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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: 1119478-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 infant playground without two staff persons’ (SP1 and SP2) knowledge or supervision for five minutes. Date of Incident(s): July 9, 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 18, 2024; from documentation at the facility and through six interviews conducted with two supervisory staff persons (P1 and P2), three staff persons (P3, SP1, and SP2), and the AV’s family member (FM). This investigator contacted another staff person (P4) and arranged a time to interview P4 via telephone. P4 did not answer the telephone at the scheduled time and did not respond to subsequent voicemails. The AV’s enrollment form stated that at the time of the incident, the AV was approximately nine months old and enrolled in the facility’s infant B classroom. The facility was located on the corner of two four lane roads each with a speed limit of 55 mile per hour. The facility was surrounded by single and multi-family housing, and fields. The parking lot was locked on two sides of the building adjacent to both roads and was accessible via both roads. The front of the building faced one road and on two sides of the building were playgrounds. One playground was the infant playground which was surrounded on three sides by an iron fence and one side by the building. The infant playground was visible to both roads and passersby. The playground was accessed via doors to the infant classrooms and the infant classrooms overlooked the playground via windows and doors. The infant classrooms shared a diaper changing/bottle warming area that had half walls and half doors. The facility had cameras that recorded video in both infant classes and the playground. On July 9, 2024, SP1 and SP2 were working in the infant B classroom with seven children, including the AV. The FM said that on July 9, 2024, P1 called him/her and said that the AV was left outside on the playground for about five minutes. The FM said that P1 did not provide “a lot of details” but that the AV was “not injured” but was “crying” when s/he was found by a staff person. The FM said that s/he has no prior “issues” with the facility and that the AV “loved” his/her teachers. P1 and P2 provided the following information: · On July 9, 2024, at approximately 12:50 p.m., P1 and P2 were in the office when P4 walked in and said that s/he saw the AV “alone” on the playground. P4 was sitting in a rocking chair in the infant A classroom near a window feeding an infant and saw the AV playing outside. P4 continued to feed the infant and then “heard” the infant B door shut and thought “they are all inside.” P4 said that as s/he was sitting s/he “caught something out of [his/her] peripheral vision.” P4 looked out the window and saw the AV outside and SP2 “running” to get the AV. · After P4 left, P1 talked to SP1 and SP2. SP1 told P1 that s/he and SP2 were outside on the playground with infant B class when the lawn service arrived and s/he decided to come inside. SP2 was at the door and when SP1 came inside s/he “saw” SP2 close the door and was “under the impression” that all the children were inside. SP1 started changing diapers and when s/he reached the AV’s name SP1 “looked” around, and then “realized” that the AV was not in the room. SP1 “quickly” looked outside and saw the AV. SP1 then asked SP2 to go outside and get the AV and bring him/her back in. · SP2 told P1 that s/he was outside with SP1 and when it was time to go inside, SP2 stood at the door and held it open for SP1. SP2 did a name-to-face count of the children as SP1 brought the children inside. SP2 “saw” what s/he “thought” was the last baby so s/he shut the door and entered the classroom. SP2 said that s/he began to lay children down for nap while also preparing bottles, as SP1 began to change diapers. While SP2 was warming a bottle, P3 called SP2 over into the infant A classroom to help with a baby. As SP2 was helping the baby, SP1 asked him/her to “come back over quickly.” When SP2 returned, SP1 said that the AV was outside and SP2 needed to go “grab [the AV] and bring [him/her] back in” and SP2 did so. · SP1 and SP2 each told P1 that they did not complete a sweep of the playground to ensure all of the children were accounted for. SP2 said that s/he “thought” SP1 did the sweep and SP1 said s/he thought SP2 completed the name-to face count and that all of the children were in because SP2 closed the door. · P1 and P2 watched then watched the videos and saw that the AV was out on the playground by him/herself for approximately five minutes. SP1 carried the infants inside while SP2 completed the name-to-face count sheet. SP1 and SP did not complete a sweep of the playground before shutting the door. · P1 and P2 said that staff persons were trained to complete a “sweep” of the playground to make sure that no children were left behind. · P1 and P2 had no prior concerns about SP1 and SP2. P3 said that s/he was in infant A sitting in the rocking chair by the classroom door and P4 was in the rocking chair by the exit door when P3 looked at P4 and saw that P4 had a “startled” look on his/her face. P4 looked out the window, then got up from the rocking chair and walked toward P3, and said, “There is a baby out there.” P3 then looked out the window and saw SP2 on the playground. P4 then left the classroom to talk with P1. P3 did not know when the infant B classroom came in but saw SP1 at the diaper changing area prior to P4 seeing the AV on the playground. There were four videos that included one of the playground timestamped 12:41-12:51 p.m., one of the infant A classroom and two of the infant B classroom. The infant videos were timestamped from 12:43-12:51 p.m. The videos provided the following information: · At 12:41 p.m., SP1 and SP2 were on the playground with seven children, including the AV. The AV was in the middle of the playground and lawn service persons were on the grassy area. · At 12:41:54 p.m., the AV crawled to the play structure and sat near another child and SP2. SP2 then picked up the other child and walked toward the door. SP1 was on the other side of the play structure and walked another child to the door while carrying an iPad. · At 12:42:57 p.m., SP1 opened the door and held it open with his/her foot. SP2 then walked into the classroom with the child in his/her arms as the AV crawled toward the play table. · Between 12:43:06 and 12:44:22 p.m., SP1 and SP2 were in and out of the classroom moving children from the playground to the classroom. During this time the AV was crawling on the playground and at points out of view of the camera. · At 12:44:45 p.m., SP2 shut the door and SP1 picked up a child and walked into the diaper changing area. SP2 then placed a child in a crib. · Between 