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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: 800955-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that three alleged victims (AV1, AV2, and AV3) left the facility and were found on a nearby elementary school playground by a community person (CP1). AV1, AV2, and AV3 were without staff person supervision for an undetermined amount of time. During the course of this investigation, it was reported that AV3 walked out of an enclosed playground and was without staff person supervision for an undetermined amount of time. Date of Incident(s): May 17, 2024 (maybe more) 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 site visits conducted on June 3 and July 16, 2024; from documentation at the facility; and through nine interviews conducted with a supervisory staff person (P1), four facility staff persons (SP1, P2, P3, and P4), two community persons (CP1 and CP2) and AV1’s and AV3’s family members (FM1 and FM3). This investigator spoke with AV2’s family member (FM2), but s/he did not provide any information to this investigator. This investigator also reached out to another staff person (SP2) and set up an interview. When this investigator called at the appointed time, SP2 did not answer and there was no further communication from SP2. The facility was located in a community center that also contained several community outreach programs. The facility had its own welcome door with a secured entrance. The facility had three classrooms. To get to the bathrooms from the toddler classroom, children passed through a Parent Welcome Lounge and down a hallway, passing the secure entrance along the way. The facility used a playground located at the front of the community center. The playground was enclosed by a five-foot-high concrete wall and there was a chain link fence that separated the toddler and preschool areas of the playground. There was a sidewalk that led from the facility’s welcome door and the community center’s main door to the playground gate. There was a parking lot in front of the facility’s entrance. The community center was in a residential area and on the opposite side of the community center from the facility’s playground, there was an elementary school with an unenclosed playground. AV1 was 39 months of age, AV2 was 26 months of age, and AV3 was 31 months of age at the time of the incident and all three were enrolled in the Toddler classroom. The facility’s Incident Reports (one for each AV) stated that on May 14, 2024, around 10:55 a.m., AV1, AV2, and AV3 ran out of the toddler classroom and went to the welcome door. One of the AVs pushed open the door and AV1, AV2, and AV3 ran to the playground of the school next door. Staff persons were looking for the children when they were met by staff from the school who had assisted in returning AV1, AV2, and AV3 to the facility. CP1 and CP2 provided the below information: · CP1 stated that on an unspecified date, around 10:45 a.m., s/he went outside on the elementary school playground with a group of students from the elementary school, and one of the students alerted CP1 that three “toddlers” (later identified as AV1, AV2, and AV3) were at the elementary school playground. · CP1 looked to see if there were adults with AV1, AV2, and AV3 but did not see any. CP1 said AV1, AV2, and AV3 seemed “fine, curious, wandering,” but one of the AVs was not wearing shoes. CP2 stated that AV1, AV2, and AV3 seemed “healthy and happy.” · CP1 and CP2 walked AV1, AV2, and AV3 over to the facility’s welcome door and rang the doorbell. No one answered the door. CP1 went to a window (based on the layout of the facility, most likely a Toddler or Preschool classroom window) and looked inside and saw another child by him/herself and no staff person present. CP1 and CP2 brought AV1, AV2, and AV3 to the community center main entrance. CP2 said a community center staff person approached them and seemed “dumbfounded.” CP1 and CP2 asked to speak to someone from the facility about how this happened. · CP1 and CP2 stated a staff person (later identified as P3) came over and “scolded” and “admonished” AV1, AV2, and AV3. P3 asked AV1, AV2, and AV3, “Why are you out here?” and told AV1, AV2, and AV3 they were “Not supposed to do that.” CP1 and CP2 then spoke with P1 while an unidentified staff person came and took AV1, AV2, and AV3 back to their classroom. After the conversation with P1, CP1 and CP2 left the facility. CP2 stated the from the facility, AV1, AV2, and AV3 would have had to walk on the sidewalk and potentially in the parking lot to get to the elementary school playground. FM1 and FM3 provided the following information: · FM1 stated that on May 17, 2024, when s/he picked up AV1 from the facility, an unknown staff person told FM1 that around 10:30 a.m. that morning, AV1 left the building for “ten minutes” and was brought back to the facility by community members from the school next door (note: based on other information, it was likely that FM1 either misspoke about the date or was told about the incident days after it occurred). FM1 asked why s/he was not notified sooner, and the staff person s/he spoke with stated the facility needed to review video footage. FM1 was not told that AV2 and AV3 were with AV1. AV1 told FM1 that s/he left to “go have fun and play” and that another child opened the door for him/her. · FM3 received a telephone call from a staff person (later identified as P1) in June 2024, stating that AV3 and two other children got out of the facility. P1 did not say how it happened, but said it was a lapse of supervision. FM3 did not remember how long s/he was told AV3 was without supervision, but it was more than a “couple of minutes.” FM3 stated that there had been staff turnover recently, but prior to that (May 2024) s/he had no concerns. SP1 provided the following information: · On or around May 15, 2024, SP1 was working with SP2 in the toddler classroom. SP1 stayed in the classroom with some children (including AV2 and AV3) while SP2 took a group of children to the bathroom (including AV1), and some of the children ran back into the classroom before SP2 returned. Once SP2 returned to the classroom, SP1 