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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.”
Certification Number and Program Type: 1089695-CCCC (Certified Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left behind after a fieldtrip to an aquatic center. The AV was without facility staff person supervision between 30 minutes and 4 hours. Date of Incident(s): July 25, 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 8, 2024; from documentation at the facility; and through ten interviews conducted with two supervisory staff persons (P1 and P2), six staff persons (SP1, SP2, SP3, P3, P4, and P5), the AV, and the AV’s family member (FM). Attempts were made by email, telephone, and mail to contact and interview another staff person (P6), but P6 did not respond to the requests. An aquatic park the facility went to on a field trip, had a pool with a zero-depth entry with spray arches, water geysers, and a tot whale slide. At the other end of the pool were lap swim lanes, diving boards, and a four-story water slide. These were all monitored by lifeguards. The area surrounding the pool had lounge chairs, picnic tables, and a sand-and-water play area. There was a concession building that attached to a recreation center which housed banquet rooms and two indoor ice arenas. The aquatic park was 13 miles from the facility. The AV was five years old and enrolled in the K-Power (kindergarten-first grade) classroom at the time of the incident. The facility had green t-shirts the children wore on fieldtrips to distinguish them as part of a group from the facility. The AV stated that s/he went to the aquatic park with the facility, they wore their green shirts, and they rode busses there. While on the bus, there were three children in a seat. Once they arrived at the aquatic park, the AV did not want to swim, so s/he and three other children (the AV did not remember their names) went to the sand pit to play while the staff persons were in the water with the other children. The AV took off his/her shirt while playing in the sand pit. When the group was on fieldtrips, the staff persons “always” called “K Power” when it was time to leave. When asked if s/he heard staff person call “K Power,” the AV did not respond. At some point, the AV noticed the facility staff and children were no longer at the aquatic park and s/he was scared and told three community persons that his/her group was not there anymore. The community persons brought the AV inside to the aquatic park staff person who gave the AV water and snacks and watched the AV until P1 and P2 arrived. Once P1 arrived, the AV and P1 played cards until the FM arrived to pick the AV up from the aquatic park. The FM stated s/he received a call from someone at the facility stating that the AV was “safe and fine,” but that the FM needed to pick up the AV from the aquatic park. When the FM arrived at the aquatic park, the AV was not wearing his/her field trip shirt, but the AV was very excited because the AV thought the staff at the aquatic park were his/her bodyguards. The FM said the AV could not swim and was not interested in getting wet. The FM learned the AV was in the sand pit and when s/he realized his/her group was gone, the AV told a community person s/he was lost or left behind, and the AV was brought into an office at the aquatic park and the facility was notified. The FM did not have prior concerns, but thought the AV was overwhelmed and the AV was not excited to be at the facility. The facility’s Accident/Incident Report stated that on July 25, 2024, the AV was left behind at the aquatic park. A name to face count was done shortly before boarding the bus, and the AV wandered back to the sand area. A name to face count was not done when getting onto the bus, so the AV was left and later noticed by lifeguards. P1 drove to the aquatic park to wait with the AV until the FM was able to pick up the AV. Information from all sources was consistent that on July 25, 2024, the facility took two busses to the aquatic park. On the first bus, SP1, SP2, and SP3 worked with the K-Power group which included 42 children on the field trip (39 K-Power children and three older children). P4 and P5 were also on the first bus working with 14 children from the second-grade group. P1 and P3 also attended the field trip. P3 worked between the second and third grade group but rode on the first bus with the second-grade group. P1 was on the second bus assisting with the third through fifth grade groups. SP1 provided the following information to this investigator and during the facility’s internal review: · On July 25, 2024, when the group arrived at the aquatic park, they ate lunch and swam. During the aquatic park’s safety break, the group returned to the picnic area, and once that was over the children went back to swimming. SP1 stated that there were a few children, including the AV, who were not swimming, so they were seated at chairs by the pool with a rotating staff person. SP1 was in the water with the children. · SP1 said when it was time to leave the aquatic park, the kindergarten-first grade group lined up. SP1 stated that a count was done but not a name to face