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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: 1000965-CCC (Child Care Center) Investigator(s): Judie Schwanke Suspected Maltreatment Reported: It was reported that the AV was in a classroom for approximately six minutes without staff persons’ (SP1 and SP2) knowledge or supervision. Date of Incident(s): July 22, 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 August 7, 2024; from documentation at the facility; and through six interviews conducted with the AV, the AV’s family member (FM), a community person (CP), a supervisory staff person (P) and two staff persons (SP1 and SP2). The facility had a main entrance located at the front of the building. Inside the main door was a foyer with access to a Great Room. Off of the Great Room were doors to four Preschool classrooms named accordingly. Preschool 1 was an open room with tables, chairs, stacked cots, a climbing structure, and toy shelves throughout the room. One wall had windows and a door to the playground. Straight ahead from the playground door at the other end of the classroom was a bathroom. Between the playground door and the bathroom were cabinets along a wall. There were lockers on the opposite wall. Outside the bathroom and around a corner was a changing table and a handsink. There were video cameras in the Preschool 1 classroom and the playground. Facility documentation showed the AV was four years old and enrolled in the Preschool 2 classroom at the time of the incident. The facility’s internal review of the incident showed that the AV was unsupervised in the classroom for approximately six minutes. While the AV was in the classroom unsupervised, s/he was in the “book area,” and did not “appear” to be “sad.” Two different unrelated community persons, who were family members of children from the facility, walked through the room and saw the AV unsupervised. One of them, the CP, met SP2 at the playground door and told SP2 that the AV was inside. The AV then walked to the playground door and met SP2 and went back to the playground. The AV stated that s/he liked his/her classroom because s/he got to ride his/her bike. The AV did not provide information relevant to this investigation. The FM stated that on July 23, 2024, s/he talked with the P and was told that the preschool children had been on the playground when some children went in to a classroom. When the children went back out to the playground, all went out but the AV who remained inside. The FM was told that the AV was inside a “short” amount of time. The FM stated that the AV’s behavior did not change after the incident, and prior to the incident, the FM did not have concerns with the facility. The P provided the following information: · The P stated that on the morning of July 23, 2024, SP2 told the P that the previous afternoon at approximately 3:47 p.m., the AV was unsupervised in the classroom. The P reviewed video footage of the incident and saw the AV and SP1 on the playground. SP1 opened the Preschool 1 door from the playground and stayed at the open door to supervise the AV who was using the bathroom. SP2 then walked into the Preschool 1 classroom from the playground. The AV walked toward the door and SP2 watched him/her. Then SP2 walked toward the door and the AV turned and went to the hand sink and washed his/her hands and SP2 walked out the door and the door shut. When the AV finished washing his/her hands s/he walked to the playground door and then went to the “library.” “Not long after” another “parent” walked into the classroom and outside and then the CP walked into the class and to the door and then the AV walked to the door. After the incident, SP1 told the P that s/he asked SP2 if all the children had gone outside and SP2 told the P that s/he “thought” that s/he saw the AV “go back outside,” and “confirmed” that with SP1. · Prior to the incident, staff persons were told that they “could” stand at the playground door and supervise children inside who were using the bathroom. On the day of the incident, SP1 and SP2 should “have double checked” the classroom before the playground door closed and should have tracked how many children went “in” and “out” and “verified” the number with each other. SP1 provided the following information: · On the day of the incident, at approximately 3 p.m., SP1, SP2, and the Preschool 2 children were on the playground with the Preschool 1 and another staff person. SP1 did not recall the number of children in the Preschool 2 classroom at the time of the incident, but stated that there were less than 10 children. SP1 opened the door to the Preschool 1 classroom to let a child in to use the bathroom. SP1 then held the door open and “supervised” the playground and the bathroom. While that child was still inside, the AV told SP1 that s/he needed to use the bathroom so the AV went inside and the other child came out. SP1 stated that as s/he stood at the door s/he could see the children on the playground, into the Preschool 1 classroom, and the AV in the bathroom as s/he held the door open. · SP1 provided conflicting information regarding what happened next. Initially SP1 stated that as s/he held the door