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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: 1095790-CCC (Child Care Center) Investigator(s): Van Mulheron thu-van.mulheron@state.mn.us Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on the toddler playground without three staff persons’ (SP1-SP3) knowledge and supervision for approximately 10 minutes. Date of Incident(s): May 23, 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 6, 2024; from documentation at the facility and through seven interviews conducted with two supervisory staff persons (P1 and P2), three staff persons (SP1-SP3), and the AV’s family members (FM1 and FM2). The AV was two years old at the time of the incident and was enrolled in the toddler classroom. The facility was located on the corner of two roads. One road was four lanes with a speed limit of 55 miles per hour and the other was a two-lane road with a speed limit of 30 miles per hour. In the area was single and multi-family housing, ponds, and fields. The back of the building faced the four-lane road and was where two playgrounds were located. One playground was a toddler playground which was surrounded on two sides by a chain link fence, one side by an iron fence, and one side by the building. The toddler playground was visible to passerby. On the playground was a playhouse near the sidewalk by the door, a play structure to the right of the door and in front of the infant playroom, and a three-side activity center behind the playhouse. The playground also had tricycles and toy cars parked in front of the infant play area that were visible through windows of an indoor infant play area. Through the front door was a reception area that had a hallway to the right that led to the toddler classroom. The toddler classroom had cubbies to the left of the door, tables in the middle of the classroom for meals and table activities and a bathroom in the left corner of the classroom near the exit door. The toddler room had a diaper area that was out of view of the camera that had a gate that connected to the classroom next door. Past the toddler classroom at the end of the hallway was a door that led to the infant play area. To the left if the infant play area was an area called the “mud room” that had a rug, hooks for coats, and a storage area for outdoor toys. The “mud room” had a door that led onto a sidewalk and the toddler playground. The facility had cameras located in the corner of the toddler classroom near the exit door and a camera on the toddler playground. On May 23, 2024, SP1, SP2, and SP3 were working in the toddler classroom with 17children, including the AV. FM1 and FM2 provided consistent information that on May 23, 2024, when FM2 picked up the AV, SP1 told FM2 that the AV had “slipped outside without the teachers noticing” but was not provided any additional information. FM2 said s/he was not “overly alarmed” at that time. The next day, P1 called FM1 and said that the AV was outside by him/herself for “over 10 minutes” which concerned each. FM1 and FM2 had no prior concerns about the facility. P1 and P2 provided the following information: · On May 23, 2024, between 5 and 5:30 p.m., P2 was in the reception area when SP2 stopped and told P2 that the toddler class came inside and was getting ready for lunch, “[the AV] got out of the classroom and ended up on the playground …. they went and got [the AV] and brought [the AV] back.” P2 did not “address it more” at that “moment” but told P1 the next morning. P1 and P2 then reviewed video footage of the incident. · P1 and P2 provided consistent information regarding the video. SP1-SP3 were outside on the playground with the toddler children. SP1-SP3 started to line the children up and the AV went inside the playhouse with another child. SP2 walked over to the playhouse to help the AV out and then as SP2 turned around to help another child, the AV ran to the back side of the play structure. SP3 was in the corner and grabbed water bottles. At the toddler room door, SP3 counted the children at the classroom doorway. P1 and P2 did not see the AV enter the classroom. SP1-SP3 were all inside and helped the children wash hands before lunch. Before eating, SP3 left the classroom to work in another class. As SP1 and SP2 handed out lunch to the children, SP2 had an extra plate of food and “realized” a child was “missing.” SP2 checked the bathroom and then left the classroom and then went to the playground, where s/he found the AV. SP2 and the AV then returned to the classroom. P1 and P2 said that while the AV was outside s/he ran around the playground, rode a trike, played and was unsupervised for approximately 10 minutes. · After watching the videos, P1 and P2 spoke with SP1-SP3 · SP1 told P1 and P2 that the AV was outside for “about five minutes” but s/he “was not sure.” SP1 did not remember who counted the children outside and said, “I think we counted going in.” SP1 also did not know what spot s/he was in line compared to SP2 and SP3 or where s/he was as they went in the classroom. SP1 said s/he noticed an extra