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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: 1086840-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left alone in a toddler room for approximately three to five 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 26, 2024; from documentation at the facility; and through four interviews conducted with a supervisory staff person (P1) and three facility staff persons (SP1-SP3). Attempts were made via telephone and mail to contact the AV’s family members (FM1 and FM2), but FM1 and FM2 did not respond to the requests. The AV was not interviewed due to his/her age. According to the AV’s enrollment information, the AV was two years and four months old and enrolled in the toddler two room at the time of the incident. The facility had a toddler one and toddler two room that often combined in the morning. Consistent information was provided that at the time of the incident, the toddler one and toddler two rooms were combined. SP2 and SP3 were assigned to the toddler one room and SP1 and another staff person (P2) were assigned to the toddler two room. The toddler rooms each had a glass exterior door that led directly to a sidewalk. The sidewalk went along the length of the building to the playground. According to the facility’s attendance sheet, prior to another child’s (the C’s) arrival, there were approximately 11 children in the toddler one room and approximately 7 children, including the AV, in the toddler two room. P1 stated that on June 5, 2024, at approximately 9:30 a.m., SP2 told P1 that at approximately 8 a.m., after breakfast and clean up, SP1-SP3 decided to bring the toddler one and toddler two children, including the AV, outside to the playground. SP1-SP3 had the children line up near the door to outside and then brought them outside. A few minutes later, SP2 received a notification that the C electronically signed in to the facility, so SP2 went back inside to get the C and found the AV alone in the room. SP2 said that the AV was alone in the room for less than five minutes. Throughout that day, P1 came and went from the toddler rooms and did not see any injuries to the AV. As a result of this incident, all staff persons received training at the next staff meeting that they were considered one room when combined, including when transitioning, and that the rooms should separate as soon as a second toddler staff person arrived. SP2 and SP3 provided the following information: · At approximately 8:05 a.m., the toddler one children lined up at the door to the playground and the toddler two children lined up behind them. SP2 had P2 leave the room because s/he had a conflict with a family member dropping off a child and then SP2 gave the “all clear” for P2 to come back. SP2 heard P2’s voice so assumed P2 had returned to the toddler two classroom. SP2 said that it was possible P2 was not in the room when SP2 heard P2’s voice, but “as far as [SP2] knew” P2 was back in the room. · SP3 went out to the playground first while SP2 stood at the door. SP2 had the toddler one clipboard and did a name to face and checked off each child as they went through the door. SP1 had the toddler two clipboard and was with the toddler two children. SP2 stated there were approximately seven children in the toddler one room and did not know how many children were in the toddler two room. SP3 stated there were approximately six children in the toddler one room and did not know how many children were in the toddler two room. · SP2 then followed the toddler one children outside while SP1 and the toddler two children, including the AV, remained inside. SP3 stated that approximately two to three minutes later, SP1 and the toddler two children came out to the playground. · While outside on the playground, SP2 received a message that the C was signed in electronically, so SP2 went back inside the toddler one room to greet the C. In the toddler one room, SP2 saw the AV standing alone by a shelf with no apparent injury. The AV had been alone in the room for approximately five minutes. SP2 took the AV’s hand, greeted the C once s/he was in the room, and then returned to the playground with the AV and the C. SP1 provided the following information: · On the day of the incident, SP1-SP3 had the children line up to go out to the playground. P2 had left the room and went into the bathroom to check supplies prior to SP1-SP3 and the children going outside. SP3 went outside first and SP2 had the list of children from the toddler one room. SP1 did not remember how many children were in the room at the time. · SP1 saw the AV standing with his/her line and checked each child, including the AV, off the toddler two list. SP1 then brought the toddler two children outside. SP1 stated that SP1-SP3 and all the children went out the door together and SP1 was last out the door. SP1 “look[ed] around” the room before going outside but did not do a sweep of the room. SP1 did not count the children after getting to the playground because s/he thought “they were all there.” SP2 went back inside and came outside with the AV. The AV was alone for three to four minutes and was not injured.
According to the facility’s Supervision/Accounting for Children Policy, children were supervised “at all times.” As children arrived at the classroom, staff persons checked the child in on the class list or attendance sheet. All staff persons were aware of how many children were present at all times. During early morning and late day, as rooms combined, staff persons must have the class list/attendance sheet from all rooms they were responsible for, marking children in when they arrived and then out when they left. When the group moved from one area to another, the attendance sheet was taken along and children were counted and accounted for as they left the room and as they re-entered the room. According to the facility’s Risk Reduction Plan, staff persons were trained to supervise children “at all times.” When transitioning from one area to another, all staff persons completed an initial head count when leaving a location and again when they reach their destination. Staff persons completed and documented a name to face check for each child using the attendance sheet. Facility documentation showed that SP1-SP3 and other staff persons interviewed in this investigation received training on the facility’s Supervision/Accounting for Children Policy, Risk Reduction Plan, and the Maltreatment of Minors Act, prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A stated that a child must have supervision at all times and that supervision was 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: SP1-SP3 provided information that on June 5, 2024, the AV was left in the toddler room for approximately two to five minutes without the knowledge or supervision of a staff person which was inconsistent with the facility’s Supervision/Accounting for Children Policy and the facility’s Risk Reduction Plan, and was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV was unharmed during the incident. However, while the AV was unsupervised in the classroom there was no caregiver present to intervene if the AV did something harmful or dangerous, or in case of emergency. Although the toddler children were counted prior to leaving the room, given that the toddler two children were not counted once they were on the playground, and as a result the AV was left unsupervised in the classroom, 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; and 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 626.556, subdivision 10e, paragraph (i): 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. Consistent information was provided that at the time of the incident, SP1-SP3 and the children left the toddler room to go to the playground. Although SP1 and SP2 provided information that they left with the toddler one children prior to SP3 leaving with the toddler two children, the rooms were combined at the time of the transition and SP1-SP3 were therefore responsible for the care and supervision of the AV at the time of the incident. SP1 – SP3 were each trained on the facility’s Supervision/Accounting for Children Policy, the facility’s Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act prior to the incident. It was determined that SP1, SP2, and SP3 were each responsible for the neglect 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. The substantiated neglect for which SP1-SP3 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident for which the AV did not sustain an injury that reasonably 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 policies and procedures were adequate but not followed. The facility reviewed all policies and procedures with SP1-SP3 and provided SP1 with a written warning. The facility created a sign off for each staff person on the attendance sheet, witnessed by another staff person, that documented that they counted the children, completed a name to face check, and did a final sweep before leaving the area. A supervisory staff person also observed each room completing this procedure three to five times to ensure it was completed accurately. Action Taken by Department of Human Services, Office of Inspector General: SP1-SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1-SP3 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-SP3 were each responsible for maltreatment is subject to appeal. On October 24, 2024, the facility was issued a Correction Order for not providing supervision. 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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