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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: 1077914-CCC (Child Care Center) Investigator(s): Van Mulheron thu-van.mulheron@state.mn.us Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left outside on the facility’s playground without three staff persons’ (SP1-SP3) knowledge or supervision for approximately seven minutes. The AV was found by a community person (CP) standing outside of the playground. Date of Incident(s): April 15, 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 May 8, 2024; from documentation at the facility; and through five interviews conducted with a supervisory staff person (P1), and three staff persons (P2, SP1, and SP2), and a community person (CP). Attempts were made by phone, email, and mail to contact and interview the AV’s family member (FM) and SP3. The attempts were unsuccessful and neither responded to the requests. The AV was 32 months old and was enrolled the facility’s pre-kindergarten class. The facility was located in a strip mall with several other business and was the second unit from the end. At the back of the strip mall were mailboxes for the businesses, a driving lane, and parking spots. On the other side of the driving lane were the facility’s playgrounds which were surrounded by a chain link fence. The facility had two playgrounds, preschool and toddler. The preschool playground was directly across from the prekindergarten room and had a gate. There was a play structure with a slide, stairs and a tunnel. To the left of the play structure was a cement area that had additional toys and a playhouse for the children. To the right of the play structure was a fence that separated the preschool playground and the toddler playground. The toddler playground had a separate gate. t. On the other side of the playground was a small grass strip that led to a ditch and past the ditch were multiple railroad tracks. Directly across the driving lane from the preschool gate was a door that led to an entryway. The entryway stored a sand and water table and additional toys that could be used on the playground. The entryway also had doors. A door on the right led to the facility’s gym and A door on the left led to the prekindergarten classroom. The pre-kindergarten classroom had video camera above the windows on the back wall. The facility’s Incident Report stated that on April 25, 2024, at 4:12 p.m., the pre-kindergarten children came in from outside. There were 17 children and 3 staff persons (SP1-SP3). Upon returning to the classroom the staff persons failed to complete a head count and the AV was left outside. The AV had hidden underneath a play structure and could not be seen while the class was going inside and during the “formal “playground sweep. At 4:18 p.m., P2 went outside to bring out the garbage and found the CP with the AV trying to get inside the facility because the AV had been left outside. P2 called P1 and P1 spoke with the CP. The CP then left the facility. P1 arrived at the facility at 4:50 p.m. and spoke with “both” staff person’s (SP1 and SP2) who were responsible (Note: P1 later identified SP1 and SP2 as the staff persons s/he spoke to.) The staff persons said that they “were not sure how [they] missed [the AV].” At approximately 5:30 p.m., when the FM came to pick up the AV, P1 told the FM about the incident. The CP provided the following information:
· On April 15, 2024, in the afternoon, the CP drove into the alley to get his/her mail and saw the AV outside the fenced playground near the end of the playground. The CP parked his/her car and approached the AV. As the CP approached the AV, the AV “took off running” onto the grassy area behind the playground and towards the ditch. The CP ran after the AV and picked up the AV before s/he went into the ditch. The CP walked with the AV to the facility windows and “beat” on one of the windows until a staff person (later identified as P2) came outside. The CP said that that there was no one in the playground and that the gates to the playground were closed. · P2 came outside and said, “Where did you find [the AV]?” and “[S/he] is not in my room.” The CP asked to speak to P1 and then they entered the entryway and into the pre-kindergarten classroom. The CP was told that P1 was not in the building, but the CP was able to speak with P1 on the phone. P1 told the CP that s/he was “grateful” and “thank you” and that s/he would be returning to the center to “take care of the situation.” · While in the classroom the AV attempted to leave the building again and the CP redirected him/her back to the class. The CP said that there were at least two other staff persons in the room, but they did not speak with him/her or assist when the AV tried to leave the classroom. · The CP said that the weather that day was nice, but it was “super, super windy outside.” SP1 provided the following information: · On April 25, 2024, there were 20-25 children, including the AV, in the pre-kindergarten classroom with SP1, SP2, and SP3. (Note: According to the video there were 19 children, including the AV, in attendance.) SP2 had just started at the facility, but SP1 was unsure of how many day SP2 had worked and that it was SP1’s first time working with SP2. SP1 said that it was also SP3’s first day at the facility. P1 