|
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: 801681-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was a reported that an alleged victim (AV) was unsupervised for approximately 19 minutes in a classroom bathroom without staff persons’ knowledge or supervision. Date of Incident(s): July 11, 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 17, 2024; from documentation at the facility; and through eight interviews conducted with the AV, the AV’s family member (FM), a community person (CP) who’s child also attended the facility, two supervisory staff persons (P1 and P2), and facility staff persons (P3, SP1, and SP2). The facility was located in the lower level of a multi-level business complex. The facility was off of a large, open hallway that also connected restaurants, a floral shop, a lounge area, and a parking ramp. From that hallway there was access to adjoining business complexes and double doors that led to an outdoor courtyard. The courtyard had picnic tables and benches, a grassy area, and a sidewalk that circled a pond and led to the facility playground. The business complex also had a back hallway with doors that led to the businesses. The facility had a secure entrance from the complex hallway. Once inside, the facility had a lobby area; an office; a kitchen; and five classrooms including, Preschool A and Preschool B, that were separated by a half wall and gate. The Preschool B classroom also had a secure door that led to a back hallway shared by the businesses in the complex. A buzzer sounded when that secure door was opened. The Preschool A classroom was rectangular with tables, chairs, and toy shelves. Cubbies were hung on the walls of the classroom. In the classroom was a hallway that led to a door to the main complex hallway. This door was secure. There was also a door that led to the facility hallway. In one corner of the Preschool A classroom there was an enclosed bathroom. The bathroom had a half-door that was approximately 43 inches high. There was not a door handle on the outside of the bathroom door, and it needed to be opened from a handle on the inside. Inside the bathroom was a toilet and toilet paper dispenser, hand sink with a soap and paper towel dispenser, a two-step stepping stool, a small plastic shelving unit with supplies, a wall mounted changing table, and on the floor was a box that contained a roll of plastic bags. There was another handwashing sink in the classroom outside of the bathroom and around a corner to the right near the door to the classroom. The facility had cameras above the door in the Preschool A classroom and in the lobby. The facility used ProCare which was a mobile application (app) platform used to communicate with families and streamline administrative functions. The facility also used a dry erase Name-to-Face form that was on a clipboard. The form had the date at the top and a row for each student’s name and five columns that stated location. Staff persons were to place a check mark in the child’s row to confirm the child was in line before leaving the classroom and then repeated the process when the class arrived at their destination. On July 17, 2024, this investigator requested to see the Name to Face form/clipboard for the Preschool A classroom. At that time, the Name to Face sheet on the clipboard for the day was dated July 15, 2024, and was incomplete. There was no information that the class transitioned anywhere on July 15, 2024, and there was no information that it had been used on July 16 or 17, 2024. Because it was dry-erase, there was no Name to Face information for July 11, 2024. Facility documentation showed the AV was four years old and enrolled in the facility’s Preschool A classroom. The AV stated that s/he liked his/her classroom “a little bit” and liked to play with toys in the classroom. The AV did not provide information relevant to this investigation. The CP stated that on an unknown date at approximately 9 a.m., as s/he was dropping off his/her children, s/he walked into the Preschool A classroom and heard someone in the bathroom. The CP walked to the bathroom door, saw the AV, and asked him/her, “How it was going?” The CP did not “understand” everything the AV said because the AV was “cry talking.” The AV “said something about poop,” and wanted “help” in the bathroom. The CP then left the classroom, walked out of the classroom, down the hall, and found P2 in the hallway. The CP told P2 that there was a child in the bathroom. P2 then “ran” to the classroom while the CP left the facility. The FM stated that on the day of the incident P2 called him/her and told him/her that the AV had been unsupervised in the bathroom for approximately five minutes after the group went outside. P2 also said that “right when” SP1 and SP2 got outside, they realized the AV was inside and “ran” in to get him/her. The AV was in the bathroom “unbothered” and was waiting for someone to help him/her in the bathroom. Prior to the incident, the FM did not have concerns regarding the facility and “loved” it. P1, P2, P3, SP1, and SP2 provided the following information: · SP2 stated that on July 11, 2024, between 9:45 and 10 a.m., SP2 was working in the Preschool A classroom with SP1 and s/he left the classroom to get water for the children. When s/he returned to the classroom, SP1 had the children “lined up” on two ropes and P3 had the Preschool B children also in the room lined up on a rope. At that time, SP2 believed the room seemed “very chaotic.” · P3 could not recall the date or exact time of the incident, but s/he worked in the Preschool B classroom and moved the children from the Preschool B into the Preschool A classroom because they were going to the playground as a large group. SP1 was “lining” up children from the Preschool A classroom and SP2 was not in the room at