12:45:19 and 12:50:13 p.m., SP1 and SP2 were in the classroom engaging in various work-related activities including making bottles and putting children down for nap as the AV remained on the playground. SP1 change a child’s diaper and did not wash his/her hands or the child’s hands after the diaper change, which was a violation of Minnesota Rule, part 9503.0140, subpart 13 and 14, which stated that a child's hands must be washed with soap and water after a diaper change, after use of a toilet or toilet training chair, and before eating a meal or snack. Staff must monitor hand washing and assist a child who needs help, and a staff person must wash his or her hands with soap and water after changing a child's diaper, after using toilet facilities, and before handling food or eating. · At 12:50:15 p.m., SP1 opened the door, looked toward the play structure, walked onto the sidewalk and then walked back to the door. SP1 held the door open with his/her foot while facing the AV. · At 12:50:34 p.m., SP2 walked out onto the playground, walked to the play structure, picked up the AV, and reentered the facility. SP1 said that s/he was on the playground with SP2 and eight children, including the AV. When it was time to go inside SP1 told SP2 to hold the door open and do name to face count as s/he brought the children inside. SP1 brought a child in and then when SP2 “shut the door,” SP1 “assumed” all the children were in the classroom. SP1 began changing diapers and “thought” that SP2 was helping P3. As SP1 was getting the AV’s diaper s/he “realized” the AV was not in the classroom. SP2 was helping P3 and SP1 “thought” s/he “yelled” for SP2. SP1 “thought” that s/he then went outside to get the AV but was not “100% sure.” SP1 said that the AV “looked fine” when s/he saw the AV and that the AV was “not crying.” SP1 and the AV came back into the classroom. P4, who was in the infant A classroom, then asked SP1 if the AV was outside. SP1 replied, “Yeah,” and then P4 went to tell P1 about the incident. SP1 said that neither s/he nor SP2 completed a check of the playground for children prior to closing the door. SP1 said that s/he did not know about “sweeping” the playground for children until after the incident and that s/he was trained to complete a name to face count of the children when they were transitioning from different areas of the facility. SP1 said that s/he did not count the children before the class came inside or once they were in the classroom. SP2 said that s/he was outside with SP1 when SP1 said it “was too hot” hot outside and that they were going inside. SP1 then told SP2, “You hold the door.” Prior to opening the door, they completed a “count” of eight children, including the AV. SP2 then opened and held the door while SP1 brought the children inside. SP2 said that as s/he “tried” to keep the door open, an infant who was inside, kept trying to crawl back outside. “A couple of minutes in,” SP2 thought everyone was inside because SP1 walked over to the diaper changing area. So SP2 “assumed” that SP1 checked the playground to ensure all the children were inside. SP2 said that as the children came inside, s/he completed the name-to face check on the attendance roster as the children came inside and “thought” s/he saw the AV come inside and s/he had “checked’ the AV’s name on the transition spot. SP2 then closed the door and came into the classroom where s/he warmed bottles. SP2 then went into the infant A classroom to help P3. SP2 heard SP1 “call out” to SP2 that “[the AV’s] outside” and asked, “Can you run out and grab [the AV].” SP2 “ran” outside and saw the AV by the slide the AV was “not crying” and “seemed fine.” According to Weather Underground, www.wunderground.com, in Ramsey, MN it was mostly cloudy and 84 degrees Fahrenheit at 12:53 p.m. The facility’s Safety and Supervision Policy and Risk Reduction Plan stated that staff persons “are to position themselves to see and hear the children in their classroom and playground. Name to face checks must be conducted hourly throughout the day and more often, during busy drop-off and pick-up times, and during times of transition. No child is allowed on the playground without and adult accompanying them.” The facility’s Name to Face and Transition Policy stated that in order “to assure that children are not left in classrooms, specialty areas, or on the playground. The staff person will complete the transition portion of the Attendance Roster. Each transition will be indicated by the place the class is traveling to and the time the transition took place. At each transition, the teacher will note very child in his/her care by looking at the child and then marking the box under the designated transition and time.” The Attendance Roster dated July 9, 2024, showed that the AV was checked into the classroom from the playground under transition box #2. Facility’s records showed that prior to the incident, P1-P4 and SP1 and SP2 were trained on the facility’s Safety and Supervision Policy, Name to Face and Transition Policy, and Risk Reduction Plan Guidance Policy, 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 was consistent that on July 9, 2024, the AV, who was nine months old, was left outside unsupervised for approximately five minutes which was inconsistent with the facility’s Risk Reduction Plan and the Safety and Supervision Policies; and a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. When SP2 went to get the AV, the AV was not injured and was not crying. Although the AV was in a fenced in playground, given that the AV was nine months old and that the playground was outside visible to passersby, the AV was at risk of potential community dangers. In addition, the AV would not 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 and would not have been able to intervene. 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. Facility documentation showed that SP1 and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s policies prior to the incident. SP1 and SP2 were each responsible for the care and supervision of the AV at the time of the incident. SP1 and SP2 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 and SP2 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 its policies and procedures were adequate but not followed by SP1 and SP2. SP1 and SP2 received additional training on proper name to face procedures. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 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 and SP2 were each responsible for maltreatment is subject to appeal. On December 13, 2024, the facility was issued a Correction Order for the violation outlined in this report and for failing to wash children’s hands and the staff persons hands after diaper changes. 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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