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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: 1114837-CCC (Child Care Center) Investigator(s): Tessa Ripka 651-431-6612 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left behind when a group of children and staff persons crossed the road. The AV started walking toward the group while there was moving traffic. Date of Incident(s): August 7, 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 August 26, 2024; from documentation at the facility; and through four interviews conducted with two facility staff persons (SP1, P) and two community persons (CP1, CP2). This investigator made attempts through phone and mail to reach another staff person (SP2) and the AV’s family member (FM), but attempts were unsuccessful. The AV was five years old at the time of the incident and enrolled in the school age classroom. The facility was a building with two classrooms. Through the entrance was a lobby area which had a door with a window that looked into the school age classroom. Through the lobby was the school age classroom which contained two bathrooms toward the side of the classroom. There was an additional classroom to the right that was not used at that time. At the back of the school age classroom was a door that exited outside. The facility was located along a busy highway. There was a sidewalk that ran along the front of the building. Past the facility was a restaurant on an intersection which bordered two highways. The intersection had a stop light. The Accident/Incident Report stated that on August 17, 2024, at 11:50 a.m., the AV was using the restroom while the rest of the class lined up to go for a walk. The class left the facility and crossed the road. The AV tried to catch up with the class. A community person waited with the AV until the class walked back to the sidewalk to the AV. CP1 said that on August 7, 2024, at approximately 11:40 a.m., s/he saw the AV running toward the highway, then heard a staff person yelling for the AV to stay there. CP1 saw two teachers and a group of children on the other side of the highway. The AV ran up to the curb and there were cars driving fast by him/her. The group waited for the cars to stop then crossed the highway to go toward the AV. When the group got across, one teacher picked the AV up and carried him/her back to the facility. CP2 said that on August 7, 2024, at approximately 11:40 a.m., s/he was stopped at the stoplight and saw two staff persons and some children cross the street in the crosswalk. Then CP2 noticed the AV alone on the other side of the street. The AV started to cross the street and there were cars coming. Bystanders and staff persons yelled for the AV to stop, and an oncoming vehicle slammed on his/her brakes. A staff person ran out into the crosswalk and met the AV in the crosswalk. The staff person picked up the AV and joined the rest of the group. SP1 provided the following information: · On the date of the incident at approximately 11:45-12 p.m., SP1 and SP2 worked in the School Age classroom with eight children. The class was going to another facility to play on a bounce house. SP1 and SP2 lined the children up in the classroom and left the building. SP1 did not check the bathrooms before they left. · SP1 and SP2 took the children out the front door of the facility and along the sidewalk past a restaurant to the stop light. They crossed the street and then crossed the perpendicular street when SP1 heard the AV. SP1 looked back and saw the AV near the intersection running toward them. · There was a community person that walked up and stood with the AV until the class came back across both streets. The AV said s/he was in the bathroom and saw the class walk out the front door. SP1 picked up the AV who was crying and the class then returned to the facility. · After the incident, the AV told SP1 that the AV ran out the back door of the facility. SP1 said that they did not count the children before they left the facility as they typically did. SP1 said it “slipped my mind.” The P said that s/he was informed of the incident and reviewed camera footage. It appeared that SP1 and SP2 did not do a count of the children. The AV was in bathroom and came out after they left the facility. The AV went toward the front door and then toward the back door and out of the facility. The entire incident occurred in three to four minutes. Staff persons were to count at every transition. The P did not have any previous concerns with SP1 or SP2. SP2 did not respond to this investigator’s requests for an interview. Video footage showed that on the date of the incident, SP1 and SP2 lined up seven children and walked out the front door at 11:37:32 a.m. At 11:38:39, the AV came out of the bathroom and went to the front door and looked out the window. The AV then ran to the back door, unlocked the door, and exited the facility at 11:38:57. At 11:42:57, the classroom along with the AV entered back into the facility with SP1 and SP2. The Supervision Policy stated that children were always supervised by sight and sound. School-age children were supervised only by sound while they were in the bathroom. Children were “double-checked” when any transition occurred. Regular name to face checks were required to ensure that the correct children were accounted for. The Risk Reduction Plan for Licensed Child Care Centers stated that all children were in sight and hearing distances at all times (exception: school age children went to the bathroom alone and were checked on in five minute intervals). When two staff persons were present, one staff person walked in the front of the line and one staff person walked in the back of the line. Children were counted when leaving as well as arriving to a destination and a name to face check was also completed. During field trips children wore matching neon shirts to be easily spotted. Staff persons completed regular name to face checks. Facility documentation showed that staff persons interviewed were trained on the facilities policies including the Risk Reduction Plan for Licensed Child Care Centers 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: Information was consistent that on August 7, 2024, the AV was left in the facility without the knowledge or supervision of a staff person 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 were each not aware that the AV remained in the facility when they took the other children out of the facility and across two sides of a busy intersection. The AV then attempted to follow them down the sidewalk and across one intersection by him/herself, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Given that SP1 and SP2 did not count the children when leaving the facility so then the AV who was five years old was left in the facility and then walked alone down the sidewalk to a busy intersection which exposed the AV to risk of injury with no staff person available to intervene if the AV attempted to do something dangerous, injured him/herself, or in the event of an emergency, and that the AV attempted to follow the classroom leading the AV to try to cross a busy intersection with oncoming traffic, 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 and SP2 were each trained on the facility’s policies including the Risk Reduction Plan for Licensed Child Care Centers and the Reporting of Maltreatment of Minors Act prior to the incident. Both SP1 and SP2 were working in the classroom at the time of the incident and in charge of the supervision of the classroom and both failed to count the children when they left the facility. SP1 and SP2 were responsible for the maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV was not injured. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by staff persons. Staff persons involved were given corrective action and retrained on the supervision policy. 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 October 11, 2024, the facility was issued a Correction Order for the violation outlined in this report. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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