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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: 801568-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 in the preschool classroom without a staff persons’ (SP1 – SP3) knowledge or supervision for approximately 12-13 minutes. Date of Incident(s): April 19, 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 6, 2024; from documentation at the facility; and through six interviews conducted with a supervisory staff person (SP2), four staff persons (P1, P2, SP1, and SP3), and the AV’s family member (FM). The AV was four years old and enrolled in the Children’s House Two classroom at the time of the incident. The AV was not interviewed per the request of the FM. The facility was located in a lower level of a church and had their own primary entrance. There was a main hallway and on one side of the hallway were two classrooms for preschool through school aged children (Children’s House One (CH1) and Children’s House Two (CH2) along with cubbies. The CH1 classroom had tables near the classroom door and to the left of the tables was a play area with shelves. In the middle of the CH1 classroom was a large pillar. Past the pillar to the right was a group area and to the left of the group area was a loft. The loft had stairs that led to a reading area and below the reading area was a quiet cave. The quiet cave was an area that children used headphones to listen to stories or music. Across the hallway from CH1 were the children’s bathrooms, benches, and across the hallway from CH2 was an office used for the facility. At the end of the hallway was a set of stairs and to the right of the stairs was a hallway that led to the gym. Information was consistent that the pillar in the CH1 classroom prevented staff persons who were standing in the classroom doorway from seeing the loft and quiet cave. In addition, a staff person would not be able to see into the quiet cave if they were reading stories next to the loft stairs. The facility’s incident report stated that on April 19, 2024, the children enrolled in after school care from the CH2 class combined with the CH1 class for snack and story time before they went to the gym. After story time at approximately 3:17 p.m., the children lined up in the classroom to transition to the gym. The staff person (later identified as SP1) did not realize that the AV was still in the quiet cave listening to music when they began the transition to the gym. A little while later, the AV opened the classroom door and met SP2 in the hallway. The AV told SP2 that “[s/he was listening to music, and they left [him/her] there.” The AV told SP2 that s/he was “a little bit scared.” The AV helped SP2 clean up snack and at approximately 3:30 p.m. SP2 brought the AV to the gym, and the AV rejoined the group. SP1, SP2, and SP3 worked in the CH1 Classroom and P3 worked in the CH2 classroom during the afternoon of the incident. Information was unclear as to the total number of children combined but consistent information was that the CH1 classroom had eight children and the total number once combined was under 20 children. P1, SP1, SP2, and SP3 provided consistent information that combining the CH1 and CH2 classrooms for snack was not a “normal” practice. On the day if the incident an afternoon staff person was out due to illness and the classes combined for staffing purposes. The FM said that s/he had no concerns about the facility and that the AV was “doing great.” P1, P2, SP1, SP2, and SP3 provided consistent information that SP1 or SP2 provided each classroom with a Daily Attendance sheet. The attendance sheet had the names of the children attending for the day, what time the children were scheduled to leave, the time children would transition to another class, and a schedule for staff with their duties for the day. SP1 provided the following information: · On April 19, 2024, at approximately 3 p.m., SP1 entered the CH1 classroom with snack and stayed in the classroom while SP3 left the classroom and went on a 15-minute break. There were eight children in the CH1 classroom. After SP3 left the classroom, children from the CH2 class, including the AV, and a staff person (P3) entered the CH1 classroom to join the class for snack. SP1 was not able to recall the how many children from CH2 came into the classroom but said that the total number of children was less than 20. SP2 then entered the classroom and P3 left. · As the children finished snack, SP1 directed them to the group area for stories while SP2 stayed with the children at the snack tables. At that time, the AV went into the quiet cave and started listening to a story using headphones. Another child was “bothering” the AV so SP1 redirected the child to the group rug while the AV remained in the quiet cave. SP1 began to read to the children and when s/he noticed that there were no more children