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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: 801675-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left in a classroom without a staff person’s knowledge or supervision for approximately five 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 15, 2024; from documentation at the facility; and through five interviews conducted with a supervisory staff person (P1), three staff persons (P2, P3, and the SP) and the AV’s family member (FM). This investigator met with the AV but s/he did not provide information relevant to this report. Facility documentation showed the AV was three years old and enrolled in the Preschool A classroom at the time of the incident. The facility was a three-story standalone building. There was an elevator in the facility that provided access to the three stories. There was a set of stairs that led from the first floor to the second floor and two sets of emergency stairs from the first floor to the second and third floors. On the first floor of the facility was a lobby area, a facility office, classrooms for younger children, a stairway, and a kitchen, all that were connected by a hallway. On the second floor were classrooms for older children, including the Preschool A classroom, stairwells, and a roof top playground, all connected by a hallway. On the third floor was a small walkway to another roof top playground, and a stairwell. Doors to the kitchen and classrooms had large windows and side windows that went from the floor to the ceiling. The Preschool A classroom was rectangular with tables and toy shelves. Along a wall near the classroom door was a changing table and on the wall opposite the changing table was a cabinet with a countertop. The classroom door had a child safety lock. In one corner of the classroom was a door that led to the Preschool B classroom. That door did not have a child safety lock. The facility had cameras in the classrooms, the lobby, and the third-floor walkway. The FM stated that on July 3, 2024, as s/he picked up the AV, an unknown staff person told the FM that the AV had been unsupervised. The AV’s class had taken the elevator to go to the playground, but the AV did not get off the elevator with the class. When the AV did get off the elevator, s/he was found by a staff person and brought to the playground. The FM stated the AV was fine and the FM did not have concerns regarding the program. Information obtained showed that on July 3, 2024, in the afternoon, P3 was working in the preschool A classroom when the SP came in so that P3 could leave. At that time, there were nine children including the AV. P2 provided the following information: · On July 3, 2024, at approximately 4 p.m., P2 was on the playground with Preschool classrooms B and C when the SP brought out children from Preschool A. Approximately 20 seconds later, P2 asked the SP how many children s/he brought to the playground and the SP said, “Eight.” P2 looked at the children and then looked at the Preschool A attendance on the iPad. P2 “noticed” that the AV was not there. · P2 then asked the SP where the AV was and the SP told P2 that s/he did not know who that was, so P2 showed the SP a picture of the AV on the iPad. The SP then said that the AV had been in the classroom and the SP left the playground to find the AV. · Approximately five minutes later, the SP and P1 came onto the playground with the AV. The AV was crying and P2 comforted him/her and then took him/her to see his/her sibling who was also on the playground. After about ten minutes, the AV “started playing” and “seemed fine.” · P2 estimated the AV was unsupervised for approximately ten minutes. · P2 stated that when transitioning from one area to another area, staff persons should “check the iPad” and “do name to face.” If the group went into the elevator, another count should be done and then when they got to the destination, staff persons “checked” the iPad and counted “again.” The SP provided the following information: · On an unknown date, the SP was working in a toddler classroom and then worked in the Preschool A classroom, which s/he had done “several” times prior. · The SP stated s/he did not know the name of the staff person who was working in the preschool classroom when s/he went into the classroom but that person (later identified as P3) told the SP to change a child’s diaper. The SP also thought that P3 told him/her that there were seven children present, and that the SP should take the children “upstairs” to the playground. · After changing a child’s diaper, the SP lined up the children at the door, counted eight children, and then left the room. The SP stated that s/he could not find the iPad to use for name to face attendance and left the room without completing name to face attendance. The SP said s/he never had a name to face sheet. · The SP and the children got into the elevator and went to the third floor. After exiting the elevator, the SP lined the children along a black rail, kept the previous count number in his/her head, and counted eight children again before letting them into the playground. · Once on the playground, P2 had an iPad and “realized” that the AV was missing. P2 showed the SP a picture of the AV and asked where the AV was. The SP told P2 that s/he did not know and then the SP left the playground to return to the classroom to look for the AV. When the SP did not find the AV in the classroom, s/he took the elevator to the first floor where s/he met up with P1 and the AV who looked “scared” and was crying. · P1, the SP, and the AV went to the playground and the AV “ran off and started playing.” The SP thought the AV was unsupervised for approximately five minutes. · After the incident, the SP