thought the classroom looked “short” on children so s/he proceeded to do a headcount and realized three children were not in the classroom. · SP2 left the toddler classroom to look for AV1, AV2, and AV3. SP2 came back into the classroom and asked SP1 if they had returned, and SP1 said, “No,” so SP2 left the classroom again to look for AV1, AV2, and AV3. · After SP2 left the second time, SP1 looked out the window and saw AV1, AV2, and AV3 with some community persons from the school next door. SP1 was not sure how AV1, AV2, and AV3 got outside but thought “most likely” they left through the facility welcome door. SP1 thought AV1, AV2, and AV3 were without supervision for approximately five minutes. · SP1 stated that s/he normally worked at the front desk of the community center, but because the facility was short staffed, SP1 helped in the facility. SP1 stated that SP2 was a regular staff person at the facility. SP1 stated that s/he started helping on May 6, 2024, and that s/he received no training on supervision from the facility. P1 provided the following information: · On an unknown date, P1 stated s/he was working when another staff person from the community center let P1 know that CP1 and CP2 wanted to speak with P1. CP1 and CP2 told P1 that AV1, AV2, and AV3 were found on the playground of the school next door and CP1 and CP2 brought the children back to the facility. · P1 stated that SP1 and SP2 were working with the toddler classroom on the day of the incident and what s/he recalled was that there was a transition from a bathroom break and when the group was back in the classroom, a count was done, and it was realized AV1-AV3 were not with the group. SP2 told P1 that s/he did not know how the children got out of the building. · P1 stated the preschool classroom was outside on the playground for their outside time, and P3 was outside walking the infant children in a stroller and had spoken with CP1 and CP2 when they returned AV1, AV2, and AV3 to the facility. P1 had no knowledge of any other instances where a child was not supervised. · P1 was in an interim position within the community center and when the facility’s supervisor left in May 2024, P1 took on the additional role of interim supervisor of the facility. P1 was not aware that this incident needed to be reported to the Department of Human Services. P2, P3, and P4 provided the following information: · P2 was not working at the facility on the day of the incident (P2 did not remember the date), but the next day when s/he worked, P2 heard that AV1, AV2, and AV3 got out of the facility. P2 said that the facility was so short staffed that staff persons were put in the toddler room at random based on who was working. · P2 stated on an unknown date in May 2024, P2 was the only staff person on the playground with the toddler class when AV3 ran out of the gate (P2 did not say whether the gate was left open or AV3 opened a closed gate). P2 stated s/he did not think s/he could leave the other toddler children unsupervised to follow AV3, so P2 screamed and called for help as AV3 went around a corner and P2 was not able to see AV3. P2 stated that P4 was at the welcome door with a family member, so P2 got P4’s attention to send someone to help. After a “few minutes,” AV3 came back to the gate by him/herself. An unknown staff person came out of the community center to help P2 but AV3 had already rejoined the class. P2 and the unknown community center staff person then went back inside, and that staff person helped P2 bring the children back to the classroom. P2 stated that P1 was not there to talk to about the incident. P2 was not sure how far away AV3 got during the incident but was worried because of AV3’s proximity to the parking lot. · P3 stated that on an unknown date in May 2024, s/he was outside on the facility’s toddler playground with another staff person. P3 saw CP1 and CP2 walk toward the facility with three children and at the time P3 did not realize they were from the facility. CP1 and CP2 knocked on the facility’s door, so P3 walked over to speak with them and then s/he realized the children were from the facility, but s/he did not remember their names. · P3 was concerned that the children got out of the classroom without staff persons knowing. P3 stated that when the incident occurred, SP1 was in the classroom but P3 did not remember who the other staff person was. P3 said P1 did not talk to him/her about what happened. · P4 stated that on an unknown date in May 2024, s/he was outside on the preschool playground with his/her classroom and when they came back inside for lunch SP2 was in the bathroom crying which caused “quite a disturbance” in the hallway. P4 asked SP2 if s/he was okay and SP2 stated s/he just “needed a moment,” but continued crying. Later that day P4 asked P1 if everything was okay but was not told at that time what had happened. · Sometime in June 2024, P4 heard about the children getting out of the facility through the facility’s secure door and that they were brought back by CP1 and CP2. P4 knew one of the children was AV1 but did not know who the other two children were. · P4 said children had run out of the toddler classroom into P4’s classroom before, and s/he did not think the toddler classroom staff persons were aware. P4 stated the toddler classroom had more temporary staff persons than the other classrooms. However, P4 was not aware of any other incidents of children being unsupervised. P3 said s/he had concerns of children running through the rooms in the facility. The facility’s Child Care Program Plan stated, “All children at [the facility] are under auditory and visual supervision at all times.” The facility’s Staff Policies and Procedures stated, “At all times, you must know exactly how many children you have in your care and where they are. Counts of the children should constantly be made throughout the day.” The facility’s Emergency Preparedness and Response Procedure stated, “If a child is missing, the director or staff [persons] will conduct a thorough search of the area (building and grounds). If unable to find within 5 to 15 minutes, the police will be notified immediately, and then the parents.” Facility