at the snack tables, s/he excused the children from the group area and directed them to line up at the door because they would be going to the gym and some children would be going home. Between 3:15 and 3:20 p.m., the children lined up at the classroom door with SP2 while SP1 called out the names of the children who were scheduled to go home at 3:30 p.m. and reminded them to get their things from the hallway and then reminded the other children to use the bathroom while they were in the hallway. SP2 then led the children into the hallway with SP1 at the end of the line. SP1 said that s/he did not complete a count of the children before they left the classroom and s/he did not know if SP2 counted the children. · Once in the hallway, SP1 went and stood by the gym hallway with the children who did not need to use the bathroom. P2, who was already in the hallway when the children exited the classroom, and SP2 supervised the children in the bathroom and the children who were scheduled to go home. SP1 told SP2 that s/he had “ten children” in line and then s/he took the children to the gym, leaving the other children under SP2’s and P2’s supervision. SP1 said s/he saw SP3 in the hallway by SP2 but did not speak with SP3. SP1 was “unsure” if SP3 was in the CH1 classroom prior to leaving the classroom. · At approximately 3:20 p.m. SP3 entered the gym. SP1 told SP3 that there were 10 children in the gym. SP1 then walked to the main hallway to get his/her coat. At 3:25 p.m., SP1 took the children scheduled to leave from SP2 and they headed to the facilities entrance. SP1 waited at the entrance until the children were picked up by their families and then SP1’s shift was over and s/he went home. · At approximately 4:30 p.m., SP2 called SP1 and asked if s/he knew that the AV was left in the classroom. SP1 said that as soon as SP2 asked, SP1 realized they left the AV in the classroom and apologized to SP2. · SP1 said that s/he did not count the children before s/he and SP2 left the classroom, and that s/he did not do a check of the classroom to make sure it was empty. SP1 said that since the group area was empty of children s/he “assumed” all the children were in line. SP1 also said that s/he did not check the daily attendance sheet on the door to verify if s/he had all the children. SP2 provided the following information: · At approximately 3 p.m., SP2 went into the CH1 classroom where the CH2 classroom has also combined for snack. SP1 and SP3 were in the classroom working and when SP2 entered the classroom, SP3 left the classroom for a break. SP2 watched the children who were at the snack table while SP1 gathered the other children to the group area for story time. At this time, SP2 saw the AV in the quiet cave with headphones on listening to music. Another child went to the quiet cave and began to “argue” with the AV and then s/he began to swing on the loft. SP2 walked over to the child and redirected him/her to the group area with SP1. SP2 then walked back to the tables where some children were still eating. · At approximately 3:10 p.m., SP3 returned to the CH1 classroom and SP2 said to SP3, “You are back early.” SP3 said, “I was not hungry,” and began to “tidy up” the shelves. SP2 then left the classroom and went into the hallway for a moment. As SP2 was about to re-enter CH1 the children began to line up at the door. SP2 remained in the hallway by the classroom door. SP2 said that s/he did not hear SP1 count the children or see SP1 use the daily attendance sheet to verify if all the children were in line but “assumed” SP1 had done so. SP2 said that SP1 was at the end of the line and SP3 was still at the toy shelves tidying up. · The children entered the hallway followed by SP1 and SP3. SP1 then stood by the gym hallway and waited for the children to line up after they used the bathroom. SP2 and P2, who was already in the hallway and by the bathrooms, supervised the children in the bathroom and SP3 stayed by the benches and supervised three children who were scheduled to leave at 3:30 p.m. · SP2 said that once most of the children used the bathroom, they lined up by SP1. There were 11 children in line ready to go to the gym. SP2 kept one child with him/her while they waited for the other children to finish up in the bathroom, while SP1 left to the gym with the ten children and after a few minutes P2 came out of the bathroom with the last child. P2 then took the two children and joined SP1 in the gym. · SP2 then sent SP3 to the gym so that SP1 could take the three children who were leaving to meet their families and then SP1 would go home. SP2 then went to the facility office where P1, was. At approximately 3:28 p.m., SP2 was leaving the office when s/he saw the AV walking towards the office. The AV told SP2 that s/he was listening to music when “they left [him/her] there.” The AV told SP2 that s/he was “a little bit