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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: 1100230-CCC (Child Care Center) Investigator(s): Judith Schwanke 651-431-4033 Suspected Maltreatment Reported: It was reported that two alleged victims (AV1 and AV2) were in a facility classroom without a staff person’s (SP) knowledge or supervision for approximately three minutes. Date of Incident(s): June 5, 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 12, 2024; from documentation at the facility; and through seven interviews conducted with a community person (CP), a facility supervisory staff person (P1), facility staff persons (P2, P3, and the SP), and AV1’s and AV2’s family members (FM1 and FM2 respectively). The facility was located at one end of a strip mall that included two other businesses. The facility had a private entrance; infant, toddler, preschool, and pre-k classrooms; a kitchen; multiple restrooms for children and staff persons; closets; and several hallways with several exit doors that led outside to a fenced area. The toddler classroom was rectangular with several tables, stacks of chairs, toy shelves, and two counter tops. There were three doors in the toddler classroom. One door was a half door that led to the front entrance of the facility, one door led to the back hallway, and one door led outside to the fenced area. Outside the back of the facility was a sidewalk that ran along the side of the strip mall to a playground at one end. The sidewalk and playground were enclosed by a chain link fence. There were video cameras in the classroom, the hallway, and outside along the sidewalk. The facility used a mobile application (APP) platform to communicate with families and streamline administrative functions. Facility documentation showed that at the time of the incident, AV1 was 23 months old and AV2 was 33 months old, and both were enrolled in the toddler classroom. FM1 and FM2 each stated that on June 6, 2024, P1 called and said that the SP brought children inside from the playground including AV1 and AV2, as another group was going out. AV1 and AV2 walked to their classroom and were unsupervised for approximately three and a half minutes. The CP then entered the toddler classroom and found AV1 and AV2 and brought them outside. FM1 stated that on June 5, 2024, when FM1 picked up AV1 from the facility, s/he was “totally fine.” FM2 stated that on June 5, 2024, when FM2 picked up AV2 from the facility s/he was “normal.” Prior to this incident, neither FM1 nor FM2 had any concerns with the facility. The CP stated that on June 5, 2024, between 5 and 5:15 p.m., s/he was in the toddler classroom with his/her child when AV1 and AV2 “wandered in” and began to play with toys. The CP “assumed” a staff person would be coming into the room so s/he “waited a bit” and talked with AV1 and AV2. When no staff person came, the CP took his/her child, AV1, and AV2, out of the classroom, down the hallway, and out the back door of the facility to the playground. There the CP met with the SP. The SP told the CP that s/he “thought” there might be two children inside, but other staff persons would not let him/her go check. The CP saw P2 and P3 on the playground but did not talk with them. The CP estimated that AV1 and AV2 were inside with him/her between five and ten minutes. Two indoor and two outdoor video segments with unintelligible audio were dated and time stamped and provided the following information: o At 5:03:45 p.m., the CP and his/her child were outside and walked down the sidewalk from the playground. The CP opened one of the facility’s back doors and s/he and his/her child entered the facility. P3 stood in the hallway with some preschool children. o At 5:04:34 p.m., the SP, who was outside, walked backward out of the playground and down the sidewalk to the back door followed by AV1, AV2, and two children (C1 and C2). C2’s family member opened the door and C2 entered the facility with his/her family member. The SP then held the door open from the sidewalk and AV2 and C1 entered the facility. As the SP held the door open, AV1 continued to walk toward the SP, while four children from P3’s classroom exited the facility. Before AV1 got to the SP, more children from P3’s classroom exited the facility and ran on the sidewalk toward the playground. At this time, AV2 and C1 also exited the facility and stood on the sidewalk near the SP. AV1 then arrived at the back door of the facility. o At 5:04:04 p.m., the CP and his/her child entered the toddler classroom. o At 5:05:37 p.m., AV1 entered the facility. Another child (C3) walked from the playground down the sidewalk toward the SP, who still held the door open. o At 5:05:54 p.m., AV1 walked past P3 who was still in the hallway and walking towards the door. AV1 walked down the hallway toward the toddler classroom. P3 then exited the facility and AV2 ran inside. o At 5:06:06 p.m., AV2 ran down the hallway toward AV1. The SP and P3 remained in the doorway talking for approximately 17 seconds and during that time, C1 and C3 entered the facility. C1 was in the hallway and could be seen on camera but C3 could not be seen. o At 5:06:14 p.m., AV1 and AV2 entered the toddler classroom and walked to the CP and for approximately the next minute, they talked to the CP, and