plate at lunch and then looked in the bathroom and realized the AV was missing. SP2 then walked out of the classroom to look for the AV and found the AV on the playground. SP1 said that s/he told FM1 on the day of the incident. · SP2 told P1 and P2 that s/he “noticed” the AV was missing when s/he was handing out lunch. SP2 checked the mud room and looked outside and saw the AV outside “playing.” SP2 then went outside and got the AV. · SP3 told P1 and P2 that s/he could not remember which staff person counted outside but that s/he was the first one to the toddler classroom door and s/he counted the children as they came into the classroom. SP3 said that s/he counted to “17” and stopped because s/he thought s/he was “two short.” SP3 then saw “two children behind [SP1]” and then thought s/he had the correct count of “19.” · P1 and P2 had no prior concerns about SP1-SP3. The facility provided two videos of the playground and one video of the toddler classroom. Video footages were time stamped and started at 11:15:49 a.m. and ended at 11:30:45 a.m. (Note: the video footage from the playground did not show a clear view of the playground door or the end of the wall where the children lined up. In addition, only the bottom half of the play structure could be seen and there was a gap in the playground videos from 11:28:30 -11:29:35 a.m.) The videos provided the following information: · At 11:17:05 a.m., SP1-SP3 were putting away toys and gathering children to line up on the sidewalk by the facility’s wall. · At 11:17:23 a.m., the AV exited the playhouse. · At 11:17:44 a.m., SP1 picked up a child and walked to the playground door at the front of the line and out of view of the camera. · At 11:18 a.m., the AV entered the playhouse and SP2 walked behind the playhouse then out of view of the camera. Children continued to walk to the line and SP3 was at the play structure. · AT 11:18:17 a.m., another child entered the playhouse with the AV. · At 11:18:25 a.m., SP2 walked to the playhouse and helped the AV exit the playhouse. As SP2 was helping the AV, SP3 walked behind the playhouse towards the fence and to the end of the line and out of view of the camera. · At 11:18:30 a.m., the AV exited the playhouse and ran behind SP2 to the left and then ran towards the back of the playground as SP2 turned toward the playhouse to help the other child exit the playhouse. · At 11:18:31 a.m., SP2 turned around and faced the back of the playground. The AV ran behind the activity center. SP2’s head appeared to follow the direction of the AV before SP2 turned completely around. The AV then ran to the play structure and went out of view of the camera. SP2 then bent down and picked up a white bucket. · At 11:18:45 a.m., the AV was underneath the play structure as the last child got into line. SP2 walked to the front of the line and then children began to walk to the playground door and out of view of the camera. · At 11:19:05 a.m., SP3 walked toward the mudroom door holding a child and then out of view of the camera. No other children followed SP3, and the AV remained out of view of the camera. · At 11:19:46 a.m., SP3 appeared at the toddler room door and turned on the lights to the toddler room and then stood by the door as children came into the classroom. Eleven children entered the classroom and walked to the bathroom. · At 11:20:05 a.m., SP2 entered the classroom holding a bucket followed by two children. Two more children entered the classroom followed by SP1, who was holding another child. (At this point 16 children had entered the classroom.) · At 11:20:14 a.m., SP3 entered the classroom and then shut the door. · From 11:20:14 to 11:20:50 a.m., SP1 was in the bathroom with some children, SP2 washed his/her hands by the diaper area sick, and SP3 was standing at the toddler classroom door with a child. · At 11:20:51 a.m., SP3 left the classroom with a child as SP1 and SP2 remained with 15 children. [Note: This was a violation of Minnesota Rules 9503.0040 subpart 1, which stated that except as provided in subpart 2, the minimally accepted staff-to-child ratios and the maximum group sizes are: for toddlers a minimum staff-to-child ratio of 1:7.] SP2 put on gloves and walked to a shelf that had the lunch bin. SP1 was in the bathroom assisting children and sending children to the tables to sit down for lunch. · At 11:21:07 a.m., a child walked toward the diaper area and disappeared from view. (Note: This child did not reappear, and information obtained showed that the child was taken into the classroom next door at an unknown time. This left SP1 and SP2 with 14 children inside, and the AV who was still outside.) · At 11:22:03 a.m., SP3 re-entered the classroom with a child, walked to the cots and waved a child that was sitting at the table over to him/her and then walked over to the cubbies. P1 entered the classroom and SP2 set out 16 plates on a shelf. · At 11:22:08 a.m., the AV appeared in the playground view at the play structure and walked to the playground door and out of view of the camera. · At 11:22:24 a.m. P1 talked with