scared” was not crying. SP2 reassured the AV that s/he was “safe.” SP2 took the AV back into CH1 and the AV helped SP2 return the left-over snack to the office before returning to his/her class in the gym. When SP2 and the AV arrived in the gym, SP2 told SP3 and P2 that the AV was left in the quiet cave and then left gym to call SP1. SP3 and P2 had not realized that the AV was missing. · SP2 then left the gym and called SP1 and told him/her what happened. SP1 said, “I am sorry. That’s on me.” · Later in the afternoon, SP2 talked to SP3 and SP3 told SP2 that s/he was still on break when s/he returned to the classroom which SP2 had not realized prior to leaving the classroom. SP3 provided the following information: · At approximately 3 p.m., SP3 was in the CH1 classroom with eight children when SP1 entered the classroom to replace SP3 for his/her 15-minute break. At this time, the CH2 classroom had not yet come into the CH1 classroom. At 3:10 p.m., SP3 returned to the classroom where SP1 was at the group area reading stories and SP2 was by the tables. SP3 said s/he looked at SP1 and “mouthed” that s/he was “still on break” but was going to tidy the toy shelves. In response, SP1 gave SP3 a “thumbs up” and continued reading to the children. At this time, SP3 did not speak with SP2 or tell SP2 that s/he was back from break. SP3 was “not aware” that SP2 had stepped out of the classroom but there may have been “a miscommunication” that SP2 “assumed” that SP3’s break was over and left the room. SP3 did not know how many children were in the room and s/he was not aware that the AV was in the quiet cave. · At 3:15 p.m., SP3 heard SP1 tell the children to line up and that they would be going to the gym. SP3 continued to tidy up the toy shelves had last seen SP2 standing by the classroom door. SP1 then took the children into the hallway. SP3 did not know if SP1 counted the children prior to leaving the classroom. At 3:17 p.m., at the end of his/her break, SP3 entered the hallway, SP2 was in the hallway -reminding the children to use the bathroom and SP1 was standing by the gym hallway with a line of children. SP2 asked SP3 to stay in the hallway with two children who were scheduled to go home at 3:30 p.m. SP3 heard SP1 say, “I have 10,” and SP1 then took those children to the gym. SP3 did not know if the AV was one of the children. P2 then came out of the bathroom with one child, and P2 and the child walked to the gym. · At some point, SP2 took the two children from SP3 and SP3 went to the gym so SP1 could leave. SP3 said that s/he did know how many children were in the gym but there were over ten children with SP1 and P2. SP1 and SP3 did not communicate the number of children when SP1 left the gym. SP3 was playing with the children and said that s/he was not aware that the AV should had been with the class as because s/he does not normally work with the CH2 classroom. SP3 did not recall the time but said that SP2 walked into the gym with the AV and said that the AV was left in the classroom. SP3 said that the AV did not seem “distressed” and immediately joined in his/her friends to play. Video footage provided was not a full video of the hallway due to technical difficulties. The video showed a view of the hallway from the office to the steps next to the hallway that led to the gym and provided the following information: · The video began at 3:17:20 p.m. after SP1, SP2, SP3, and the children were already in the hallway. At 3:28 p.m., CH1’s classroom door opened, and the AV entered the hallway. The AV walked toward the facility office and stopped before the doorway. · At 3:28:19 p.m., SP2 backed out of the office and into view of the camera and stood by the office door. The AV continued to stand in the hallway. · At 3:29 p.m., SP2 turned to his/her right and saw the AV. (The AV was unsupervised for at least 12 minutes.) P1 stated that on the day of the incident s/he worked with SP3 in CH1. P1 left the classroom at approximately 3 p.m. when there were “less than ten children.” At that time the children from CH2 had not come into the classroom. At approximately 3:25 p.m., P1 was talking to SP2, who was standing by the office doorway, when s/he heard the AV ask, “Where is everybody?” SP2 turned and went to the AV. P1 heard SP1 say, “Everyone is in the gym. Let’s head down to the gym.” P1 remained in the office. P2 said that on the day of the incident at approximately 3:05 p.m., s/he was in the hallway with SP2 when SP1 and the CH1 classroom entered the hallway SP2 asked P2 to take one child to the restroom. While doing this, P2 heard SP1 ask, “Do we have all the kids?” and SP2 said, “Yes.” When P2 came out of the bathroom with the child, the hallway was empty except for SP2. P2 and the child then went to the gym where SP1 and SP3 were with the other children. SP1 then left the gym and P2 stayed. At this time, there were 14 children