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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: 1051952-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was inside a classroom without staff person knowledge or supervision for approximately 13 minutes. Date of Incident(s): June 4, 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 June 13, 2024; from documentation at the facility; and through five interviews conducted with two supervisory staff persons (P1 and P2), two facility staff persons (the SP and P3), and the AV’s family member (FM). The AV was four years old and enrolled in a preschool classroom at the time of the incident. The AV was not at the facility on the day this investigator visited. The facility was a stand-alone building that had six classrooms. The Preschool Three classroom had tables, toy shelves, learning centers, carpeted areas, and had two bathrooms in it for children to use. The bathrooms had half doors. There was an exterior door inside the Preschool Three classroom with a glass middle to see through that led directly to the preschool playground. There was also a large floor to ceiling window next to the door. The FM was aware of the incident and the AV told the FM s/he was using the bathroom when the incident occurred. The FM had no prior concerns. P1 provided the following information: · On June 4, 2024, around noon, P1 was in the kitchen getting lunch ready. The SP told P1 that s/he accidentally left the AV in the classroom when the class went outside. · P1 went to the office and reviewed video footage which showed the SP lined up the children on a rope (used to help transition children), performed a name to face, and counted the children. However, another class was outside, so the SP had the children walk away from the rope and play inside for five more minutes, then had the children line up again, performed a name to face again, and counted the children again. The AV “snuck” into the bathroom during the SP’s second name to face count. · Once the SP and the children got outside, the SP counted the children. The SP told P1 that s/he second guessed how many children s/he was supposed to have, because the facility had moved children around between classrooms that day to stay in ratio. P1 saw on the video footage that the exterior door was opened shortly after the classroom went outside. · The SP told P1 the AV exited the bathroom and pushed on the exterior door and the alarm went off, so the SP (who was on the playground) realized the AV was still inside. However, on the video P1 saw the AV leave the bathroom and stand by the exterior door. P1 stated the children were told only adults push on the doors and the AV seemed unsure of what to do when s/he came out of the bathroom. P1 stated the video showed the AV was in the classroom without supervision for 13 minutes. · P1 stated staff persons were trained to line children up on the rope, do a name to face using a Name to Face Attendance Form and count the children prior to a transition. Staff persons said the children’s names as the children went outside, and once outside staff persons were to count the children with them again. · P1 stated the SP was “upset” that the incident happened, the SP “owned up to it,” and s/he made a “mistake.” P2 provided the following information: · On an unknown date, P2 was assisting in another classroom, when s/he heard that the SP said his/her attendance number was wrong, and the SP thought a child was “missing” but was not sure which one. · When P2 was able to leave his/her classroom and go out onto the playground, the AV was already out there. The AV seemed “sad” and P2 reminded the AV it was not okay to hide from staff persons. The SP told P2 that s/he lined the children up and performed a name to face before going outside, and counted the children once outside, and that was when s/he noticed a child was “missing.” The SP said s/he opened the door and did not see anyone, and the SP called out, but there was no response. The SP then notified P3. · P2 said there was another child who was having a hard time near the time of the incident, and that child “may have been a distraction” for the SP. P2 said the SP was very concerned, and s/he wanted to make sure s/he had all of his/her children. P2 stated that the AV was not at the facility every day. · P2 said staff persons were trained to line children up on the rope, count them, and read names off a list on the Name to Face Attendance Form, ensuring each child on the list was present. P2 said the SP knew to count the children but P2 was not sure if the SP knew to “go down the list” of names. P2 had no prior concerns with the SP and stated the SP genuinely cared for the children and his/her job. The SP provided the following information to this DHS investigator and during the facility’s internal review: · The SP did not remember the date of the incident but stated the other staff person s/he usually worked with was not at the facility that day. P2 moved some children from the SP’s classroom into other classrooms to maintain a ratio of one staff person to ten children. · When it was time to go outside, the SP lined the children up on the rope, and s/he had the Name to Face Attendance Form to bring the children outside. When s/he opened the exterior door, s/he saw that the class from the next room was outside, so the SP had his/her children sit back down inside. · When the other class went inside, the SP lined the children up again and counted but the SP was unaware the AV had gone into the bathroom. The SP said the AV must have gone to the bathroom when the SP’s back was turned. There was another child who was running around the room and hitting the other children at this time. The SP counted the children when they got outside and only counted nine children when s/he thought s/he should have ten. The SP opened the exterior door to look inside the classroom and did not see anyone. The SP listened and did not hear anything. The SP went back outside, counted again, and thought maybe s/he was wrong in his/her count because they had been moving children all morning. The SP stated that the AV was not listed on the Name to Face Attendance Form at that time. (Note: the facility did not keep the Name to Face Attendance Form from that day, so it was not available for the DHS investigator to review). · After about 15 minutes, the SP saw the AV in the classroom and opened the exterior door for the AV to come outside. The AV started crying when the SP saw him/her. The SP then went to the exterior door of the next classroom, opened it and told P3 that the AV had been left inside and to notify P2. · The AV was not at the facility every day, but the SP said that was not an excuse, and the AV should not have been left behind. The SP believed P2 was in the classroom before the SP arrived for his/her shift. P2 told the SP that there were ten children, but after that children continued to arrive at the facility, and P2 took some children into other classrooms, but the SP did not know how many. · The SP stated that s/he was trained to line up the children, have the Name to Face Attendance Form, walk around the classroom and make sure no children were left behind, and then go outside. Once outside, s/he was trained to perform a headcount and make sure all of the children were there. P3 did not remember the date but stated that the SP told P3 that a child (P3 did not remember who) was not in the SP’s care for an unspecified period of time. P3 stated that staff persons were to line children up, use a rope, and perform a name to face count when