then they each picked out a stuffed animal from a bin and sat down under a counter. o At 5:06:19 p.m., the SP held the back door open and looked around the doorway corner down the hallway that AV1 and AV2 had gone down as P3 walked down the sidewalk toward the playground. C3 then walked into camera view past C1 and stood in the facility near the doorway. The SP guided C1 and C3 outside and then C1, the SP, and C3 walked out of the doorway and the SP held C3’s hand as the door to the facility closed behind them. C1 walked down the sidewalk toward the playground followed by the SP and C3. o At 5:06:33 p.m., P2 walked onto the sidewalk and met with the SP, C1, and C3. P2 and the SP talked. o At 5:07:50 p.m., AV1 and AV2 stood and walked around the room. The CP walked to the classroom door and looked out. The CP then turned and faced his/her own child, AV1, and AV2 and talked to them. All three children walked toward the CP. AV1 and AV2 exited the room and the CP walked to the middle of the room to pick up a bag and then the CP and his/her child, walked out of the classroom. o At 5:08:52 p.m., P2, C1, and two children walked back to the playground as the SP held C3 on the sidewalk. o At 5:08:32 p.m., AV1 and AV2 walked into the back hallway and ran toward the back door. The CP and his/her child followed down the hallway and to the back door. o At 5:09:13 p.m., AV1, AV2, and the CP with his/her child walked outside on the sidewalk toward the playground where they met the SP, and they all walked to the playground. o Based on times provided in the videos, AV1 and AV2 were unsupervised for approximately three minutes. The SP provided the following information: · On an unknown date, at approximately 5 p.m., the SP and P2 worked in a preschool classroom and were on the playground with five children, including AV1 and AV2 who had combined from the toddler classroom. The SP told P2 s/he was taking AV1 and AV2 into the facility to use the restroom. P2 told the SP to go and s/he would watch the rest of the children and bring them inside when s/he was ready. The SP then walked AV1 and AV2 down the sidewalk to the door to the facility to bring them inside. The SP did not recall any other children coming with him/her other than AV1 and AV2. The SP said s/he did not count the number of children s/he had and was “not sure” if P2 counted and communicated a number to the SP. · When the SP reached the door to the facility, P3 was there with his/her group of preschool children. P3 walked out the door and talked with the SP for “a while” about what they were going to do next. Then P3 went down the sidewalk with his/her group of children. The SP stated that it was “very chaotic” and AV1 and AV2 ran inside while the SP, P3, and P2 talked and decided to stay outside. · Then P2 yelled to the SP, “Come on, let’s go,” and “Hurry up.” The SP “thought” there were children inside and “freaked out,” left the door area, and walked down the sidewalk toward the playground. The SP stated that s/he should have “listened to what” s/he “wanted to do” and grabbed AV1 and AV2 but panicked because P2 and P3 were “yelling” at him/her. · Approximately three minutes later, other children needed their diapers changed so the SP walked back toward the door with them when the CP walked out of the facility with AV1 and AV2. The CP asked the SP if AV1 and AV2 were “supposed to be” inside. The SP told him/her that s/he “knew” there were kids inside but P2 and P3 told him/her to “hurry.” The SP stated s/he “apologized” to the CP. · The SP felt his/her training was adequate but did not “feel confident” that s/he remembered what s/he read. The SP stated that s/he did not know what the facility’s supervision policy was but knew that children had to be supervised by sight and hearing at all times. P2 provided the following information: · On June 5, 2024, at approximately 5 p.m., P2 and the SP were on the playground with five children including AV1 and AV2. P2 and the SP decided they were going to bring the children inside, so they gathered the children. At that time the SP “pointed” and “counted” five children. P2 said, “Wait,” and “before I knew it,” the SP walked out of the playground with all five children. P2 said the SP’s name but did not think the SP heard him/her because s/he continued to walk to the facility back door. · P2 walked around the playground and picked up items. When s/he was done, s/he went to the entrance of the playground, turned and saw P3 outside and the SP holding the door to the facility open. The SP asked P2 what s/he should do and P2 told the SP s/he should come back to the playground. · The SP closed the back door and the SP, P3, and the children walked toward the playground to P2. · P2 stated s/he “noticed” that two children were “missing” but thought that their family members had picked them up. P2 did not ask the SP about the missing children and was “not sure” why s/he did not ask. · P2 stated that the SP did not tell him/her that AV1 and AV2 were inside the facility. · At some point, the CP brought AV1 and AV2 out to the playground. The CP did not talk with P2. AV1 and AV2 resumed playing on the playground and did not seem upset. P2 did not talk to the SP about the incident because it was a “privacy” issue. P3 provided the following information: · On an unknown date, P3 open the back door of the facility and the SP was standing there outside the door. P3 asked the SP where s/he was “going,” and the SP told P3 that P2 had told him/her to bring the children inside. P3 told the SP that if his/her children were going to combine and stay with P3, the SP should bring them back to the playground because that was where P3 was going with his/her children. The SP told P3, “Okay.” P3 said s/he was focused on his/her group of children and did not see AV1 or AV2 walk into the facility. P3 then turned and walked down the sidewalk toward the playground with his/her group of children. · When P3 entered the playground, s/he saw P2 and one child and then the SP came to the playground with two children. Because the group was getting ready to combine, P3 asked P2 and the SP how many children they had And P2 and the SP each told P3 that they had six children. At that point, the CP then came outside with AV1 and AV2 and asked if AV1 and AV2 should be outside. P2 and the SP turned around to look at the CP and the SP stated that s/he “forgot” that AV1 and AV2 went inside. · P3 stated that s/he “absolutely” did not tell the SP that s/he could not go into the facility to get AV1 and AV2. · P3 stated that staff persons should always do a “head count” to know how many children they had, and classroom counts were on the APP. P1 and facility documents provided the following consistent information: · On the evening of June 5, 2024, the CP messaged P1 via the APP and told P1 that while s/he was in the toddler classroom with his/her child, AV1 and AV2 had come into the classroom. The CP waited for a staff person and when no one came, the CP took AV1 and AV2 out to the playground. · The next morning, P1 reviewed camera footage and talked with P2, P3, and the SP who provided P1 information that was “pretty much” what s/he had seen on the videos. The SP told P1 that s/he did not do a head count when s/he arrived at the back door and did not do a head count when s/he went back to the playground. P2 and the SP told P1 that they should have left the playground at the same time with all the children. · Staff persons were trained to complete a “head count” and match it to the APP when they transitioned children from one area to another. P1 trained the SP, P2, and P3 on this procedure. The facility’s Program Plan stated that staff persons supervise children within “sight and/or sound at all times.” The facility’s Risk Reduction Plan stated that staff persons did a “head count” of the children when they left the facility and again when entering the facility…” Staff persons maintained “head counts” and “constant” supervision at all times when exiting and entering the facility. Facility documentation showed that P1, P2, P3, and the SP were each trained on the Reporting of Maltreatment of Minors Act and the facility’s policies, including the Program Plan and the Risk Reduction Plan 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: Consistent information was provided that on June 5, 2024, at approximately 5 p.m., AV1 and AV2 were in the facility hallway and classroom for approximately three and a half minutes without the supervision of the SP, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although AV1 and AV2 went into their toddler classroom which was designed for children their age, AV1 and AV2 walked past the open bathrooms, and had access to the facility front door and were unsupervised for approximately three and a half minutes. AV1 and AV2 were found by the CP, who brought them to the playground unharmed. Given that AV1 was 23 months old and AV2 was 33 months old, it was unlikely that they would be able to provide for themselves in an emergency and other hazards and P2, P3, and other staff persons who were inside the facility, were not aware that AV1 and AV2 were in the facility and would not have been able to intervene in the event of an emergency. Therefore, there was a preponderance of the evidence that there was a failure to supply AV1 and AV2 with the necessary care and a failure to protect AV1 and AV2 from conditions or actions that could seriously endanger AV1’s or AV2’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 Risk Reduction Plan and Program Plan prior to the incident. At the time of the incident, P2 and the SP were responsible for the supervision of five children on the playground, including AV1 and AV2. Although the SP stated that s/he was taking AV1 and AV2 to use the bathroom, P2 and P3 each stated that the SP was going inside with the group of five children which was corroborated by the video. Regardless, the SP said when s/he was at the door, s/he saw AV1 and AV2 run inside and the SP was the sole staff person who was aware that they went inside yet did not follow AV1 and AV2 and did not tell P2 or P3 that AV1 and AV2 were inside. Therefore, the SP was responsible for maltreatment of AV1 and AV2. 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 AV1 and AV2 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 but not followed. On June 6, 2024, the facility retrained staff persons on transitions. 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 October 23, 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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