in the gym. After SP1 left, P2 said to SP3, “I wonder where [the AV] is?” and SP3 replied back, “Yeah,” and P2 then said “[s/he] probably went home.” At approximately 3:30 p.m., SP2 walked onto the gym with the AV and the AV told P2 that s/he was left in the classroom. P2 said that the AV was “happy” and was not crying when s/he came into the gym. The facility’s Staff Handbook stated that, “Children are not left unattended at any times. Staff [persons] will maintain attendance and count the children frequently. After transitions, staff [persons] will take attendance and ensure all children are accounted for.” The facility’s Risk Reduction Plan stated that, “Children are always within sight and hearing of a staff [person], due to the fact that we are located in a public space.” Facility documentation showed that the SP1-SP3, P1, and P2 were each trained on the facility’s Risk Reduction Plan, Staff Handbook, and the Reporting of Maltreatment of Minors Act. 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 Although SP1, SP2, and SP3 provided different information regarding the number of children and when SP3 returned from break, consistent information was provided that on April 19, 2024, the AV was left alone in the CH1 classroom unsupervised without staff persons knowledge or supervision for at least 12 minutes, which was a violation of the facility’s policies and procedures, and a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was four years old and, in a classroom designed for children, no staff person was aware the AV was in the room, so no staff persons were available to intervene if the AV if necessary or in the event of an emergency. Therefore, 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 were each trained on the facility’s policies including the Risk Reduction Plan and the Reporting of Maltreatment of Minors Act prior to the incident. At the beginning of the incident, SP3 was out of the classroom on break, SP1 was reading stories at the group area, and SP2, who was in the classroom to relieve SP3, supervised children at the snack tables. Both SP1 and SP2 saw the AV in the quiet cave. When SP1 saw that the snack tables were empty s/he had the class line up with SP2 by the door. Information from SP2 and SP3 was consistent that at this point, SP3 returned to the classroom. SP3 stated that s/he “mouthed” to SP1 that s/he was still on break but would be tidying up the room and that SP1 responded with a “thumbs up” sign and that s/he did not talk to SP2. However, SP1 said s/he saw SP3 in the hallway by SP2 but did not speak with SP3 and that s/he was “unsure” if SP3 was in the CH1 classroom prior to leaving the classroom. SP2 stated that when SP3 returned to the classroom, SP2 left the classroom because s/he thought SP3 came back to break early because SP3 told him/her that s/he was not hungry and began to tidy the shelves. However, SP2 failed to tell SP1 or SP3 that s/he was leaving the classroom. In addition, after the incident SP3 told SP2 that his/her break was not yet done when s/he returned to the classroom. Given the aforementioned, it was more likely that SP3 was still on break but in the classroom, when the children left the classroom. Therefore, SP3’s responsibility for maltreatment was mitigated. SP1 and SP2 were responsible for the care and supervision of the children when they transitioned from the classroom, into the hallway, and subsequently into the gym. SP1 said that s/he did not complete a head count and SP2 “assumed” that SP1 completed a head count because s/he saw the children already in line. Therefore, SP1 and SP2 were responsible for the maltreatment of the AV. In addition, given that SP2 had significant administrative and supervisory authority over the operation of the facility and for ensuring and maintaining compliance with Minnesota Rules and/or Statutes, the facility is also 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. The Office of Inspector General is also required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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, SP2, and the facility 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 require 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 found their policies and procedures adequate, but not followed by SP1 – SP3. All staff persons were retrained on supervision of children including during transition times. The facility added a section to the Risk Reduction Policy that included that the quiet space/quiet cave was area difficult to supervise and that the last staff person in the classroom would conduct a sweep of the classroom to ensure that all children were accounted for. 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 27, 2024, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. 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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