|
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: 1105093-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on a playground without staff person knowledge or supervision for approximately five minutes. Date of Incident(s): July 17, 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 July 31, 2024; from documentation at the facility; and through nine interviews conducted with a supervisory staff person (P1), four facility staff persons (SP1, SP2, SP3, and P2), a facility board member (P3), a county social worker (SW), and the AV’s family members (FM1 and FM2). The AV was 22 months old at the time of the incident and enrolled in a toddler classroom. Due to his/her age, the AV was not interviewed for this report. The facility was a stand-alone building. There were two playgrounds on the front of the building with a parking lot in between them. Each playground was surrounded by a four-foot-high chain link fence. There was a gate from the infant/toddler playground that led to a sidewalk in front of the building. The main facility entrance was just outside of the infant/toddler playground. Facility documentation showed that on July 17, 2024, at 11:09 a.m., P1 found the AV alone on the infant/toddler playground, unharmed. The SW, FM1, and FM2 were all aware the incident happened. FM1 stated that someone from the facility called him/her right away and said the AV was outside for five minutes. FM1 had no prior concerns. FM2 stated that P1 called him/her, but FM2 was not sure how long the AV was unsupervised. FM2 did not have prior concerns. P1, P2, and P3 provided the following information to this investigator: · P1 said that on July 17, 2024, around 10:30 a.m., P3 was at the facility to help P1 with some new playground equipment pieces in the facility’s office. While the toddler classroom was outside, P2 stepped inside to speak with P1 about a child in the classroom (not the AV). SP1, SP2, and SP3 brought the toddler class inside, and then about two minutes later, SP1 came to the office asking for P2 to return to the classroom as s/he was about to start changing diapers. · P1 stated that P2 went back to the toddler classroom so P1 went to bring a piece of playground equipment outside and saw the AV sitting in woodchips on the playground. The AV was not crying and seemed to be “fine” playing in the woodchips. P1 brought the AV inside and had another supervisory staff person go into the toddler classroom and ask them how many children they had and if they counted when they came inside. They said they had 18 children, and they did count. P1 then brought the AV into the classroom and said the AV was outside alone. · P1 met with SP1, SP2, and SP3. SP1 said a count was done at the gate, but SP1 was not sure if a count was done once inside the classroom. SP2 and SP3 both stated a count was not done. After speaking with SP1, SP2, SP3, and P2, P1 determined the AV was outside for five minutes. P1 stated the policy was to count children at the gate before heading inside and then count again once back in the classroom. · P2 stated that on July 17, 2024, around 10:45 a.m., s/he was inside the facility speaking with P1 and another supervisory staff person about some children in his/her classroom. SP1, SP2, and SP3 were outside with the class and came inside without P2’s help. P2 thought they had 17 children that day. · P2 went back into the classroom after SP1, SP2, and SP3 had brought the classroom back inside, and was talking with SP2 about what was discussed with P1 when P1 entered the classroom and asked the other staff persons how many children they had and if they counted when they came inside. · P2 said P1 found the AV outside playing in the woodchips and when P2 saw the AV, the AV seemed “fine.” P2 thought the AV was outside unsupervised less than five minutes. P2 was trained to count the children at the gate outside, and as the class walked through the front door, and again upon return to the classroom. · P3 stated on an unknown date, s/he was at the facility because some new playground equipment had come in. P3 peeked in the toddler classroom, and no one was there and when s/he turned around, a child was running inside followed by SP1. P3 went into the toddler classroom with SP1 and told SP1 that s/he would stay in the classroom until the other staff persons came back inside. · When the class returned to the toddler classroom, P3 knew P2 was talking to P1, and that SP2 was one of the other staff persons who came into the toddler classroom, but P3 did not remember who else was in the classroom. P3 stayed in the classroom for about five minutes after the class returned to the classroom and did not see a name to face performed, a headcount done, nor did s/he hear any communication among SP1, SP2, and/or SP3 about the transition. P3 left and when s/he returned to the office area, P1 was holding a child who was left on the playground (likely the AV). SP1, SP2, and SP3 provided the following information to this investigator: · SP1 said that on an unknown date, s/he was outside on the playground with SP2 and SP3. Around 10:50 a.m., P2 was inside in the office, when SP1, SP2, and SP3 brought the toddler class back inside. SP1 stated that s/he was at the front door and when s/he counted five children through the door SP1 had SP2 come to the front door to hold it so SP1 could go with the five children already through the front door to the classroom. · SP1 stated s/he told SP2 how many children s/he had and to count up from there. When SP1 entered the classroom, P3 was in there to make a report for a maintenance staff person. P3 told SP1 s/he would stay in the classroom with him/her until the other staff persons came back. · SP1 said SP2 and SP3 entered the toddler classroom and stated they had everyone but did not state the number they had (18 children). SP1 started changing diapers, and then P2 entered the classroom and P3 left. Another supervisory staff person entered the toddler classroom to ask them how many children they had, and if they counted when they came in. P1 then entered the classroom with the AV after finding the AV out on the infant/toddler playground. SP1 thought the AV was outside unsupervised for less than five minutes. · SP1 was trained to count children before leaving the playground, again while children went through the front door, and again as they went into the classroom door. SP1 was not sure who (SP2 or SP3) counted the children after s/he left the front door. · SP2 stated that on the day of the incident, s/he, SP1, and SP3 were outside on the playground. P2 had been outside with them but had gone inside to speak with P1. SP1, SP2, and SP3 were