was not at the center. · At 2:30 p.m., after the children had snack the class prepared to go outside to the playground. SP1 had the children line up by the entryway where s/he completed a head count of the children, grabbed the outdoor backpacks, and then led the children to the playground. SP3 was at the end of the line and they all went to the playground. SP2 remained in the classroom to clean up snack. SP1 said that SP2 did not come outside to the playground at any time while the class was outside. SP1 stated that it was approximately 20 feet from the building to the playground. · At 4 p.m. SP1 had the children line up along the fence next to the playground gate to return inside. SP1 was in the front of the line and SP3 was at the end of the line. SP1 counted the children and “glanced” at their faces. SP1 said that all the children, including the AV, were in line. SP1 opened the gate and led the group to the facility door. SP1 opened the door, and the children walked into the entryway and then into the classroom. SP3 walked into the classroom before SP1 because SP1 was putting away the outdoor backpacks. SP1 said that s/he did not count the children at the facility door because the children walked immediately into the classroom where s/he had planned to count them. · When SP1 entered the classroom SP2 was standing outside the bathroom near the entryway and SP3 was playing with the children. SP1 said that s/he was about to complete another head count when the CP walked into the classroom via the back entry holding the AV’s hand. The CP said, “I found [the AV] outside … playing. The [AV] was going into the ditch area.” SP1 “thanked” the CP for finding the AV. · The CP then asked to speak with P1 so SP2 called P1 and handed the phone to the CP. SP1 said that s/he “stepped back” and the CP and P1 spoke for one to two minutes. SP1 said that P2 was also in the classroom but s/he did now know when P2 entered the room. P2 was standing next to SP1 and also spoke with the CP but SP1 did not remember what P2 said. The CP waited near the entryway until P1 arrived at the facility. SP1 did not speak with the CP again and neither SP2 nor SP3 spoke with the CP. · Approximately five to ten minutes later, P1 arrived. P1 spoke with the CP for about ten minutes and then the CP left. P1 and SP1 then talked and SP1 told P1 that the AV was alone outside for about five minutes. · The AV was “fine” when s/he came into the room and the AV began to play with the other children. · SP1 said that it was about five minute” from the time s/he entered the classroom until the CP came in with the AV. SP1 was not sure how the AV was left outside and s/he was “distraught,” “flabbergasted,” and “sad” about the incident. SP1 did not talk with SP3 about the incident. SP2 provided the following information: · On April 25, 2024, SP2 was working with SP1 and SP3, and 19 children including the AV. It was SP3’s first day. At 2:30 p.m., SP1 and SP2 spoke with each other and decided that SP1 and SP3 would take the children to the playground while SP2 cleaned the room. SP2 did not participate in getting the children lined up or getting the class outside. SP2 stayed inside and cleaned the room and “once or twice” went outside to check on the class and help children who needed to use the bathroom to do so. · The group returned to the classroom around 3 p.m. “a little later” and said the group was not outside for more than “an hour.” When they came inside, SP2 helped with diaper changes in the bathroom. While SP2 was in the bathroom, s/he heard “pounding” but thought that it was a staff person pounding on the playground door. SP2 then saw SP1 walk past the bathroom toward the entryway. · SP2 then looked out of the bathroom door and saw SP1 with the CP. The CP said that s/he “found the [the AV] outside.” SP2 replied, “Oh,” and let SP1 talk to the CP while SP2 continued changing diapers. SP2 said that P2 was also in and out of the classroom and spoke with the CP. SP2 did not speak with the CP because P2 “was in control of the situation.” SP2 did not speak to SP1 or SP3 about the incident. · SP2 said that when s/he saw the AV in the classroom, the AV was “fine” and was running around the class. · At approximately 4:15 p.m., P1 arrived in the classroom and asked SP2 how long the AV was outside. SP2 said that s/he “wasn’t 100% sure” because s/he was not outside with the class. SP2 then left for the day. There were two videos with sound of the classroom. Video one was from 16:12:27 -16:13:41 p.m. and video two was from 16:18:39-16:20:40 p.m. The entryway was located in the lower right corner of the video and not in view of the camera. The children and staff persons entered the classroom through the entryway. The videos provided the following information: · From 16:12:36–16:13:15 p.m., 16 children enter the classroom via the entryway followed by SP3. · At 16:13:25 p.m., two more children enter the classroom followed by SP1. · At 16:19:25 p.m., a series of knocks could be heard as P2 walked out of sight into the entryway. SP1 stood up holding an electronic devise and walked toward the back wall as a child said, “Teacher!” SP1 said, “Yes, what’s up?” SP1 then tuned around and walked in the other direction as the child said, “Some one at the window.” SP1 did not respond and continued to walk away.