open, SP2 went inside the Preschool 1 classroom with a “group” of children. Later, SP1 stated that SP2 went inside with one child and did that child’s hair. SP1 did not recall if they talked at that time. SP2 walked approximately “three feet” into the room and stood at the cabinets between the door and the bathroom. When SP2 was “done,” SP1 held the door open “wider” for the “group” of children who walked out the door. SP1 “knew” the AV went inside to use the bathroom but SP2 brought more kids inside and SP1 only saw “little heads” walk out of the classroom but did not see the AV walk out. · SP2 walked toward the door and from the doorway, SP1 and SP2 “looked back” into the classroom and did not see any children so SP1 “assumed” the AV went out with the group of children. SP1 did not recall if s/he talked with SP2 at this time. SP1 and SP2 shut the door and went back out to the playground. Once back on the playground, SP1 did not specifically look for the AV but saw children who had the same hairstyle as the AV. · Approximately three minutes later, the CP opened the playground door, talked with SP2, and the AV came outside. SP1 did not hear what they said. SP2 then told SP1 that the AV had been left inside. · The AV joined SP1 and other children at a table for a water break. The AV seemed “calm” and was not crying. SP1 asked the AV if s/he was “okay” and the AV was “fine.” · SP1 had been trained that when a child was outside and needed to use the bathroom, s/he could stand at the playground door and let the child inside and then watch the children on the playground and the child in the bathroom. Usually, when children needed to use the bathroom, they used the bathroom in the Preschool 2 classroom and that bathroom was “very” close to the playground door. On the day of the incident, the Preschool 2 playground door was “locked.” SP2 provided the following information: · On July 22, 2024, at approximately 3:30 p.m., SP2 and SP1 were was on the playground with the Preschool 2 children, including the AV. Preschool 1 and Preschool 3 children were also on the playground. SP2 stated there were approximately 16 children total at the time of the incident. One child needed a rubber band for his/her hair so as SP1 held the playground door open “doing bathrooms,” SP2 walked past SP1 and told SP1 that s/he was going inside to get rubber bands and did so. · SP2 was standing in the classroom between the playground door and the bathroom, when the AV walked out of the bathroom behind SP2. At that time, SP2 “thought” the AV had already washed his/her hands and said, “Hi,” to the AV. SP2 turned and “thought” s/he saw the AV run toward the door. SP1 then asked SP2 if “everyone was out,” and SP2 told SP1 that s/he “thought so” but that s/he did not know who SP1 let inside to use the bathroom, and SP1 should “keep track” of what children went in and out of the classroom. · SP2 then walked out the door and SP1 closed the door behind him/her. SP1 and SP2 did not talk as SP2 walked through the door and onto the playground. · A “couple” of minutes later, the CP opened the door and SP2 saw the AV inside by the door. SP2 asked the CP if the AV was inside and the CP told SP2 that the AV was in the room on a couch. SP2 thought the AV was inside unsupervised between four and five minutes. · The AV then walked out the door and SP2 asked the AV if s/he was “left inside,” and the AV said, “Uh huh.” SP2 asked the AV where s/he “went,” and the AV told SP2 that s/he went to “wash” his/her hands. SP2 told the AV they would make sure that never happened again. The AV was calm and then went to play on the playground. · SP2 then told SP1 that the AV had been left inside. SP2 stated that SP1 “should have” watched to make sure the children that s/he sent inside came back out. · Before the incident, staff persons sent children into the Preschool 2 classroom and held the door to the playground open. On the day of the incident, the Preschool 2 playground door was locked so they used the Preschool 1 bathroom instead. Typically, SP2 sent two children inside and made sure two children came back out. The facility provided four videos of the incident that did not have audio. The videos provided the following information: o At 3:43:57 p.m., the AV was on the playground and walked toward the Preschool 1 playground door. The door was partially open. There was a large glass window in the door and a staff person was seen holding the door open. [Note: Although the staff person was not identifiable at this point in the video, based on clothing seen later in the video, the staff person was SP1.] Inside the Preschool 1 classroom was a child near the bathroom. o At 3:44:47 p.m., SP1 opened the door wider and the AV walked into the Preschool 1 classroom. o At 3:45:06 p.m., the AV entered the classroom bathroom. o At 3:46:18 p.m., SP2 was on the playground and approached the Preschool 1 door. As SP2 stood outside the door, a child on the playground walked up and stood beside SP2. The child that was inside, walked through the door and out onto the playground. o At 3:46:46 p.m., SP2 walked into the Preschool 1 classroom and stopped at the cabinets between the bathroom and the playground