learned that there had been nine children in the classroom and stated that s/he “did not think” s/he heard P3 “properly” because although s/he did not know the “exact” number of children in the classroom, s/he thought P3 told him/her that there were seven children in the class. · The SP stated that s/he “knew” s/he could not leave the Preschool A classroom without the iPad and was “supposed” to complete name to face attendance. The SP stated that if s/he could not find the iPad, s/he “should have stayed in the room.” · The SP stated that his/her training was adequate and was trained on “everything.” P1 provided the following information: · On July 3, 2024, at approximately 3:40 p.m., P1 was in the kitchen when the AV “pressed” his/her face up “against the window” and “tapped” on it. The AV was crying and P1 stepped out of the kitchen and hugged the AV. The AV “gripped” onto P1 and P1 then picked up the AV. · P1 asked the AV who s/he was with and where s/he was going, but the AV did not respond and “just looked at” P1. P1 carried the AV and walked to the stairs to see if his/her class was on the stairs. P1 did not see anyone so s/he walked to the elevator and took it to the second floor. When they got off the elevator, they went and looked in the Preschool A classroom but no one was in the room. · P1 and the AV then took the elevator to the third floor. When they got off the elevator, the SP was there and asked P1 if the AV was the “missing” child. P1, the AV, and the SP went out to the playground where P2 was with the iPad and who asked P1 where the AV had been. P1 told P2 that the AV had been found inside. · P1 asked the SP how many children s/he brought to the playground and the SP said, “Seven.” P1 asked the SP where the iPad and the name to face sheet were and the SP told him/her that s/he “could not find” them. The SP told P1 that s/he was nervous and apologized for leaving the AV. · The SP “should have counted” the children in the classroom and then “called their names” using the list in the iPad. · When P1 watched the video, s/he saw “a little bit of communication” between the SP and P3. The SP did not complete a name to face check before leaving the classroom and did not take the iPad or a name to face with him/her as s/he exited the classroom. · P1 stated the AV was unsupervised for a “little over five minutes.” The facility provided five video segments from different locations in the facility. The video was time stamped and did not have audio. The videos provided the following information: o At 3:46:58 p.m., the SP and P3 stood in the preschool A classroom, facing each other near the changing table and appeared to talk with each other while six children stood near the classroom door. Three other children, including the AV, were visible throughout the room. The SP left the changing table area and walked through the room, past the AV, and stood approximately five feet away from an iPad on a counter. o At 3:47:14 p.m., P3 walked to the counter, picked up the iPad, and then set it back on the counter. The SP faced the direction of P3. Then P3 picked up a bag, nodded his/her head at the AV, and walked out the classroom door. The SP then walked near the door, picked up a child, placed the child on the changing table, and changed his/her diaper as the six children continued to stand at the door of the classroom. At this time, the AV pushed in chairs at a table and another child walked away from the table area. o At 3:49:19 p.m., the AV walked to the corner of the room near the Preschool B door, out of camera view. o At 3:49:46 p.m., the AV walked back into camera view and to the changing table. The AV stood along side the SP and showed the SP his/her right arm. The SP turned and bent toward the AV and talked with him/her. The SP then lifted the child from the changing table and placed him/her on the floor. The AV walked to the corner of the classroom near the Preschool B door and out of camera view. o At 3:50:45 p.m., the SP washed his/her hands at a handwashing sink connected to the changing table. The child who had his/her diaper changed joined the group without washing his/her hands. o At 3:51:02 p.m., the SP took three steps from the handwashing sink and joined the children at the door. o At 3:51:20 p.m., the SP pointed his/her pointer finger at each child standing at the door. Then s/he opened the classroom door and walked into the hallway as s/he held the classroom door open, and eight children walked out. o At 3:51:40 p.m., the Preschool A classroom door shut. o At 3:51:54 p.m., the AV walked back into camera view in the classroom. S/he stood in the classroom and moved his/her head back and forth. Then the AV ran to the classroom door and looked out a side window next to the door. o At 3:52:17 p.m., the AV placed both of his/her hands on the door handle and attempt to pull and push the door open. o At 3:52:37 p.m., the AV turned toward the camera and appeared to be crying. The AV walked away from the door but then walked back to the door and attempted to open the door again. The AV then kicked the door five times, moved the handle, and kicked again four times. The AV stood at the side window and looked to the hallway and then turned and walked out of camera view. o At 3:52:46 p.m., the SP and eight children arrived at the third-floor hallway via the elevator and walked to the playground door. o At 3:53:08 p.m., the SP raised a finger and pointed at the children. Then the SP opened the door, and the children went out to the playground. P2 and another staff person were already out on the playground with other preschool children. o At 3:53:20 p.m., the AV, who appeared to still be crying, opened the door between the Preschool A and Preschool B classroom and walked into the