going outside and then check to make sure the children were all outside. P3 provided no further information. The facility’s Risk Reduction Plan stated, “When transitioning from one area to another, children will form a line using a walking rope. Staff [persons] will call the children by name to hold on to the walking rope. Staff [persons] will use face to name every time the rope is used. If only one staff [person] is present, they will be at the front of the line facing the children. Staff [persons] will count the number of children transitioning to ensure all children are present.” The facility’s Safety and Supervision Policies stated, “All children must be within sight and sound 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 to 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. This investigator reviewed video footage from the incident and noted the following: · On June 4, 2024, at 10:59:47 a.m., the AV entered the bathroom in the classroom. The SP was sitting at a table with another child with his/her back toward the bathroom. · At 11:01:52 a.m., the SP stood up from the table s/he was at and went to the exterior door. The other children in the classroom came to the exterior door and lined up using the rope. The SP walked out of view of the video footage and when s/he came back into view, the SP had the Name to Face Attendance Form in his/her hand and s/he went and stood at the front of the line by the exterior door. Based on the angle of the video footage, only the SP’s legs were visible. There was also no sound, so this investigator was not able to determine if the SP counted the children or performed a name to face count. · At 11:03:12 a.m., the SP opened the exterior door, light shone inside, and the children exited the classroom. (Note: there were only nine children lined up on the rope at that time). Although the door was not visible in the video footage, at 11:03:26 a.m., it was evident the exterior door closed based on how the lighting changed inside the classroom near the exterior door. · At 11:04:41 a.m., the light changed again in the classroom and the SP’s leg stepped over the threshold in the classroom. At 11:04:49 a.m., the exterior door shut again based on the light. · At 11:10:45 a.m., the AV exited the bathroom, looked around the classroom, and slowly walked to the exterior door. The AV walked away from the exterior door and stood leaning against a table in the classroom for over five minutes. At 11:16:07 a.m., the AV went over to the exterior door and looked outside and then backed away to where s/he was previously standing. At 11:16:19 a.m., the exterior door opened, and the AV put his/her head down and walked out the exterior door. · Exterior video footage only showed from when the SP and the other children were already outside. The SP was sitting down on a block facing a climbing structure (away from the exterior door). A child came off of the stairs and went to the exterior door. The SP stood up and opened the door at 11:16:19 a.m. for the AV to come outside. The AV went to stand by the climbing structure and the SP went to the exterior door of the next classroom and knocked on the door. That door was opened by an unknown staff person (based on information provided by the SP this staff person was P3), and P3 and the SP had a conversation. The video footage ended there. Facility records showed the SP, P1, P2, and P3 were each trained on the facility’s Risk Reduction Plan, the facility’s Safety and Supervision Policies, the facility’s Transition Policy, and the Reporting of Maltreatment of Minors Act. Relevant Rules and/or 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: On June 4, 2024, the SP lined up the children in his/her classroom to go outside using the walking rope but when the SP opened the exterior door to go outside there was another classroom still outside. The SP had his/her group of children let go of the rope and go back to play in the classroom for another few minutes. It was during that time that the AV went into the bathroom while the SP was interacting with another child in the classroom. The SP then lined the children back up using the walking rope, grabbed the Name to Face Attendance Form, and counted the children. Once outside the SP counted again and only had nine children but thought s/he should have had ten. The SP opened the classroom door, looked around and listened to see if s/he heard anything. The SP did not see or hear anything so s/he shut the door. The SP thought maybe s/he was off on how many children s/he had in his/her care because the facility was short staffed that day, children were moved to other classrooms to maintain staffing ratios, and the SP thought a child might have been removed from his/her classroom without his/her knowledge. When the SP saw the AV in the classroom, the SP let the AV out onto the playground and the AV began to cry. The SP then alerted P3, so that P3 could alert P2. P2 came out to talk to the SP and the AV. P1 stated that the AV “snuck” away after being lined up on the rope the second time while the SP was completing the second name to face; however, video footage showed the AV entered the bathroom before the SP had the children line up on the rope the second time, so there were only nine children lined up on the rope when the SP took the group outside. The SP said s/he counted nine children once outside, thought maybe a child was still inside, opened the door, looked around and called out with no answer. Video footage showed that after the door shut, the AV came out of the bathroom and remained in the classroom without the knowledge or supervision of a staff person for approximately 13 minutes, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and also a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. P2 stated that the SP knew s/he was “missing” a child and alerted another staff right away. However, the SP stated s/he did not tell P3 s/he was “missing” a child until after the AV was found, which was consistent with the video footage. While the AV was unsupervised, the AV was in the bathroom by him/herself for part of the time, and for the entire time, staff persons were not with the AV to intervene in the event of an injury or 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 his/her 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. The SP stated the AV was not listed on the Name to Face Attendance Form, and that s/he was confused about the number of children s/he was supposed to have with him/her when the incident occurred. However, the SP’s responsibility was not mitigated because the SP was responsible for knowing which children were in his/her care and was also responsible for the supervision of the AV at the time of the incident. In addition, the SP was trained on the facility’s Safety and Supervision Policies, Transition policy, Risk Reduction Plan, and the reporting of Maltreatment of Minors Act. 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 as it was a single incident, and the AV sustained no injuries. 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 were adequate, and were followed by the SP, but the SP miscounted the children. The SP was retrained on the facility’s Supervision and Safety and Transition Policies. 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 October 16, 2024, the facility was issued a Correction Order for the violations outlined in this report along with additional violations for rough handling and separation of a child. 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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