SP1-SP3, grabbed a fork, plate, and cup from the lunch bin, and then left the classroom. · At 11:23:02 a.m., the AV ran from the playground door to the playhouse and then to the side fence on the left and out of view of the camera. · At 11:23:13 a.m., P1 re-entered the classroom and then left the classroom with two children. SP1 came out of the bathroom, helped children into chairs at the table, and then walked out of view of the camera. · At 11:23:33 a.m., the AV appeared near the side fence and walked to the playground door and out of view of the camera. · At 11:24:40 a.m., SP3 left the classroom and SP2 began placing food onto the plates. · At 11:24:56 a.m., the AV appeared by the playground door and ran onto the play structure and out of view of the camera. · At 11:26:06 a.m., SP1 helped SP2 with the lunch plates. There were 11 children sitting at the tables and 2 children standing next to the lunch tables. · At 11:26:57 a.m., the AV reappeared on the grass near the back of the playground and then ran to the left corner of the playground to the chain link fence and climbed approximately two to three feet up and down the fence several times. · At 11:27:58 a.m., SP1 and SP2 handed plates to the toddlers at the tables. · At 11:28:44 a.m., SP1 and SP2 gave all the children a plate of food and then stopped and looked at the children. SP1 and SP2 each had a plate of food, and one additional plate was left on the shelf. SP1 then put his/her plate on the shelf and began to pour milk into cups. SP2 then helped to pass the cups to the children. During this time, the AV ran to the right of the playground and out of view of the camera. · At 11:29:28 a.m., the AV appeared between the play structure and the wrought iron fence and walked toward the infant play area and out of view of the camera. · At 11:29:49 a.m., SP2 stopped and looked at the children, walked to the bathroom and looked inside, and then walked out of the classroom. SP1 continued to pour milk and supervised the children in the classroom. · At 11:30:10 a.m., the AV reappeared and was riding in a toy car near the play structure. · At 11:30:23 a.m., SP2 walked onto the playground and walked to the play structure towards the AV. SP2 and the AV then walked back into the facility. SP1 provided the following information: · On May 23, 2024, SP1 was outside on the toddler playground with SP2 and SP3 and 18 children, including the AV. At approximately 11:15 a.m. they began to get the children ready to go inside for lunch. As the children lined up against the wall SP1 stood by the door to the facility and “monitored” the children to “make sure they stayed inline.” · SP1 said that “usually” s/he was the “first” one to go inside and “count” the children but did not remember what s/he did the day of the incident or if s/he counted the children. SP1 “thought” SP3 as at the front of the line, SP2 was in the middle of the line and that s/he was at the end of the line and that s/he shut the door to the playground once everyone was inside. · SP3 then led the class to the toddler room and stopped at the door. SP1 did not hear SP3 count but saw SP3 “touch” the children’s heads as they walked into the classroom. SP1 had two or three children in the hallway with him/her when SP3 entered the classroom. Once in the classroom, SP1-SP3 helped the children use the bathroom and wash their hands before lunch. SP1 did not know if SP2 or SP3 checked the playground or the play house for any children before coming inside. SP1 could “not remember” everything s/he did when it was time to head inside but remembered that s/he parked the cars and then was at the door to “monitor” the children who were lined up. · SP3 left the classroom with four children to work in another classroom before lunch was served. When SP1 and SP2 handed out lunch plates, SP2 said, “Hey, where is [the AV]?” SP1 looked in the bathroom and behind the toy shelves. SP1 said that the AV had “ran out” of the classroom before and thought that s/he did it again. SP2 then left the classroom. When SP2 returned s/he was with the AV and said that the AV was “outside riding a bike.” The AV was “unfazed” and joined the class for lunch and then nap time. · At pick up time, SP1 told FM1 that the AV had “ran outside” and was “alone” but did not tell FM1 how long the AV was outside. SP2 provided the following information: · SP1, SP2, and SP3 were on the playground with 17 or 18 children, including the AV until approximately 11:20 a.m. At 11:20 a.m. they had the children line up against the wall next to the door to go inside. SP3 was at the front of the line, SP1 was at the end of the line, and SP2 was at the middle of the line. SP2 did not remember if s/he checked the playhouse prior to going inside. · SP2 said that initially s/he heard SP3 counting the children out loud as they went inside but then did not hear SP3 count anymore and “assumed” that SP3 was “counting in [his/her] head.” As the children entered the mud room SP2 had the children sit on the carpet “to make sure everybody was in.” SP1 was the last person in and