door. o At 3:46:54 p.m., the AV walked out of the bathroom toward the playground door and past SP2. The AV turned and walked back toward SP2 and SP2 looked toward the door. SP2 then walked toward the door and the AV and SP2 passed each other. o At 3:47:13 p.m., the AV arrived at the hand sink in the classroom. o At 3:47:19 p.m., SP2 walked through the playground door and exited the classroom. SP1 left the doorway. o At 3:47:24 p.m., the playground door shut and SP1 and SP2 walked to a shade structure on the playground. o At 3:47:55 p.m., the AV finished washing his/her hands, used paper towels to dry his/her hands, threw them away, and walked to the playground door and stood. o At 3:48:56 p.m., the AV turned and walked a couple of steps away from the playground door, stood for almost a minute, turned, and walked back to the door. o At 3:51:14 p.m., the AV turned away from the door and walked away as the door from the Great Room opened and a family member walked into the classroom. The AV walked to the corner of the room under the camera and was not visible. o At 3:51:30 p.m., the playground door opened and the family member walked out on the playground to the shade structure and s/he talked with SP2. A child ran up to the family member and they stay near the shade structure and SP2 walked toward the classroom door. o At 3:51:53 p.m., the CP opened the classroom door from the Great Room and stepped into the classroom with his/her two children. The CP looked at the AV and then toward the playground door. The CP then walked to a locker in the corner of the room near the AV and then walked toward the playground door. o At 3:52:27 p.m., the SP opened the Preschool 1 playground door and SP2 approached the door. The CP’s two children walked onto the playground and the CP stood in the doorway with his/her back on the door and held the door open. SP2 faced the CP. o At 3:52:53 p.m., the family member and his/her child walked into the Preschool 1 classroom from the playground. They walked to a locker near the AV and then the AV walked to the playground door and stood near it. o At 3:53:23 p.m., SP2 walked into the Preschool 1 classroom from the doorway, took the AV by his/her left wrist, and walk to the playground door. o At 3:54 p.m., SP2 walked out the door onto the playground with the AV. The AV walked to the shade structure and SP2 wrote on a clipboard. The AV joined a line of children at the shade structure. o At 3:54:58 p.m., SP2 walked toward the shade structure and the video ended. The CP did not recall the incident and did not provide further information. The facility’s Safety and Supervision Policies stated that children must be in sight and sound at all times and staff persons should “always know the exact number of children” they were responsible for, their names, and where they were at all times. Facility documentation showed that the P, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and the facility’s Safety and Supervision Policy before the incident. Relevant Rules and 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 was consistent that on July 22, 2024, at approximately 3:47 p.m., the AV was left in the Preschool 1 classroom for approximately six minutes without the knowledge or supervision of SP1 or SP2, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. The AV was found in the Preschool 1 classroom by SP2 and was brought to the playground unharmed. Although the AV was in a classroom designed for children who were the AV’s age, the AV was in the classroom without staff persons’ knowledge unsupervised for approximately six minutes prior to being found by SP2. Given that the AV was four years old, 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 in the classroom in the event of an emergency. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with the necessary care and a failure to protect the AV from conditions or actions that could seriously endanger the AV’s physical 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. 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 Safety and Supervision and Transition Policies. At the time of the incident, SP1 allowed the AV to enter the classroom and was responsible for the care and supervision of the AV. However, in the classroom, SP2 saw and acknowledged the AV and SP1 and SP2 left the classroom at the same time. Given that SP1 and SP2 were both in the classroom, aware the AV was in the classroom, and left the classroom at the same time, SP1 and SP2 were each responsible to ensure the AV transitioned to the playground after using the bathroom. SP1 and SP2 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 and SP2 were 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 their policies and procedures were adequate but not followed by SP1 and SP2. The facility updated the procedure when children were outside and needed to use the bathroom and all staff persons were retrained on this change.
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 the disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal.
On December 20, 2024, the facility received 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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