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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: 1086484-CCC (Child Care Center) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that three staff persons (SP1, SP2, and SP3) left an alleged victim (AV) unsupervised on a playground for approximately three minutes. The AV was found by another staff person (P1) and returned to the facility. Date of Incident(s): May 7, 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 May 23, 2024; from documentation at the facility; and through ten interviews conducted with three administrative staff persons (P2 – P4), P1, SP1, SP2, SP3, the AV, and two of the AV’s family members (FM1 and FM2). The AV was three years old and enrolled in the preschool classroom at the time of the incident. The facility was located in a rural area at the intersection of two roads and was surrounded by trees and large open areas. Single family homes surrounded the facility. A playground was located on one side of the building and a parking lot was located in front of the building and playground and was the length of the building and playground. The playground had a large climbing structure, which included a partially enclosed play area and tunnel. There was also a smaller climbing structure that had a partially enclosed tunnel area under it. The playground was enclosed by a chain link fence and there were two gates in the playground fence. One gate led to the facility’s parking lot and one gate led to an adjacent toddler playground. The gate that led from the playground to the facility’s parking lot had a latch that had to be “flipped up” to open but did not have a lock. The AV’s classroom was located at one end of the facility’s hallway. A door to the bathroom, as well as a sink area, was located along one side of the hallway. At the other end of the hallway was a glass door that led to a small entryway. A second glass door accessed the playground from the entryway. The AV stated that there was one occasion when the staff persons “left me outside.” The AV was in the tunnel when the other children went into the facility and s/he felt “sad” when s/he was outside by him/herself. FM1 stated that the AV loved attending the facility and, prior to the incident, FM1 had no concerns about the care that the AV received at the facility. On the day of the incident, the AV told FM1 that s/he was left alone on the playground and P1 found the AV crying and brought the AV into the facility. The AV told FM1 that it was raining and s/he was “really scared.” SP1 called FM1 and told him/her that after recess the staff persons took all the children into the facility and did not realize that the AV was hiding on the playground and was not with the group when they entered the facility. FM1 stated that the AV hid from FM1 “every time” FM1 picked the AV up at the facility so the staff persons were aware that the AV liked to hide. FM2 stated that the AV was “adventurous” and frequently hid from FM1 when s/he picked the AV up at the facility. Prior to the incident, FM2 had no concerns about the care the AV received at the facility. P1, P2, P3, P4, SP1, SP2, SP3, and the facility’s documentation provided the following information: · SP1 and SP2 each stated that the staff persons used a clipboard to keep track of the children in the classroom and to note when the children arrived and when they left the facility. Prior to taking the children to the playground, the staff persons did a “roll call” where they called each child’s name and each child then responded to their name. The children lined up and SP1 led the children outside while one of the staff persons walked at the end of the line and the other one helped as needed. When they reached the outside door, SP1 again counted the children as they walked outside. SP1 wrote the number of children on his/her clipboard. Once they were outside, the staff person spread out across the playground so that they could supervise all of the children. · SP1 stated that when it was time to return to the classroom, the staff persons had the children line up near the door. SP1 stated that the AV typically was “very good about lining up.” Once the children were lined up, SP1 counted the children. SP2 stated that s/he was usually at the end of the line and SP3 was in the middle of the line. Once the children arrived at the classroom, the staff persons again counted the children. SP3 stated that the staff persons did not typically count the children immediately because they usually “scattered” when they entered the classroom. Once they were settled in one area, the staff persons counted. The staff persons typically did not bring the children back to the classroom in the afternoon because the family members picked the children up while they were on the playground. P2, P3, and P4 each stated that it was the responsibility of all the staff persons to know how many children were in their classroom at all times. · On May 7, 2024, SP1, SP2, and SP3 worked in the preschool classroom. At approximately 3 p.m., they lined up the children to take them to the playground. As they prepared to take the children outside, three family members picked up their respective children. The staff persons gave the family members the clipboard to sign out their children. SP1 stated that it was “pure chaos” as they got the nine remaining children ready to go outside. At that time, the children took their backpacks outside with them so they would have them when their family members picked them up. SP1 stated that on that day s/he did not do a roll call as they lined up, but s/he counted the children as they went outside. · Because it rained earlier in the day, the playground equipment was wet, so the staff persons used a towel to dry the equipment. The towel became wet, so SP1 gave his/her door key to SP2 to go inside to get another towel. After SP2 entered the facility, it began to thunder and rain and SP1 decided to bring the children inside. SP1 and SP3 called to the children to line up. Some of the children were afraid of the thunder and pushed to be at the front of the line. SP3 then picked up the children’s backpacks. SP1 did not have his/her key to the door, so s/he looked in the window and saw SP2 walking to the door. SP2 opened the door and a child (C) ran inside so SP2 waited at the door for the others to enter. SP1 stated that s/he “looked” around, believed “everybody is here,” and went inside without counting the children. SP2 stated that s/he assumed SP1 counted the children prior to entering the facility. SP3 stated that the staff persons “walked around and scanned everything” before entering the facility. · SP1 had the children remain in the entryway for a brief time, because s/he wanted to see if it stopped raining so that