the time. · SP1 stated that on an unknown date s/he was in the Preschool A classroom with SP2. At approximately 9:20 a.m., s/he lined up children on the rope by the classroom door. SP1 told SP2 that s/he had “five” children on the first rope as SP2 grabbed the clipboard with the name to face sheet. SP2 did not reply so SP1 looked at SP2. SP2 said, “Let’s go,” and the groups walked out the door. SP1 stated that it “slipped” his/her “mind” to do name to face and SP2 had the clipboard and the iPad. SP1 stated that “whoever” was at the end of the line should “do rounds” in the classroom and bathroom to ensure there were no children left in the classroom. · P3 stated that SP1 counted his/her children as they stood in line and held the rope. P3 only heard SP1 count one time during the transition to the playground. P3 did not “recall hearing” SP2 count his/her children or “seeing” SP2 walk around the room to look for any children before s/he walked out of the room. · SP2 stated that s/he and SP1 “counted” in their “heads” the number of children on each rope but did not share their numbers with each other because they were “all over the place in that moment.” Then they walked out the classroom door, through the lobby, and to the playground. SP2 said that as the group walked to the playground at each exit, s/he did not count the number of children on his/her rope. · SP1 stated that a name to face count should have been completed using the iPad and the name to face sheet in the classroom before exiting the classroom, at the facility lobby door, at the double doors to the courtyard, and before entering the playground. No name to face counts were completed that day because SP1 an SP2 “were not on the same page.” · P3 stated that once the Preschool A and Preschool B groups where inside the playground area, s/he applied bug spray to the Preschool B children and SP1 and SP2 walked around the playground. When s/he was finished, s/he applied bug spray to the Preschool A children. P3 took out the AV’s spray, looked for him/her and called his/her name a “couple of times,” but could not find him/her. P3 then told SP1 and SP2 that s/he could not find the AV. SP1 and SP2 walked the playground area a “couple of times” looking for the AV and when they did not find him/her, SP2 left the playground and went into the facility. · P2 stated that at approximately 9:50 a.m., s/he was in the kitchen when the CP came to the kitchen door and told him/her that the AV was in the bathroom “yelling or crying.” P2 then went “straight” to the bathroom to check on who it was and if there was a staff person with him/her. When P2 got to the bathroom, s/he saw the AV “sitting on” the toilet. The AV seemed “upset,” had his/her arms “crossed,” and told P2 that s/he wanted someone to wipe him/her. After a “minute or two,” SP2 came “running” into the bathroom. SP2 “consoled” the AV and helped clean him/her. Then SP2 and the AV went to the playground. · SP2 stated that when s/he went inside, s/he walked to the Preschool A classroom with P2. The AV was in the bathroom and was “kind of shook up” and cried. The AV was “frustrated” that no one was there to assist him/her with cleaning. SP2 helped the AV, then hugged him/her, and the AV washed his/her hands. Then SP2 and the AV walked to the playground and talked about what happened. SP2 told the AV that s/he was now “safe.” · P3, SP1, and SP2 each stated that the AV was happy when s/he arrived on the playground. The AV played with friends and ran around the playground. · SP1 and SP2 each estimated the AV was unsupervised between five and ten minutes based on the amount of time the group was on the playground before SP2 left to find the AV. · SP1 stated that the AV did not ask a staff person to use the bathroom so when they left the classroom, SP1 “thought” the light was off in the bathroom and did not know the AV was in the bathroom. SP1 stated that a staff person should stand at the bathroom door as children used the bathroom. Children should not use the bathroom without staff persons’ supervision. · SP1 stated that s/he understood the process and the importance of the name to face count sheet and using the iPad for counts and that s/he was not told to use the name to face sheet “every day.” SP1 stated that s/he failed to supervise the AV on the day of the incident. · SP2 stated that prior to going outside, s/he “knew” that the children had a bathroom break. When they left the classroom, SP2 did not know the AV was in the bathroom. SP2 stated that children using the bathroom should be checked on every two minutes. · SP2 stated that s/he was trained that to get children from one place to another in the safest way, “counting was the biggest factor.” Staff persons knew how many children were in their room by using the iPad and the name to face sheet. SP2 stated that the iPad had a name to face option in the APP but his/her “first choice” was the clipboard with the name to face sheet because it was “quicker.” The iPad was in the backpack that was taken outside and not used for name to face attendance on the day of the incident. SP2 stated that s/he did not “think” there was a name to face sheet for the classroom and one was not used on the day of the incident. · SP2 stated that s/he failed to supervise the AV and the AV was unsupervised because of his/her and SP1’s · P3 stated that s/he had been trained to “always count” the children, have the children hold the rope when walking to the playground, and “repeatedly check” to make sure you have all the children. · P1 stated that Preschool A and Preschool B each had their own name to face sheets and their own ropes to use when they walked to and from the playground. The facility provided four video segments of the incident. The videos were time stamped and did not have audio. The videos provided the