documentation showed P4 was trained on the Reporting of Maltreatment of Minors Act. Facility documentation showed that SP1 and P1 were trained on the facility’s Child Care Program Plan, however, the form documented that they received this training on May 3, 2024, but the form was not signed by SP1 or P1 and another supervisory staff person until June 5, 2024, which was after it was requested by this investigator. In addition, the facility was unable to locate training records for SP2, P2, or P3 and could not provide training on the Reporting of Maltreatment of Minors Act. These were violations of Minnesota Statutes, section 245A.40, subdivision 1; and section 245A.04, subdivision 14, paragraph (b), clause (1), which states in part that the license holder hold must ensure that directors and staff persons are provide training in accordance with Minnesota Rules and Statute. Relevant Rule and/or Statute Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states 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: Regarding AV3 leaving the playground: P2 said that on an unknown date in May 2024, P2 was the only staff person on the playground with AV3 and other children. AV3 ran out of the gate and P2 was not able to see AV3 for “a few minutes.” P2 did not think s/he could leave the other children unsupervised to run after AV3, so s/he yelled for help. P4 was at the welcome door and P2 got his/her attention to send someone to help. AV3 came back to the playground by him/herself before another staff person was able to assist P2. There was no additional information available about this incident. Although AV3 was out of P2’s line of sight and therefore P2’s supervision, given that P2 saw AV3 leave the playground and tried to get help to protect AV3 without leaving the other children unsupervised, there was not a preponderance of the evidence P2 failed to protect AV3 from harm when reasonably able to do so. It was not 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). Regarding AV1-AV3 leaving the building: A. Maltreatment: On May 14, 2024, SP1 and SP2 were working in the toddler classroom. SP2 brought some children (including AV1) to the bathroom. SP1 was in the classroom with the remaining children (including AV2 and AV3) when some of the children returned from the bathroom to the classroom by themselves. When SP2 returned to the classroom, SP1 thought the class did not look as full as it should, so s/he performed a head count and noticed that three children were missing. SP2 left the toddler classroom to look for AV1, AV2, and AV3; stopped back at the toddler classroom to see if they had returned, but they had not; and left the classroom again to continue looking for them. During this time CP1 noticed AV1, AV2, and AV3 at the elementary school playground. CP1 and CP2 proceeded to bring AV1, AV2, and AV3 back to the facility. CP1 and CP2 knocked on the welcome door of the facility and no one answered. They looked inside and saw another child standing alone, with no staff person present. CP1 and CP2 then went to the community center’s main door where they were met by P3 who seemed upset with AV1, AV2, and AV3 for being out of the building. CP1 and CP2 made sure AV1, AV2, and AV3 made it back to their classroom. CP1 and CP2 stated AV1, AV2, and AV3 did not seem bothered by what happened but CP1 stated one of the AVs was not wearing shoes. FM1 was told AV1 was “gone” for ten minutes, FM3 thought it was for longer than “a couple of minutes,” and SP1 thought AV1, AV2, and AV3 were gone for approximately five minutes. It was unclear as to when or how AV1, AV2, and AV3 left the classroom and subsequently the facility; however, information was consistent that AV1, AV2, and AV3 left the facility without staff person knowledge and were without staff person supervision for an undetermined amount of time which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1 and SP2 started searching for AV1, AV2, and AV3 once they noticed they were not in the classroom. However, before they were returned by CP1 and CP2, AV1, AV2, and AV3 were on a playground that was not fenced in which gave AV1, AV2, and AV3 access to community dangers including unknown community persons, parking lots, streets, homes, and community buildings. Therefore, there was a preponderance of the evidence that there was a failure to supply AV1, AV2, and AV3 with the necessary care and a failure to protect AV1, AV2, and AV3 from conditions or actions that seriously endangered their 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. Although SP1 and SP2 were responsible for the supervision of AV1, AV2, and AV3 at the time of the incident, given that the facility failed to provide training and orientation to staff persons, which was a violation of Minnesota Statutes, section 245A.40, subdivision 1; and section 245A.04, subdivision 14, paragraph (b), clause (1), SP1’s and SP2’s individual responsibility was mitigated and the facility was responsible for the maltreatment of AV1, AV2, and AV3. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 facility was responsible did not meet statutory criteria to be determined as serious or recurring, as AV1, AV2, and AV3 did not sustain injuries as a result of this single incident of maltreatment. 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 needed amending but stated that SP1 and SP2 followed the Emergency Preparedness and Response Procedure. The facility was not aware of any other supervision issues involving P2. SP1, SP2, and P2 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On December 6, 2024, the license holder was ordered to forfeit a fine of $1,000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal. During the course of the investigation, it was determined that the facility failed to initiate a background study as require. On December 6, 2024, the facility was issued a $200 fine for the background study violation. The Order to Forfeit a Fine is subject to appeal. On December 6, 2024, the facility was issued a Correction Order for not having a child in the correct designated age group category. 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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