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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: 1118093-CCC (Child Care Center) Investigator(s): Judie Schwanke Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on a facility playground without staff persons’ (SP1 and SP2) knowledge or supervision for 30 minutes. Date of Incident(s): August 14, 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 29, 2024; from documentation at the facility; and through five interviews conducted with the AV’s family member (FM), a supervisory staff person (P1), and facility staff persons (P2, SP1, and SP2). The facility was a stand-alone building located on the corner of a “T” intersection of two roads each with a speed limit of 20 miles per hour. The front door was located facing the top of the “T.” The facility was located in a residential neighborhood next to a church and had businesses nearby. An alley ran between the facility and the church. A facility playground was also located on the corner and there were sidewalks between the roads and the playground. The playground was enclosed by two different types of five-foot tall fencing, vertical wrought iron and chain link. The playground was divided into two sections, preschool and toddler, by a wooden fence that ran from the chain link fence to approximately two feet from the facility. This left a gap where children could move freely between the two areas. There were multiple gates on the playground. Gate A was located in the corner of the toddler playground nearest the church, entrance to the alley, and one road. The toddler playground had a second gate and neither of the gates were locked. Gate B was located in the preschool playground near the front door and there was a sidewalk in the preschool playground that led to this gate. Gate B was locked and had a number pincode pad on the outside and a push bar on the inside of the playground. On the playground was a large cell phone tower to which the children had access. The cell tower was secured to a concrete foundation with nine exposed, metal bolt ends that were two inches in diameter and protruded nine inches up from the base of the tower. Small shrubs were planted around the base of the tower. The children also had access to pipes protruding from the wall near the facility door, inside the playground. One of the pipes had an exposed wire inside of it. At the time of the site visit, garbage was also on the playground including two used disposable paper cups, a torn plastic bag, and a piece of bubble wrap which were violations of Minnesota Rules, part 9503.0140, subpart 9, which states in part that outdoor space and equipment of the center must be clean; subpart 17, which states in part that plastic bags must be stored out of reach of children; and subpart 20, which states in part that the areas used by children must be free from debris and litter. The facility front door had a secure entrance that required a key to open. Inside the front door was a foyer and another set of doors. Past those doors was a hallway to two sets of stairs, a facility office, and an elevator. There were classrooms on the upper level of the facility, including the Frog classroom and there was a kitchen on the lower level of the facility. According to weatherunderground.com, the temperature on August 14, 2024, at 11 a.m., was 80 degrees Farhenheit, with 54 percent humidity. Facility documentation showed the AV was 31 months old and enrolled in the Frog toddler classroom at the time of the incident. The FM stated that on August 14, 2024, the P called and said that, the AV, his/her class, and two staff persons went out to the playground “mid-morning”. The Frog classroom normal staff persons were not there on the day of the incident and the FM did not know what staff persons were working. When the class went inside, the two staff persons “did not do a head count” of the children and the AV was left outside on the playground for approximately “20” minutes. One staff person “realized” the AV was not in the room and went to find him/her. When the staff person found the AV on the playground s/he was “upset” and the staff person “comforted” the AV and held him/her. The AV’s behavior did not change after the incident and the FM did not have prior concerns with the facility. P2 provided the following information: · On the day of the incident, at approximately 10:20 a.m., P2 walked his/her group of 10 children to a local park. P2 did not know if the Frog classroom was on the playground when s/he left the facility. · At 11 a.m., P2 received a phone call from P1 who told P2 to come back to the facility with his/her class for soccer class. At 11:15 a.m. they arrived back to the facility and walked to the playground and went in gate A. On the playground, P2 met the soccer coach who asked P2 to get water for the children. P2 and the children walked through the playground and when s/he arrived at gate B, s/he saw the AV sitting on the sidewalk, crying. The AV was “facing” the gate and “grasping” the