Preschool B classroom. The AV walked to the side window of the classroom door that led to the hallway. o At 3:53:34 p.m., on the playground, P2 picked up an iPad and began to work on it. The SP was in and out of camera view as s/he walked on the playground. o At 3:53:39 p.m., the AV, still in the Preschool B classroom, turned away from the window and walked into the classroom area. o At 3:53:55 p.m., the AV walked back to the Preschool B classroom door. The view of the AV was obstructed by a column in the classroom. The AV’s hand was seen turning the door handle and then the AV moved into camera view. The AV opened the door and walked out of the Preschool B classroom doorway and into the hallway. From a window in the door, the AV’s head was visible as the AV moved left toward the elevator. o At 3:54:08 p.m., P2, on the playground, raised his/her head from the iPad and appeared to be talking with the SP. P2 and the SP walked past each other and P2 appeared to be looking for someone. o At 3:54:32 p.m., P2 walked up to the SP and appeared to be talking with him/her. P2 walked away from the SP and around the playground. Then the SP walked toward P2. P2 showed the SP the iPad, the SP took the iPad from P2, looked at it, and then gave it back to him/her. Then the SP and P2 looked around the playground. The SP squatted down and looked into a play tunnel, stood up, walked toward the door, and then off camera. o At 3:55:29 p.m., the SP opened the playground door, walked through it, and walked off camera toward the back emergency stairwell. o At 3:56:45 p.m., in the facility lobby, P1 carried the AV into camera view. They passed through the lobby and off camera near the stairs between the first floor and the second floor. o At 3:58:59 p.m., the SP and P1 walked out of the elevator. P1 carried the AV and they walked out the door and onto the playground. P3 stated that on July 3, 2024, s/he worked in the Preschool A classroom and was scheduled to leave at 4 p.m. Just before 4 p.m., the SP came into the classroom. P3 asked the SP to change a child’s diaper and did not remember the number but thought s/he told the SP that there were eight children present. P3 then left the classroom for the day. P3 stated the classroom iPad and Name to Face Tracker were on a countertop in the classroom. P3 stated that when the SP entered the classroom s/he should have completed a name to face check using the Tracker and should have looked at the children in the iPad to see who was in attendance. P3 stated that all staff persons were trained as such. The facility’s Safety and Supervision Policies stated that children must be in sight and sound at all times and staff persons should “always know the exact number of children” they were responsible for, their names, and where they were at all times. The facility’s Transition Policy showed that “for the safety of the children in our care and to properly supervise the children at all times, it is essential to know the correct number of children under your care.” The policy also showed that as children transitioned from the classroom to the playground they were to line up on “the rope,” then a staff person was to count the number of children lined up, and use the Name to Face Tracker to complete a name to face count. Staff persons were to document their name to the face tracker with the time, location, and number of children leaving. Staff persons were to do a sweep of the classroom before leaving. When the group arrived at their destination, the staff person was to again count the children and use the Name to Face Tracker to complete another name to face count and mark their name, time, location, and number of children entering the destination. Facility documentation showed that P1, P2, P3, and the SP each received training on the Reporting of Maltreatment of Minors act, and on the facility’s policies including the Safety and Supervision Policies and the Transition Policy prior to the incident. 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 July 3, 2024, the AV was left unsupervised in the Preschool A classroom when the SP brought the rest of the children to the playground, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV was unsupervised for approximately five minutes during which time the AV left the Preschool A classroom, went into the Preschool B classroom, exited that room into the hallway, got into the elevator, and took it to the first floor. Being unsupervised in the classroom and other areas of the facility gave the AV access to dangers including the stairs, the elevator, and entering the community. Although the AV was found by P1 and brought to the playground unharmed, given that the AV was three years old, it was unlikely that the AV would be able to provide for him/herself in an emergency. In addition, given that the SP was not aware that the AV was left in the classroom, s/he would not have been able to intervene to protect the AV 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 Safety and Supervision Policies and the Transition Policy prior to the incident. At the time of the incident, the SP was responsible for the supervision of 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 and Internal Review and determined that their policies and procedures were adequate but not followed. The SP no longer worked at the facility. 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 September 19, 2024, the facility was issued a Correction Order for the violation outlined in this report, for failing to wash a child’s hands after a diaper change, and failing to submit a background study request as required which was then self-corrected. 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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