following information: o At 9:26 a.m., seven children, including the AV, SP1, and SP2 were visible in the Preschool A classroom. The half door to the bathroom was open approximately six inches. o At 9:26:17 a.m., the AV walked into the bathroom and shut the door behind him/her and then the light to the bathroom came on and shone into the classroom. o At 9:28:09 a.m., SP2 opened the classroom door and walked through it out of camera view. o At 9:32:01 a.m., SP1 took two ropes out of a storage bin and threw them on the floor. Approximately 40 seconds later, s/he picked up the ropes and children began to grab sections of the ropes. o At 9:33:43 a.m., SP2 walked back into the classroom into camera view. o At 9:36:18 a.m., P3 walked into Preschool A from Preschool B, followed by a group of children that held onto a rope. P3 and his/her group stopped near the carpet area and the other children on the ropes. SP2 stood and a child that s/he was with ran and grabbed a rope while SP1 worked on and iPad. o At 9:37:21 a.m., SP1 grabbed a backpack, placed a cell phone inside of it, and handed it to SP2. SP2 put it over his/her shoulder. Then SP1 grabbed the iPad and walked past the children holding the rope and out the door. The children holding the first rope followed SP1. o At 9:38:26 a.m., SP2 held onto a child’s hand and his/her group of eight children stood near P3 and his/her group of children. P3 walked out of the door followed by his/her group of children that held onto the rope. o At 9:38:29 a.m., SP1 walked into the lobby of the facility, opened the lobby door, walked out, and held the door open for his/her group of five children. SP2 then walked out of the Preschool A classroom followed by his/her group of children that held onto the second Preschool A rope. o At 9:38:39 a.m., P3 walked into the lobby and passed through the door being held open by SP1. P3 was followed by five children hanging onto a rope. SP2 then entered the lobby still holding onto the hand of one child. Eight children held onto a rope followed SP2 out the lobby door. Then SP1 walked through the double set of doors to the courtyard. P3, his/her group of children, SP2’s group of children and SP2 followed. All of them walked out of camera view into the courtyard. o At 9:45:18 a.m., the CP walked into the Preschool A classroom carrying one child and another child walked in behind him/her. The CP looked around the room and then walked near the bathroom and looked inside. The CP smiled and then walked toward the Preschool B classroom and out of camera view. o At 9:46:56 a.m., the CP walked back into camera view in Preschool A from Preschool B and then walked out of the Preschool A classroom. o At 9:47:38 a.m., P2 walked into the Preschool A classroom and walked to the bathroom door and approximately ten seconds later, SP2 walked into the Preschool A classroom and to the bathroom, opened the bathroom door, and entered the bathroom. o At 9:48:14 a.m., P2 walked out of the Preschool A classroom. o At 9:49:35 a.m., the AV walked out of the bathroom followed by SP2. The AV washed his/her hands at the sink outside the bathroom and then SP2 and the AV walked out of the Preschool A classroom and the video ended. The facility’s Safety and Supervision Policies showed 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 should line up on “the rope.” Then a staff person should count the number of children lined up and then use the Name to Face Tracker to complete a name to face count. Staff persons should mark their name on the face tracker with the time, location, and number of children leaving. Staff persons should then do a sweep of the classroom before leaving. When the group arrived at their destination, the staff person should 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 documents showed that P1, P2, P3, SP1, and SP2 each received training on the Maltreatment of Minors Act and the facility’s Safety and Supervision Policies and 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 11, 2024, the AV was left in the classroom bathroom for approximately nine minutes without the knowledge or supervision of SP1 and SP2, 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 found alone in the bathroom by the CP who then alerted P2. At approximately the same time, P3 discovered that the AV was not on the playground and told SP1 and SP2. SP2 then entered the facility. P2 found the AV in the bathroom and then SP2 entered the classroom and tended to the AV. Although the AV was in a bathroom within a preschool classroom designed for children who were the AV’s age, the AV was in the bathroom without staff knowledge unsupervised for approximately nine minutes prior to being found by the CP. 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 bathroom 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 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. SP1 and SP2 were trained on the Maltreatment of Minors Act and the facility’s Safety and Supervision Policies and Transition Policy. At the time of the incident, SP1 and SP2 were working in the Preschool A classroom and were each responsible for the care and supervision of the children, including the AV, and responsible for ensuring all the children were present after the transition from the classroom to the playground. SP1 and SP2 were each 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 because it was a single incident and 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 and followed. The facility retrained all staff persons on their supervision and transitions 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 September 20, 2024, the facility was issued a Correction Order for the violation outlined in this report and for hazardous items being accessible to children. 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.
|