s/he closed the door behind him/her. Once the door was closed the children stood up and they walked to the toddler room. SP2 said that s/he did not count the children because that was the “job” that the “first” person in line was supposed to do. · SP3 was still at the front of the line. SP2 said that when they reached the classroom, the children went to wash their hands for lunch and no one “counted” the children as they entered the classroom. · As SP2 and SP3 were plating the food for lunch, P1 came into the classroom and asked for a staff person to work in a different classroom. SP3 then took four children with him/her and left the classroom. SP2 was about to sit down at the table for lunch when s/he “looked around” and said, “Where is [the AV]?” SP2 walked over to the bathroom but did not see the AV and then realized that the AV was still outside. SP2 walked outside and saw the AV riding a toy car. SP2 and the AV then they walked back to the classroom. SP2 said that the AV was “fine” and that s/he went straight to the lunch table and began to eat. SP3 provided the following information: · SP1, SP2, and SP3 were outside with 19 children, including the AV. At approximately 11:25 a.m., they had the children line up at the wall to go inside. SP3 “looked around” the playground and saw no other children and then went to the front of the line. SP3 said that staff persons were trained to “look around” the playground and if they “did not see” anyone still playing then the first staff person in line was to “count” the children lined up at the wall as the children “went into” the facility. · At 11:30 a.m. SP3 opened the door and counted the children “loud enough” for SP1 and SP2 to hear. SP3 said s/he “counted 19 children” as they entered into the mud room and sat down on the carpet. After counting s/he told SP1 and SP2 that s/he “counted 19 children.” SP2 was at the end of the line and SP1 was at the middle of the line. The children sat on the carpet until “everyone” came in. · From the mud room the class walked to the toddler room. SP3 was in front and counted “out loud the same number” of children as they entered the classroom. SP3 waited at the door until everyone entered the classroom. SP3 then went to the bathroom and helped children wash their hands for lunch and SP1 and SP2 began to plate lunch for the children. · Five minutes later, P1 came into the room and asked SP3 to work in another classroom and to take five children with him/her to another classroom so that SP1 and SP2 would remain in ratio. At approximately 11:35 a.m., SP3 left the classroom with 5 children. At an unknown time before 12 p.m., another staff person told SP3 that the AV was left on the playground. SP3 said that s/he did not know that the AV was not in line because “I wasn’t looking to see if [the AV] was gone.” The facility’s Supervision policy stated that “the teacher must be able to see and hear children at all times.” The facility’s Risk Reduction Plan stated that staff persons are to “maintain supervision of all children while playing outdoors”, “children are never left unattended”, and “staff persons count children when exiting and entering any new areas outside of the classroom.” Facility records showed that P1, P2, and SP1- SP3 were trained on the facility’s Supervision Policy, Risk Reduction Plan, and the Reporting of Maltreatment of Minors Act. 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: Information from all sources was consistent that on May 23, 2024, the AV was left unsupervised on the playground for approximately ten minutes, 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 two years old and unsupervised for approximately 10 minutes on the facility’s playground exposing the AV to community hazards including the AV’s attempts to climb the fence. 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-SP3 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. SP1-SP3 were each responsible for the care and supervision of the AV at the time of the incident. Although SP1 and SP2 each stated they did not count the children, SP3 stated that s/he counted 19 children when coming inside and in the classroom yet information showed that there were 17 children in attendance and according to the video the AV was never in line and therefore, the count was not accurate and it was not until they were passing out lunch, approximately ten minutes, that they realized the AV was missing. Therefore, SP1-SP3 were each 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-SP3 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 found that their policies and procedures were adequate but not followed by SP1 -SP3. The facility added the following to their Transition Policy: teachers who are counting children will be required to count out loud so that other staff persons can hear the counting. 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 December 6, 2024, the facility was issued a Correction Order for the violations 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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