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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: 1053885-CCC (Child Care Center) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) left an alleged victim (AV) unsupervised on a playground for under one minute. The AV was discovered by another staff person (P1), unharmed. Date of Incident(s): July 23, 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 30, 2024; from documentation at the facility; and through interviews conducted with the AV’s family members (FM1 and FM2), facility staff persons (SP1, SP2, and P1), and a supervisory staff person (P2). At the time of the incident, the AV was two years old and enrolled in the facility’s toddler classroom. The facility was a stand-alone building set along a two-lane road with a center turn lane and speed limits of 45 miles per hour. The surrounding area including houses, apartment buildings, parks, a fire station, and a lake. Along the east side of the facility was a playground fully enclosed by wrought iron fencing and portions of the building, itself. The fencing had two-to-three-inch spaces between each vertical slate. The fencing separated the playground from the parking lot. The playground was divided in half by additional fencing, separating the preschool area from the toddler area. The toddler area was closest to the parking lot. The toddlers had a swing set and two play structures with stairs and slides, and a covered play area under one of the structures. Most classrooms, including the toddler and preschool, had exterior doors that opened directly into the playground. The facility did not have a camera system. At the outset of this investigation, information was provided that on July 23, 2024, SP1 and SP2 left the AV unsupervised on the toddler playground. P1 happened to be walking by the playground to the parking lot and saw the AV sitting alone under one of the play structures. P1 alerted P2. “[The AV] was happy and not aware of what had just happened.” The AV was unsupervised on the playground for “under one minute.” SP1 and SP2 provided the following information: · On July 23, 2024, SP1 and SP2 were working in the toddler classroom with 14 children, including the AV. SP1 and SP2 did not typically work together. SP1 said the day was “chaotic” and SP2 said it was “hectic.” Around 4:15 p.m., the classroom went outside to the toddler playground. The preschool classroom was outside on their side of the playground during this same timeframe. · While on the playground, some parents arrived to pick up their respective children for the day. SP1 said that this did not typically occur while they were on the playground. SP1 said that SP2 was holding the iPad, which had the toddler classroom attendance; SP2 said that SP1 was holding the iPad. Neither staff marked the children gone on the iPad attendance roster as they were picked up. · Then, a child had an “accident” in their pants and needed to be taken inside to be changed. SP1 and SP2 prepared to take the entire classroom inside at that time. The preschool classroom was also headed inside at that same time. [Note: SP1 and SP2 did not mark on the iPad when the toddler classroom returned inside. However, the preschool teachers marked on their iPad that they went inside at 4:45 p.m., which was the same time as the toddler classroom.] · SP1 believed they had ten children in attendance at that time. SP1 led three children inside ahead of the rest because their parents were waiting inside. SP2 was right behind SP1 bringing the rest of the children inside. SP2 was at the end of the line with the children walking in front of him/her. SP1 counted ten children as they walked through the exterior door and into the classroom. This was using a head count method, not a name to face method and/or by checking the iPad. SP1 later learned that they had 11 children at that time and so when SP1 counted ten children, s/he was off by one (the AV). · SP1 said that SP2 was responsible for completing the final “sweep” of the playground since s/he was the last inside. However, SP2 was “new” to the classroom and SP1 did not tell him/her how to do the playground sweep. The sweep should have included checking under the play structures. However, SP1 did not clarify with SP2 if it was done. · SP2 said that s/he was trained to walk around the playground prior to coming inside but did not do so on the day of the incident. Instead, SP2 was “gathering the children,” who were lined up at the door, while one child was “throwing a tantrum.” SP1 had walked inside ahead of SP2. SP1 was standing in the door threshold and SP2 believed SP1 was counting the children as they entered the building. SP1 then turned and went further inside when SP2 reached the door as the last person in line. SP2 looked back and “did a quick glance” around the playground but did not see any children. SP2 could not see under the play structures from that vantage point. SP2 then went inside and closed the door. SP2 believed there were 12 children at that time and that all of the children were in the classroom. After SP2 closed the exterior door, s/he went to the bathroom leaving SP1 in the classroom with the children. Next SP2 went to P2’s office. While SP2 was talking to P2 about an unrelated matter, P1 came to the office and said that s/he saw a child, later identified as the AV, on the playground unsupervised. SP2 believed the AV was unsupervised for “no more than three minutes.” [Note: P2 alerted another