count and SP1 was “confident” in his/her numbers. SP1 thought SP3 was standing by SP1 and SP2 when they lined the children up to get on the bus but did not remember if SP3 or another staff person loaded the coolers onto the bus. Once on the bus, SP1 and SP2 counted front to back and counted 42 children both times. · Once the group was back from the fieldtrip, they got off the bus, washed hands, and it was rest and relax time when P1 approached SP1 and said a child from the facility was left at the aquatic park. When SP1 learned that the AV was left, SP1 “started crying” and was “disappointed” in him/herself. SP1 stated that if s/he had done name to face when leaving, s/he would have noticed the AV was not with the group. SP1 thought the AV was unsupervised between 30 to 60 minutes. SP2 provided the following information to this investigator and during the facility’s internal review: · SP2 provided information that was consistent with the information provided by SP1. SP2 also stated that after lunch, the AV and another child sat out with P6 while everyone else was swimming. At one point, SP2 switched places with P6, and at that time, the AV was no longer seated by P6, so SP2 thought the AV must have gone into the pool. · When it was time to leave, the group lined up and a count was done. SP2 said that s/he thought s/he saw the AV with the group, but the bus was late, so the group had to wait so SP1 and SP2 let the children play in the area near them. When the bus arrived, SP1 and SP2 lined the children up again and counted and got the accurate number, but they did not do a name to face. Once on the bus, they did not do a name to face, but counted again. SP2 did not remember where SP3 was or who loaded the coolers onto the bus. · About 30 minutes after the group arrived back at the facility, P1 told SP1 that a child had been left at the park and to perform a name to face which was whenSP1 and SP2 realized the AV had been left at the aquatic park. SP2 stated his/her “heart dropped” when s/he heard the news and SP2 felt “bad” for what happened. After the incident, SP2 heard that at some point while waiting for the bus, P1 told the AV that the AV could go to the play area. SP2 said that the AV was unsupervised for approximately 30 minutes. · SP2 was trained to do a name to face before getting children on the bus, and once on the bus to count the children. SP3 provided the following information to this investigator and during the facility’s internal review: · SP3 provided information that was consistent with the information provided by SP1 and SP2. SP3 also said that as they waited for the bus to pick them up, s/he saw the AV in the grass with the other children. · When it was time to leave, SP3 put a cooler on the bus and waited on the bus for SP1, SP2 and the children to board. During this time, SP1 and SP2 performed a headcount of the children. SP3 stated that SP1 and SP2 did not do a name to face or headcount once they were on the bus, but SP3 heard them say they had “all the numbers and every [child] was there.” SP1 and SP2 also told SP3 they were “confident” in the number of children they had on the bus. · Around 3 p.m., after arriving back to the facility, the children changed and went to the bathroom and started to rest and read books. At this time, P1 told SP1 that a child was left behind and they realized the AV was missing. SP3 was trained to have staff persons say a child’s name, have that child raise his/her hand, and then staff persons checked the child off of a list. P1 provided the following information: · P1 was at the aquatic park with the group from the facility and a majority of the children swam. P4 and P6 were at “home base” to supervise children who did not want to swim which included the AV, and to supervise children who needed to use the bathroom. There were a few groups who went into the sand play area and P1 saw P4 there with the children. · The AV was with the group when the aquatic park did a safety break. Around 2 p.m., when it was time to leave, P1 heard SP1 and SP2 perform a name to face count while waiting for the bus. P1 was on a different bus, so s/he did not know if they performed another name to face count prior to getting on the bus. P1 thought the AV might have wandered back to the sand area while the group was waiting. After the incident, SP1 and SP2 told P1 that they counted when they got on the bus, and that the number matched the number of children they had. P1 was not sure how it matched because the AV was not on the bus. Once the staff persons gave the total number of children to P3, P3 gave the “all clear” to leave. · P1 stated that the second bus left the aquatic park around 2:30 p.m. and it was a 30-minute drive back to the facility. About ten minutes after the P1 and the second group arrived back at the facility, P2 called P1 and said a child had been left at the aquatic park and it was determined it was the AV. P1 then left the facility and P2 left the location s/he was at, and they arrived at the aquatic park at the same time, around 4 p.m. P1 said the AV was in “good spirits” and was with the lifeguards. P1 and P2 waited with the AV until the FM arrived at the