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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: 800440-CCC (Child Care Center) Investigator(s): Lindsay Arth/Alice Percy 651-431-6537 Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) left an alleged victim (AV) unsupervised on a playground. The AV was found by a community person (CP) who brought the AV into the facility. Date of Incident(s): May 20, 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 10, 2024; from documentation at the facility; and through five interviews conducted with a facility administrative staff person (P1), SP1, SP2, the CP, and the AV’s family member (FM). The AV was 20 months old and enrolled in the toddler classroom at the time of the incident. The facility was located in an area with single family homes, a church, a dentist office, a strip mall, and various other businesses. The facility’s parking lot was located along one side of the facility and between the parking lot and the facility was a playground where the incident occurred which was enclosed by a chain link fence. Facing the playground, from the parking lot, on the left was a sidewalk that led to the front entrance of the facility. There was a gate that provided access from the playground to the sidewalk leading to the front of the facility. The gate had a latch that needed to be lifted to open the gate, as well as a chain and a carabiner preventing the gate from being opened by a child. A second back gate provided access to the back of the building to a fenced walkway area that led to the doors to the individual classrooms. At the other end of the walkway was another playground, that was not part of the incident. A large climbing structure was located on the playground. The playground was visible to persons in the facility parking lot and Information was provided that the CP initially saw the AV standing near the back gate. The CP stated that s/he arrived at the facility between 4 and 4:30 p.m. to pick up his/her child. As s/he exited the facility, s/he looked at the playground and saw the AV alone on the playground next to the back gate near the walkway. The CP went back into the facility and told P1 that the AV was unsupervised on the playground. The CP believed the AV was unsupervised for less than five minutes, because the toddler class had just entered the facility from the playground when the CP arrived at the facility to pick up his/her child from the toddler classroom. P1, SP1, and SP2, and the facility’s documentation provided the following information: · On the afternoon of May 20, 2024, SP2 and another staff person (P3) worked in the toddler classroom with 14 children. At approximately 3:30 p.m., they took the children to the playground. At approximately 4 p.m., SP1 replaced P3 on the playground. At approximately 4:20 p.m., SP1 took a “handful” of children to the back gate while SP2 brought the other children. SP1 stated that instead of waiting for all the children to line up by the gate, s/he opened the gate and began to lead the children down the walkway to the classroom door. SP2 stated that when s/he reached the gate, s/he stopped and looked around the playground, but believed that s/he did not do a “thorough enough” check because it was “hectic” at the time. SP2 then continued to the classroom door and inside. · Once they entered the classroom, SP1 and SP2 gave the children water and were beginning to change the children’s diapers. Neither SP1 nor SP2 counted the children when they left the playground or when they returned to the classroom. SP2 stated that “it was so hectic and it kind of slipped our minds” to count the children during the transition from the playground to the classroom. SP2 believed SP1 had the Child Supervision Record (CSR) while they were on the playground, but SP1 did not recall if s/he had it. · P1 stated that at 4:20 p.m., s/he went to the toddler classroom to take out the classroom garbage as SP1, SP2, and the children were returning into the classroom from the playground. As P1 entered the classroom, s/he saw the CP leave the classroom with his/her child. P1 then took a short telephone call that lasted approximately two minutes. After P1 finished the telephone call, the CP re-entered the facility and told P1 that the AV was alone on the playground. P1 “immediately” went to the playground and saw the AV in the on the playground. The AV was not crying and did not appear to be upset. P1 then brought the AV into the facility. Before returning the AV to the classroom, P1 called the FM and another administrative staff person (P2) and told them about the incident which took about five to ten minutes. P1 stated that when P1 brought the AV to the classroom and told SP1 and SP2 that the AV was unsupervised on the playground, they were “very, very surprised.” A short time later, the FM arrived at the facility to pick up the AV. · P1 stated that the staff persons were trained to do a name-to-face count of the children during each transition from one area to another. The staff persons were to complete a CSR after each transition. P1 was uncertain if SP1 or SP2 completed the CSR after returning to the classroom on the day of the incident. SP2 believed that s/he would have soon realized that the AV was not in the classroom because s/he was changing the children’s diapers and would have checked the CSR at that time. · Consistent information was provided that the AV would not be able to open either of the playground gates. After the incident, the staff persons began using a walking rope when transitioning the children from one area to another. The FM stated that s/he was notified of the incident the day it occurred. The AV “seemed perfectly normal” when the FM picked the AV up that day. Prior to the incident, the FM had no concerns about the care the AV received at the facility. According to the facility’s CSR policy, the staff persons were to maintain a record of all of the children in the classroom each day. As children arrived at the classroom, the staff persons added the child’s name to the CSR. When a child left the classroom, their name was taken off the CSR. Whenever the staff persons transitioned the children from one area to another, they were to conduct a name-to-face count of the children and document it on the CSR. In addition to counting the children during each transition, the staff persons were trained to do name-to-face counts eight times each day. Facility documentation showed that SP1, SP2, and P1 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies 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, state 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: On May 20, 2024, at approximately 4:20 p.m., SP1 and SP2 brought the toddler children into the facility from the playground. SP1 and SP2 returned to the classroom with the other children, but did not count the children as they lined up at the playground door or once they returned to the classroom. Approximately three minutes to five minutes later, the CP saw the AV standing outside the playground gate and told P1 that the AV was unsupervised on the playground. P1 immediately went outside and got the AV but did not return the AV to his/her classroom for an additional five to ten minutes later. The AV was not crying when P1 found him/her and did not sustain any injury during the incident. SP1 and SP2 were not aware that the AV was not in the classroom and was left outside unsupervised, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; 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 not injured, the AV was 20 months old and unsupervised for several minutes on the facility’s playground which was visible to passerby and therefore placed the AV at risk of community dangers and placed the AV at an increased risk of harm. In addition, it was unlikely that the AV would be able to provide for him/herself in an emergency and staff persons were not aware that the AV was on the playground 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. Facility documentation showed that SP1 and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. SP1 and SP2 were each responsible for the care and supervision of the AV at the time of the incident. 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 each 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 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 the facility’s policies were adequate, but were not followed by the staff persons. After the incident, all of the staff persons were retrained on the facility’s policies. 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 30, 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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