bars of the gate. The AV saw P2 and “scooted” toward P2. · P2 picked up the AV and went inside with the AV and his/her ten children. P2 walked to the kitchen and found P1 there. P2 told P1 that s/he had found the AV outside. P1 took the AV from P2 and P2 took his/her children to get water. · At the time of the incident, it was “sunny” and between 75 and 80 degrees. The AV had on “long pants” and a “short sleeved shirt.” The AV did not have water on the playground. · P2 was trained to do “name to face” count and not “just count” when children transitioned from one area to another. · The Frog classroom usually went inside from the playground at 10:30 a.m., and based on that, P2 estimated that the AV was outside, unsupervised between 30 and 45 minutes. P1 provided the following information: · On August 14, 2024, between 10:40 and 10:45 a.m., P1 was in a facility office and watched SP1, SP2, and the children enter the facility from the sidewalk. At approximately 11 a.m., P1 was in the kitchen and P2 brought the AV to P1 and said that s/he found the AV on the playground alone. The AV was crying and P1 took the AV from P2 and “held” the AV until s/he “calmed.” P1 then took the AV back to the Frog classroom. · P1 did not recall where in the classroom SP1 and SP2 were or what they were doing when P1 entered the classroom. P1 “thought” the children were washing hands and sitting down at tables for lunch. P1 told SP1 and SP2 that the AV had been found on the playground by P2. P1 looked at the name to face sheet and saw that neither SP1 nor SP2 completed the sheet when they went from the playground to the classroom. P1 did not ask SP1 or SP2 why they did not complete the sheet but told them that it needed to be completed. Neither SP1 nor SP2 said anything to P1 when s/he brought the AV into the classroom. · Later in the afternoon, SP2 went to the office to talk about the incident with P1. P1 was “not ready” to talk with SP2 at that time and they did not discuss the incident. · P1 then called the FM and told him/her that the AV had been unsupervised on the playground for 20 minutes. · P1 stated that when staff persons brought children into the facility from the playground, they should count children before they leave the playground, in the foyer, and in the classroom. SP1 provided the following information: · On August 14, 2024, at approximately 10:00 a.m., SP1, SP2, and the children, including the AV, went to the preschool playground. It was hot outside and while the group was on the playground, “several” more children arrived and joined the classroom, “one after another,” and the amount of children was “different” from when the group when to the playground. · While they were on the playground, as the children arrived, SP1 checked them in on an iPad and also wrote each name on the name to face sheet. SP1 “thought” there were 13 children present and did not “double check” with SP2. SP1 learned after the incident that there were 14 children on the playground. · At approximately 10:30 a.m., SP1 had the children line up by gate B. SP1 and SP2 “counted” heads. SP1 counted and told SP2 that there were 13 children and SP2 told SP1 that s/he “thought” there should be 14 children. SP1 told SP2 that s/he thought there should be 13 and SP2 said, “Okay, 13.” SP1 looked around and did not see “anyone.” Neither SP1 nor SP2 used the iPad or the name to face sheet when bringing the children inside. · SP1, SP2, and the children then left the playground, entered the facility, and walked to their classroom. SP1 was at the front of the line and SP2 was at the back. SP1 said s/he did not count the children as they entered the front door of the facility because s/he did not know s/he had to. When they arrived at the classroom, the children immediately washed their hands and sat down at tables. At that time, SP1 “recounted” 13 children. SP1 stated s/he did not compare that number to the name to face attendance because s/he was “tired.” · SP1 then started an activity with the children and SP2 “realized” that the AV was not in the classroom and told SP1 that the AV was not in the room and asked SP1 for the front door key. At approximately 11:25 a.m., SP2 left the classroom and SP1 “thought” SP2 brought the AV back to the classroom. When the AV rejoined the class, s/he was “quiet” and ate lunch. Then the AV napped and after nap s/he cried a “little bit.” · SP1 stated that the AV was unsupervised between 30 and 45 minutes. · SP1 had been trained to “check kids’ names and confirm with their face” and make sure they were present every time they went out and transferred back inside. Prior to the incident, P1 told SP1 how to use the name to face form. SP2 provided the following information: · On the day of the incident at approximately 10 a.m., SP1 and SP2 worked in the Frog classroom and the group went outside with 12 children, including the AV. While they were on the playground, two more children arrived so there were 14 children. · Between 10:45 and 11 a.m., SP1 lined the children up on the