the AV was in the Bluebird classroom for approximately nine minutes without the knowledge or supervision of the SP, 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 in a classroom designed for children who were the AV’s age, the AV was unsupervised for approximately nine minutes. The AV was found by the CP who brought the AV to the SP who was on the first-floor playground. Given that the AV was four years old, it was unlikely that the AV would be able to provide for him/herself in an emergency and staff persons were not aware that the AV was in the room 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 the SP received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies including the Risk Reduction Plan and Center Administration Procedures for the Child Supervision Log prior to the incident. At the time of the incident the SP was responsible for the supervision of the children, including the AV. 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 because it was a single incident of maltreatment for which the AV did not sustain an 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 adequate but not followed. The SP completed additional “face to name” training on May 21, 2024. 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 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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