aquatic park. P1 stated that it was about two hours from when the first bus left and when P1 arrived back to the aquatic park to get the AV. · P1 said staff persons were trained to do a name to face count while children get on the bus. Children should not get on the bus until they hear their name, and then staff persons put a check by the child’s name once a bus headcount was done and made sure the total number of children matched how many children were supposed to be on the fieldtrip. P2 provided the following information: · P2 stated that on July 25, 2024, s/he worked at another location and did not go the fieldtrip with the group. Around 2:45 p.m., P2 received a telephone call from someone at the aquatic park who said that a child (later identified as the AV) was left and that the group had left approximately 45 minutes prior. P2 called P1 and then they both went to the aquatic park to wait with the AV until the FM arrived. · After the AV was picked up from the aquatic park by the FM, P2 went to the facility. P2 spoke with SP1, SP2, SP3, P1, and P6. P2 was told by P1 and staff persons who P2 could not recall, that the AV did not want to swim and was told that the AV was told s/he could go to the play area that was nearby and still be supervised. P2 stated that a few staff persons said they were not aware the AV had been at the play area. · P2 said staff persons were trained to perform a name to face count of the children and that the children were to get on the bus when they heard their name called. Once on the bus, two staff persons counted the children again and that number was compared to the number of children who were on the fieldtrip. P2 was told that SP1 and SP2 counted, had the correct number, and were “confident” in their headcount, but that a name to face count was not performed. · P2 said that based on when the group was supposed to leave the fieldtrip (2 p.m.) and when s/he received a telephone call from the aquatic park, s/he thought the AV was without staff person supervision for approximately 45 minutes. P3 provided the following information: · On the day of the incident, P3 did not work with the kindergarten-first grade group but was on the bus with them. · When it was time to leave, P3 loaded coolers on the bus so s/he did not see staff persons do name to face counts but was on the bus as the children got on. P3 did not think that SP3 helped load the coolers on the bus but SP3 was on the bus with P3 to help seat children prior to SP1 and SP2 getting on the bus with the K Power group. After the incident, P3 heard that SP1 and SP2 performed a name to face count when they lined the group up by the sidewalk but did not do so while getting on the bus and once on the bus, SP1 and SP2 were “comfortable” with the number they told P3, which was 42 children. P3 did not count the children but confirmed the numbers s/he was told by SP1, SP2, and P4, which when totaled, matched 56 children which was how many children were on the field trip. · Once the group returned to the facility, P3 went to work with another age group, and when it was learned that the AV was at the aquatic park, SP1 and SP2 “broke down and cried.” P3 called the FM to tell him/her about the incident. SP1 and SP2 told P3 they were “comfortable” in their numbers and that they had the correct number of children. P3 thought the AV was unsupervised for three to four hours based on how far away the aquatic park was from the facility and traffic at that time of day. · P3 said staff persons were trained to perform a name to face count as children got on the bus and then once on the bus staff persons counted each group separately and combined and told P3 the number to confirm. P3 heard afterward that the AV was told by an unknown staff person that the AV could go to the play area while they were waiting. P4 provided the following information: · P4 was not aware that the AV had been left at the aquatic park until contacted by this investigator. At the aquatic park, there was an area to play if children did not want to swim. P4 remembered sitting on a bench near the play area with three unknown children from kindergarten-first grade group. Because some children brought money, P4 also went back and forth from the bench by the play area to the concession area with children. When the aquatic park took a safety break, P4 and the children returned to the group for a headcount. · P4 worked with the second-third grade group but was on the bus with the kindergarten-first grade group. P4 did not remember if SP1 and SP2 performed a name to face count or a headcount. · P4 was trained to line children up for the bus, call a child’s name, and then the child got on the bus. Once on the bus, each age group performed a head count, stated the number of children, and then another head count was done of all of the children to make sure the number was correct. P5 provided the following information: · P5 was not aware that the AV had been left at the aquatic park until contacted by this investigator. On the day of the incident, once the group arrived at the aquatic park, they put their towels down in an area, ate lunch, and then went into the pool. Some children