within ratio and the children were getting warm, so SP1, SP2, and SP3 decided to take the group inside. · SP2 said SP1 went to the facility front door to hold it open, SP2 was at the gate to make sure no children ran into the parking lot, and SP3 went around the playground to round up some children who did not want to line up at the gate. · SP2 then went to the facility door so SP1 could bring the children into the classroom and SP3 moved to the gate. SP2 asked SP3 if they had all of the children and SP3 responded, “Yeah.” SP3 exited the gate carrying a child and went to hold the door, and SP2 went to shut the gate. · SP2 and SP3 went inside with the remaining children. SP1 was in the classroom with P3 and SP2 thought they had counted the children as they entered the classroom. SP2 started wiping children’s faces, SP1 started changing diapers, and SP3 was playing with the children. SP2 said there was no communication between SP1, SP2, and SP3 about whether all of the children made it inside. SP2 thought they had 17 or 19 children that day. · SP2 stated P1 came in then and asked SP1, SP2, and SP3 if they had all of the children, and stated s/he found the AV out on the playground. SP2 said the AV seemed “normal” when P1 brought him/her into the classroom. SP2 thought the AV was outside without supervision for about five minutes. · SP2 was trained to have a staff person holding the front door, a staff person at the gate, and a staff person walking the children to the classroom. SP2 said a count was “typically” done by tapping a child on the head when they walked through the front door and when entering the classroom. SP2 thought SP1 was counting and that when they switched spots at the front door that was when the counting was lost. · SP3 did not remember the date, but stated s/he, SP1, SP2, and P2 were outside on the playground. SP3 said that P2 and SP1 had gone inside to set up stations, so it was just SP2 and SP3 bringing the children inside. · SP3 tried to keep the children who were lined up to go inside in line, while simultaneously gathering the children who ran out of line. SP3 was holding a child, and SP2 was holding the front door. SP3 went to the front door and asked SP2 to grab the children’s water bottles by the infant door and check for more kids on the playground, but SP3 was not sure if SP2 heard him/her since SP2 was already walking toward the playground gate to shut it. · SP3 and SP2 got the children into the classroom, and SP1 and P2 were in there as well. SP1 started changing diapers while SP2 and SP3 were with a group in the main area of the classroom. SP3 said SP1 thought they missed someone because s/he was counting, and they were off one child. SP1 went back outside but did not see anyone. · SP3 stated SP1 returned to the classroom and then P1 brought the AV back in the classroom and said the AV was left outside. SP3 said the AV’s face was red and that SP3 thought the AV was unsupervised for less than ten minutes. SP3 did not remember how many children they had that day. · SP3 was trained to count children at the gate, at the front door of the facility, and at the classroom door. SP3 said no one counted the children during the incident. The facility’s Risk Reduction Plan stated, “Staff [persons] will count how many children they have before they leave one area, while they are moving to the new area, and once they get to their destination.” According to www.wunderground.com, the temperature in Lake Crystal, MN on July 17, 2024, at 10:53 a.m. was 70 degrees Fahrenheit (F°). Facility documentation showed that P1, P2, SP1, SP2, and SP3 were each trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. 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: A. Maltreatment: Consistent information was provided that on July 17, 2024, SP1, SP2, and SP3 were outside with the toddler class when they decided to come inside. P2 was inside speaking with P1 about some children in the classroom. Initially, SP1 was at the front door, SP2 was at the playground gate, and SP3 was gathering children on the playground. At some point SP1 went inside with some of the children, SP2 moved to hold the front door open, and SP3 moved to the gate. SP3 was carrying a child when s/he exited the playground and moved to the front door, and SP2 went back to close the gate. SP1 said s/he told SP2 how many children had already entered the front door (five) and to count the children from there. SP2 stated that SP1 did not tell him/her how many children s/he had already counted and thought that was when the count was lost. SP3 said that no count was completed while the children entered through the front door. Neither SP1, SP2, nor SP3 said they ensured the children were counted upon return to the classroom. In addition, P3 (who was in the classroom when the class returned) said s/he did not witness any count or communication between SP1, SP2, and/or SP3 about the transition. Once in the classroom, SP1 started changing diapers, SP2 was wiping children’s faces, and SP3 was playing with the children. P3 left the classroom and P2 came back inside. Simultaneously, P1 brought a piece of playground equipment outside and saw the AV playing in the woodchips on the playground. P1 brought the AV back inside and told P2, SP1, SP2, and SP3 that the AV was outside by him/herself. Information from most sources was consistent that the AV was outside by him/herself for approximately five minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules part 9503.0045, subpart 1, item A. Although there was no apparent harm to the AV, given the AV’s age of 22 months, that the design of the fence meant the AV was visible to community persons, and as a result, the AV was exposed to community dangers, 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. 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 responsible for the AV’s supervision at the time of the incident, each was trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act, and each failed to account for the AV at all times as trained. SP1, SP2, and 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, SP2, and SP3 were each responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV did not sustain any injuries. 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 adequate, but not followed by SP1, SP2, and SP3. All three staff person were retrained on the facility’s policies. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1, SP2, and 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, SP2, and SP3 were each responsible for maltreatment is subject to appeal. On December 6, 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.
|