supervisor (P3), who was sitting in the front lobby, and asked them to go check the playground based on P1’s information.] · SP1 believed they were inside from the playground for about 45-60 seconds, when P3 brought the AV to the classroom via the playground exterior door. P3 told SP1 that the AV under a play structure. The AV was unharmed, “giggly and laughing.” · SP1 said that s/he and SP2 did not communicate their counts or numbers that day. SP2 said, “The pace was going fast.” SP2 could not recall what their communication was like, but believed they would have been communicating because they “always do.” The facility’s time entry system showed that at 4:37 p.m., on July 23, 2024, P1 clocked out for the day and prepared to leave for the day. P1 said that around 4:45 p.m., s/he walked out of the building and towards his/her vehicle in the parking lot. Around 4:46 or 4:47 p.m., P1 abruptly stopped on the sidewalk when s/he heard a child talking or making noises. P1 glanced around but did not see anyone on the playground, including the toddler side or the preschool side. P1 took a few steps backward and then saw the AV sitting under the play structure playing with his/her hands or a toy. P1 immediately walked back into the building and told P2. P2 said that s/he saw P1 leave for the day and then return stating the AV was on the playground alone. P2 asked P3 to go outside and check. P3 discovered the AV and brought him/her inside using the toddler classroom’s playground exterior door. P3 later told P2 that SP1 and SP2 did not know the AV was missing. P2 met with SP1 and SP2 and described them as “distressed” and “felt terrible.” P2 said that SP1 and SP2 were “wonderful” teachers and P2 had no prior concerns. (Note: Based on the time the preschool classroom came inside from the playground according to their documentation on the iPad, which was the same time as the toddler classroom, and the time P1 clocked out plus the amount of time it took P1 to walk outside to the parking lot, P2 believed the AV was unsupervised on the playground from 4:45 to 4:46 p.m., or for 45 to 60 seconds.) FM1 and FM2 each did not have concerns with the facility’s overall care and supervision. The facility’s policies and procedures provided the following information: · Teachers should directly supervise infants, toddlers, and preschoolers by sight and hearing at all times … including when the children are indoors or outdoors. · Teachers should be aware of the children in their care at all times. Never leave children unattended. Know exactly how many children are present at all times – whether in the classroom, on the playground, or in ancillary activities – and who those children are. Use the facility’s iPad to conduct head counts every time the class moves locations and every 15 minutes. · Staff completed name to face counts of the children in their care anytime they cross a threshold within the building or outdoor areas. Facility documentation stated that SP1, SP2, P1, and P2 received training on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act.
Relevant Minnesota Statutes and Rules: 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: On July 23, 2024, SP1 and SP2 left the AV on the toddler playground unsupervised 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 did not know the AV was missing until P3 arrived with the AV in hand. The AV was not harmed. SP1 and SP2 did not count the children on the playground and did not update the classroom roster on the iPad to indicate who was picked up by their parent and who remained and because of these things, SP1 and SP2 each did not know how many children they were responsible for on the playground and/or once back inside. Although the AV was unsupervised on the playground most likely for under one minute, given that the AV was two years old and left unsupervised on the playground, which was visible from the parking lot, the AV was exposed to community dangers, and 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 on the playground in the event of an emergency and would not have been able to intervene if necessary. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and/or protect the AV from conditions 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 and SP2 were responsible for the AV’s care and supervision at the time of the incident. SP1 and SP2 received training on the facility’s policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. SP1 and SP2 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 SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious. SP1 and SP2 were each responsible for a single incident of maltreatment for which the AV did not sustain a serious injury. 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 not followed. The facility planned to examine their policies and procedures to determine the adequacy and if any changes were needed, provide additional training to staff on those changes. The facility provided staff with additional training on name to face counts and planned to provide more one on one training regarding counts during orientation and ongoing throughout the year. There was not a history of this sort of incident occurring at the facility. P2 stated that the day of the incident, SP1 and SP2 received a retraining on name to face counts. 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 September 12, 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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