did not want to go into the pool, so a staff person stayed out of the pool with those children. When the aquatic park took a safety break, the children returned to the area they had their towels laid out. · P5 said when it was time to leave, prior to getting on the bus, a staff person from the child’s group, called a child’s name and the child got on the bus. Once on the bus, two additional headcounts of that age group were completed. P5 said that s/he did not remember who was working with the kindergarten-first grade group. P5 was not sure if anyone performed a full headcount of who was on the bus, but P3 relied on the lead staff persons for each age group to perform a headcount. The facility’s Risk Reduction Plan stated, “Staff [persons] must utilize tracking procedures and conduct head counts regularly.” The facility’s Employee Handbook stated, “On every fieldtrip, there is a safety /attendance check a minimum of once every hour. Document the hourly check on your Bus Count Roster.” At the end of a fieldtrip to load the bus, “Staff [persons] must be first on and last off the bus, a name to face attendance check will be done to board the bus, and a minimum of two different staff need to do a headcount and match the overall group numbers before leaving.” According to www.wunderground.com, the temperature in the Twin Cities metro area on July 25, 2024, at 1:53 p.m., was 78 degrees Fahrenheit (F°). Facility documentation showed that SP1, SP2, SP3, P1, P2, P3, P4, P5, and P6 were each trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rules and/or Statues Minnesota Statutes, section 245H.13, subdivision 10, states staff must supervise each child at all times. Staff are responsible for the ongoing activity of each child, appropriate visual or auditory awareness, physical proximity, and knowledge of activity requirements and each child’s needs. Staff must intervene when necessary to ensure a child’s safety. In determining the appropriate level of supervision of a child, staff must consider: (1) age of the child; (2) individual differences and abilities; (3) indoor and outdoor layout of the child care program; and (4) environmental circumstances, hazards, and risks. Conclusion: A. Maltreatment: Information from all sources was consistent that on July 25, 2024, the AV was left at the aquatic park unsupervised for between 30 minutes and 4 hours which was a violation of Minnesota Statutes, section 245H.13, subdivision 10. Although there were lifeguards at the aquatic park and the AV, who was five years old, was able to verbally communicate to community persons and park staff persons that she had been left, according to the FM, the AV could not swim. Being unsupervised at the aquatic park for 30 minutes to 4 hours gave the AV access to community dangers, including unknown community persons, community buildings, and safety hazards in and around the aquatic park. In addition, during this time, no staff person was aware the AV was left behind and would not have been able to intervene if necessary to ensure the AV’s safety. Therefore, there was a preponderance of the evidence that there was a failure to provide 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. 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, SP2, and SP3 were each working with the K-Power group at the time of the incident and were each trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. SP1 and SP2 could not recall where SP3 was or who loaded the coolers onto the bus. However, SP3 said that at the time the children were getting on the bus, SP3 was responsible for putting the coolers on the bus prior to the children boarding, was on the bus when the children got on, and was not the staff person responsible for performing the name to face as children got on the bus. P3 also stated that SP3 was on the bus helping seat children when SP1, SP2, and the K Power group got onto the bus. Therefore, SP3’s responsibility was mitigated. SP1 and SP2 were each responsible for ensuring the children from the K-Power group, including the AV, got on the bus and were accounted for prior to the bus leaving the aquatic park. SP1 and SP2 each stated that they counted the children prior to getting on the bus and twice once on the bus and got the correct numbers. However, there was no information that the AV got on the bus and left again, so it was more likely that each of their counts were incorrect. SP1 and SP2 each stated that they did not conduct a name to face count after getting on the bus. SP1 and SP2 were both 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 SP1 and SP2 were each 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 a serious 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 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 December 3, 2024, the facility was issued a Correction Order for the violation outlined in this report, for allowing one staff person to provide direct contact services before receiving a background study clearance notice, and for failing to submit a background study request for one staff person. 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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