· At 16:19:50 p.m., a child said, “Look! There’s a kid. There’s a kid outside!” SP3 said, “What?” and walked to the window. The child again said, “There’s a kid outside!” and SP3 asked, “By [him/herself]?” The child replied, “Yeah,.” as SP3 looked out the window. · At 16:20:06 p.m., P2 walked into view holding the AV followed by the CP. P2 stopped in the middle of the room and put the AV down and then walked out of the classroom. The CP stopped near the bathroom door, SP1 stood in the classroom, and SP3 remained by the classroom windows. · At 16:20:21 p.m., the AV walked toward the entryway and out of view. The CP followed the AV into the entryway and was out of view. SP1 walked toward the entryway and out of view of the camera. P1 and P2 provided information that was consistent with the information provided by the CP, SP1, SP2, and in the video. Each also provided the following information: · P1 said that the day of the incident was SP2’s third day of work and that s/he had spent the other two days training SP2 in the classroom. It was SP3’s first day of work in the classroom but SP3 had completed orientation on April 17, 2024. · At an unknown time after 4 pm. P2 called P1 and was told that the AV was left outside, and that the CP would like to speak with P1. P1 spoke with the CP and the CP said that “[s/he] saw [the AV] outside the fence, [s/he] watched [the AV] for a while, and then grabbed [the AV] and brought [the AV] into the facility].” P1 thanked the CP and said that s/he was returning to the facility and would look into the incident. · P1 and P2 provided consistent information regarding SP1’s and SP2’s replies when asked about the incident. SP1 said that s/he completed a head count but did not say where s/he completed the head count and SP2 did not say anything. P1 and P2 did not speak to SP3 about the incident because it was his/her first day working at the center. · P1 said that SP1 and SP3 could not have completed a sweep of the playground before they went inside because there was a clear view under the play structure and staff persons would be able to see a child underneath it. P1 stated that SP1 and SP3 did not shut the gate because the AV would not have been able to get out of the playground because the gate would have been “difficult” for him/her to open. · P2 said that the AV was not upset and came straight to P2. According to wunderground.com, in Dilworth, MN, on April 25, 2024, between 2:30-4 p.m., it was 79 degrees Fahrenheit with winds gusts of 45 miles per hour. The facility’s Policy Handbook stated that “All children must be supervised at all times.” Facility documentation showed that P1, P2, and SP1-SP3 received training on the Policy Handbook and the Reporting of Maltreatment of Minors Act prior to the incident. SP3’s personnel file showed that SP3 was hired on April 15, 2024, and was trained on facility policies and procedures on April 17, 2024. In addition, SP3’s Personal Information Form, signed by SP3 provided information that SP3 had 48,512 hours of previous childcare experience. 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 April 25, 2024, the AV, who was 32 months old, was left outside without the knowledge or supervision of a staff person for approximately seven minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The CP found the AV behind the facility outside of the playground which allowed the AV had access to community dangers including cars, the ditch, the railroad tracks, and unknown community persons. Given this and that there was no staff persons able to intervene if the AV injured him/herself or in the event of an emergency, 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, SP2, and SP3 worked in the classroom at the time of the incident and were each trained on the facility’s policies including the Policy Handbook and the Reporting of Maltreatment of Minors Act prior to the incident. At the time of the incident SP2 was working inside and not responsible for the supervision of the children on the playground. Therefore, SP2 was not responsible for the maltreatment of the VA. SP1 and SP3 were on the playground supervising the children. Although it was SP3’s first day working in the classroom, SP3 received training one week prior to the incident and had 48,512 hours of previous childcare experience. Therefore, SP1 and SP3 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 SP3 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 and procedures were adequate but not followed by SP1 – SP3 at the time of the incident. The facility changed their policies to reflect the counting of children before and after transitions and created clear defining roles for each staff person during a transition. SP1, SP2, and SP3 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 and SP2 were each responsible for maltreatment is subject to appeal. On September 11, 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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