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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: 1097632-CCC (Child Care Center) Investigator(s): Lindsay Arth/Brittany Dolen 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised on the facility playground and found by a community person. Date of Incident(s): September 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 October 1, 2024; from documentation at the facility; and through seven interviews conducted with the AV, the AV’s family members (FM1 and FM2), a facility supervisory staff person (P1), and three staff persons (SP1, SP2, and P2). At the time of the incident, the AV was three years old and enrolled in the facility’s preschool classroom. The facility had two playground areas, including a preschool playground (where the incident occurred) and a playground for younger children. The AV’s classroom had a door that exited directly onto the preschool playground. There was a bank next to the preschool playground. There was an approximately 5-foot-tall chain link fence surrounding the playground and the preschool playground fence had two gates. One gate led to the other playground, and the other gate led to walkway that led to the parking lot/front of the building. There was a bathroom inside of the classroom, very near to the door that exited outside. The Child Supervision Record (CSR) policy said that staff persons were to ensure the children were “safe and supervised at all times.” The CSR was to be utilized to ensure that at all times when “transferring children,” including from outside to inside, that staff persons could account for every child in their care. Staff persons were to do a name to face count of all the children when transitioning from outdoors to indoors. A name to face count must be done again when returning back to the classroom. Counting of the children instead of performing the name to face count was “not permitted.” According to the Risk Reduction Plan, staff persons were required to follow the name to face supervision policy. Staff persons were trained in the supervision and name to face policy, which stated that during transitions from one area to another, staff persons were required to complete a name to face count prior to leaving the original location and again upon arriving at the destination. Facility documentation showed that on September 17, 2024, there were 20 children, including the AV, in the preschool classroom with SP1 and SP2. P2 provided the following information: · On September 17, 2024, at approximately 10:50 a.m., P2 brought lunch into the preschool room. At this time, the preschool class was outside on the playground. · At approximately 11:05 a.m., P2 was in the kitchen heating up his/her own lunch when s/he saw a community person (CP) drive into the parking lot. P2 was not aware of who the CP was so P2 watched the CP in the parking lot for approximately three minutes before s/he answered the door. The CP told P2 that there was a child alone and crying on the playground. P2 did not know the CP and did not get their contact information but thought the CP was from the nearby bank. P2 thanked the CP and then went to get the child (Note: P2 did not know who the child was at this time). P2 walked through the preschool room to get to the playground and saw SP1 and SP2 in the classroom with other children. However, P2 did not say anything to them when s/he walked through and went outside. When P2 got outside, which P2 said was at 11:10 a.m., s/he found the AV sitting on the steps of the playground by him/herself crying. P2 then brought the AV inside. · When P2 came inside with the AV, SP1 was serving lunch to the other children. P2 asked SP1 and SP2 if the AV was in their room because the AV was transitioning between the PreK and preschool classrooms at that time and SP1 said that the AV was in their class. Neither SP1 or SP2 were aware that the AV had been outside. P2 then left the classroom and told P1 about the incident. The AV did not sustain any injuries. However, risks to the AV being unsupervised included the potential for heat stroke, the AV exiting the playground by either climbing over the fence or opening the gate, or someone accessing the AV if the gate was not locked. · P2 estimated that approximately four minutes passed between when the CP arrived to tell P2 about the incident to when P2 went to get the AV. The AV told this investigator that s/he was three years old and in the PreK classroom (which the AV moved to following the incident). When asked about the playground, the AV said that s/he “likes all of it.” The AV denied ever being left alone on the playground. P1 provided the following information: · P1 said that on September 17, 2024, s/he was in the toddler classroom. At 11:15 a.m., P2 told P1 that someone from the bank came to the facility and told P2 that the AV was on the playground unsupervised and that P2 had returned the AV to his/her classroom. P1 then spoke to SP1 and SP2 and learned that at the time of the incident, SP1 and SP2 had split the classroom and each had 10 children. SP2 was in the classroom changing diapers and SP1 was outside with the remaining children. SP1 told P1 that prior to coming inside, s/he counted the children both outside and inside, but did not complete a full name-to-face count, which staff persons were trained to do. · P1 estimated that the AV was unsupervised for one minute because the classroom documentation showed that the AV’s class came inside at 11:09 a.m., and P2 told P1 that s/he brought the AV inside at 11:10 a.m. · When coming inside from the playground, staff persons were trained to document that they saw the child at the beginning of the transition, then have the children line up and do a name-to-face count as they were going through the door to come inside. Staff persons were also trained to complete a second name-to-face count as the children walked through the door, and a final check upon completing the transition. The final check consisted of staff making eye contact with each child to verify they had completed the transition. SP1 and an untitled document written by SP1 and dated September 17, 2024, provided the following information: · SP1 did not recall the date of the incident but said that it happened on a Tuesday in or around September 2024. Before lunch, SP1’s and SP2’s classroom went outside to the playground. At some point, SP2 took some children inside to change diapers in the bathroom attached to the classroom, while SP1 remained outside with the rest of the children. While SP2 was inside, SP1 began getting the remaining children ready to go in for lunch. SP1 did not say whether or not s/he spoke with SP2 about how they would keep track of where each child was during the transition. · SP1 had a large class that day and said it was “a process” to get everyone inside and lined up. SP1 got the “majority” of the class lined up, and those children were sent inside with SP2. There were two additional children on the playground so SP1 went to get them and then “ushered” them inside. SP1 “assumed” s/he had all the children. SP1 then did a “quick” head count of the children once they were inside and counted 20 children. SP1 did not complete a name-to-face count and s/he instead, “counted heads [but] did not check faces.” SP1 believed s/he may have counted a child twice because s/he counted the number of children that s/he should have had. Staff persons were trained to complete name to face counts and document who was present before they went through a threshold, such as a door, and again after they went through a threshold. At the time of the incident, SP1 felt rushed during transitions and said that they were a “little stressful” because the kids were “antsy.” · SP1 and SP2 then began getting lunch ready when P1 brought the AV inside and told SP1 and SP2 that they “left [the AV] outside.” The AV was “distressed” and “scared to have been left outside.” The AV cried for approximately five minute but was later “fine.” SP1 thought that the AV was unsupervised between two and five minutes. · There were no injuries to the AV. However, risks to the AV being left unsupervised included that the AV could have climbed the fence and exited the playground. A member of the community could have also climbed the fence and taken AV from the playground. Additionally, the AV could have been injured by falling off of equipment. SP2 and an untitled document written by SP2 and dated September 17, 2024, provided the following information: · On September 17, 2024, around 10:30 a.m., SP2 and SP1 brought the children outside to play on the playground. · At some point, SP2 began bringing some of the children, not including the AV, inside to change diapers in the bathroom attached to the classroom. From the bathroom, SP2 could see children in the bathroom and children in the classroom because s/he had the bathroom door open. Once the first group of children’s diaper changes were done, SP2 had them remain in the classroom instead of going back outside so that it was not “confusing.” SP2 then asked SP1 to send additional children inside to have their diapers changed. The AV was potty trained so was not one of the children that came inside to have his/her diaper changed. It was SP2’s third day working at the facility, so SP2 did not know all the children by name. However, SP1 had the CSR outside and SP2 believed SP1 kept track of which children were iniside and which were outside. SP2 did not say whether s/he had conversations with SP1 regarding how they would keep track of which children were where. Around 11 a.m., while SP2 was still in the bathroom changing diapers, SP1 brought the remaining children inside. When SP2 finished diapering, s/he began lunch and saw P1 go outside through their classroom door and bring the AV in. SP2 realized that the AV had been outside unsupervised. The AV cried for a “little bit” but then ate lunch as normal. · SP2 believed the AV was unsupervised for less than three minutes. SP2 was unaware of any potential risks to the AV being unsupervised within the enclosed playground but said that there could be risks if the AV were to exit. The AV was typically a “very obedient kid” and SP2 was unsure why the AV did not come inside with the rest of the class. FM1 and FM2 both said that on September 17, 2024, P1 contacted them and informed them that the AV was left outside unsupervised and found by a nearby bank employee. When the AV came home, the AV told FM1 and FM2 that s/he was left outside alone and was “sad.” The AV did not sustain any injuries as a result of this incident. FM2 had concerns because there was a similar prior incident (See Investigation Memorandum 202306409) with other children but did not have other concerns with the facility. According to www.wunderground.com, on September 17, 2024, at the approximate time of the incident, the tempteracture outside was 81 degrees Fahrenheit with a head index of 81 degrees Fahrenheit. Facility documentation showed that prior to the incident, SP1, SP2, P1, and P2 were trained on the facility’s policies, including the Child Supervision Record policy, the facility’s 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 “supervision” means 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; and that children are required to be supervised at all times. Conclusion: A. Maltreatment: Information from all sources was consistent that on September 17, 2024, at approximately 11:00 a.m., the AV was left outside on the enclosed preschool playground, unsupervised and without the knowledge or supervision of SP1 and SP2, for between one and five minutes. This was inconsistent with the facility’s Child Supervision Record policy and was also a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. A community person saw the AV in the enclosed playground and notified P1. Being unsupervised on the playground gave the AV access to dangers both on the playground and in the community including unknown community persons, traffic, local businesses, and exposure to the weather. Although the AV returned to the classroom unharmed, given the AV was three years old, it was unlikely that the AV would be able to provide for him/herself in an emergency. In addition, given that staff persons were not aware that the AV was outside the facility, they would not have been able to intervene to protect the AV in the event of an emergency. Therefore, there was a preponderance of the evidence 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. 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. SP1 and SP2 each received training on the facility’s policies, including the Child Supervision Record and Risk Reduction Plan, prior to the incident. On the day of the incident, SP1 and SP2 were responsible for the supervision of all of the children in the preschool room, including the AV. Given that SP2 was assisting other children in the bathroom at the time of the incident, SP2’s responsibility was mitigated. However, SP1 transitioned children inside without counting them first, and miscounted the children when they had returned to the classroom. As a result, SP1 failed to notice the AV did not return to the classroom with the rest of the group. Therefore, SP1 was 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 was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not sustain an injury that required the care of a physician. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by SP1 and SP2. This included that the name to face count during transition was not completed using the CSR. There were no prior similar concerns with SP1 or SP2. Following the incident, SP1 and SP2 were retrained on the CSR and transitions. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 was 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 the disqualification of SP1. The determination that SP1 was responsible for maltreatment is subject to appeal. On December 11, 2024, the facility received a correction order for the violation outlined above. 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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