they could return to the playground. During this time, the C attempted to open the second door to go to the classroom and SP2 followed. SP1 did not want the group separated so s/he decided to take all of the children to the classroom. SP3 stated that it was “chaos” because some of the children tried to run ahead of the staff persons to the classroom. At approximately 3:07 p.m., they arrived in the classroom and the children put their backpacks and outerwear away while the staff persons assisted them. SP1 did not immediately count the children. SP2 stated that while they typically counted the children when they entered the classroom, it was “chaotic” because some of the children were “frantic” because they did not like storms. · P1 stated that s/he was in the hallway going to the art supplies room when s/he saw the AV looking in the window of the playground door. At approximately 3:10 p.m., P1 went to the door and found the AV crying and told P1 that s/he was locked outside. P1 carried the AV into the facility, took the AV to his/her classroom, and asked the staff persons if they were missing a child. P1 told the staff persons that s/he found the AV unsupervised on the playground and then P1 left the classroom. The staff persons were assisting the children with their outerwear and told P1 that they had not yet counted the children when P1 returned the AV to the classroom. P1 telephoned P2 and told him/her about the incident. SP1 believed it was approximately ten minutes between when they called the children to the door and when P1 brought the AV to the classroom. SP2 believed the AV was unsupervised for approximately five minutes and SP3 believed it was “a minute and a half.” · The AV was not crying when s/he entered the classroom and s/he told SP1 that s/he was in the playground tunnel when everyone else entered the facility. SP1 stated that s/he was “very upset” about the incident and waited until all of the children were picked up before s/he called FM1 and told him/her about the incident. · P2 stated that after the incident, s/he talked to all of the staff persons about the need to count the children during each transition, even when something unexpected like a thunderstorm occurred. P2, P3, and P4 each stated that there were no previous concerns about SP1’s, SP2’s, or SP3’s supervision of the children. A video camera was located above the door to the facility and provided a view of the playground. A video recording, which was 5 minutes and 58 seconds long, showed the following occurred on the day of the incident: · At :03, the children and staff persons exited the door and walked outside to the playground. · At 2:38, the staff persons moved around the playground and the children began to walk to the door. · At 3:21, one of the staff persons picked up back packs that were near the fence and took them inside the facility with children. · At 5:24, the AV exited the enclosed area of the large climber and then quickly re-entered the enclosed area. · At 5:47, the AV again exited the enclosed area of the climber, walked down the steps, walked to the facility, and out of the camera range. A second video camera was located above the classroom door and provided a view of the hallway and the doors to the playground at the far end of the hallway. A video recording, which was 3 minutes and 36 seconds long, showed the following: · At :05, the door to the entryway was opened and the staff persons and children entered the hallway and walked towards the classroom. · At :45, the staff persons and children entered the classroom and were out of the camera range. · At 2:44, P1 walked down the hallway toward the playground doors, opened the doors, picked up the AV, and carried the AV down the hallway toward the door to the preschool classroom. According to the facility’s Active Supervision of Children policy, the staff persons were to supervise the children at all times and to keep count of the children. According to the facility’s December 2023 Information and Updates, the staff persons were to ensure that they counted the children during transitions and were designating a staff person for the front, middle, and end of the line of children when transitioning from one area to another. The staff persons were to count the children out loud so that the other staff persons were also aware of the number of children present. The staff persons were to bring their attendance list to the playground and do a name-to-face count when leaving the classroom to transition to the playground and again when leaving the playground to return to the classroom. Facility documentation showed that SP1, SP2, SP3, P1, P2, P3, and P4 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. 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: On May 7, 2024, at approximately 3:07 p.m., SP1, SP2, and SP3 brought the preschool children into the facility from the playground when it began to rain. The AV was left outside the facility on the playground unsupervised for approximately three minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1, SP2, and SP3 returned to the classroom with the other children, but did not count the children as they lined up at the playground door or once they returned to the classroom. Approximately three minutes later, P1 found the AV standing outside the playground door, returned the AV to his/her classroom, and told SP1, SP2, and SP3 that s/he found the AV unsupervised on the playground. The AV was crying when P1 found him/her but did not sustain any injury during the incident. SP1, SP2, and SP3 were not aware that the AV remained outside when they took the other children into the facility, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s policies and procedures. Although the AV was not injured, given the AV was three years old and unsupervised for approximately three minutes outside during a thunderstorm on the facility’s playground which was visible to passerby the AV was placed at risk of community dangers and at an increased risk of harm. 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 on the playground in the event of an emergency and would not have been able to intervene if necessary. 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, SP2, and SP3 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. SP1, SP2, and SP3 were each responsible for the care and supervision of the AV at the time of the incident. SP1, SP2, and SP3 were 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 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 the facility’s policies were adequate, but were not followed by the staff persons. 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 11, 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.
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