sidewalk near the gate to go inside. SP2 was at the end of the line and held hands with two children. SP1 was at the front of the line and had the iPad and the name to face form. SP2 did not recall if a count was done at the gate. · The group walked through the gate to the front door of the facility. SP1 had the door key and opened the door and children “ran” inside. The interior door was “open” and the children “started running” to their class. SP2 did not recall if a count was done at the door. · When the group got into the classroom, the children sat down and SP1 and SP2 gave them water. SP2 did not recall if a count was done in the classroom. · At some point, SP2 did not see the AV and looked for the AV in the book corner which the AV liked, but did not see him/her there or anywhere else. SP2 then told SP1 that the AV was not in the room. SP1 gave SP2 the door key and SP2 left the classroom to look for the AV. As SP2 walked down the stairs, s/he saw P1 with the AV. The AV was “quiet.” SP2 went back to the Frog classroom and P1 brought the AV to the classroom. SP2 did not know how long the AV was unsupervised on the playground. · SP2 stated that s/he was trained and “knew” to count the children when they left and returned to a location but did not do so the day of the incident because s/he did not have the iPad or the name to face sheet, s/he did not usually “work in the room,” and s/he was “busy.” SP1 also should have counted at the gate and at the front door.
The facility’s Supervision of Children showed that all children were “within sight and hearing” of a staff person “at all times,” so that a staff person could “intervene to protect the health and safety” of the child. The facility’s Name to Face policy showed that staff persons used name to face attendance “any time the class…transitions to any location outside of the classroom.” At the top of the name to face form “under T”, staff persons wrote the code for the transition destination. Then the staff person read the child’s name, visually located the child, and checked off his/her name on the form. After completing the name to face check, staff persons counted the check marks, verified the correct total and if the numbers matched, initialed the form. If the number did not match, staff persons corrected the total and/or retook name to face attendance. If the name to face count was accurate, staff persons proceeded to their destination, and upon arrival, counted to be sure all children were accounted for. The Name to Face sheet, dated August 14, 2024 showed that the AV arrived at 7:55 a.m. Two other children arrived at 10:15 and 10:17 a.m., respectively. Another child was added to the list after but the time of that child’s arrival was listed as 8:10 a.m. The total number of children present at 10:17 a.m., was 14. Facility documentation showed that P1, P2, SP1, and SP2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including the Supervision of Children and the Name to Face policy. 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 August 14, 2024, the AV was on the preschool playground between 20 and 45 minutes without the knowledge or supervision of SP1 and SP2 which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. P2 found the AV on the playground and brought him/her inside to P1 who returned the AV to the Frog classroom. Although SP1 stated that s/he counted the children, SP1’s count was inaccurate and SP2 did not count which left the AV, who was 31 months old, unsupervised on the facility playground between 20 and 45 minutes before being found by P2. Given that the AV was visible to passersby; that the location of the playground exposed the AV to community persons, vehicle traffic, and other hazards; and that there were hazards on the playground, it was unlikely the AV would be able to provide for him/herself in an emergency and staff persons were not aware the AV was on the playground in the event of any 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 were trained on the Reporting of Maltreatment of Minors Act and on the facility’s procedures including the Supervision of Children and Face to Name policy. At the time of the incident, SP1 and SP2 were working in the Frog classroom and were each responsible for the care and supervision of all the children in the classroom, including the AV, and responsible for ensuring all the children were present after transitioning from the playground to the classroom. SP1 and SP2 were each responsible for 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. However, information obtained by the Department of Human Services, in combination with this report, resulted in SP2 being disqualified for recurring maltreatment. SP2 was disqualified from providing direct contact services. 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 of the incident and determined that their policies and procedures were adequate but not followed by SP1 and SP2. SP2 was retrained on the facility’s Name to Face policy. All other staff persons reviewed the Name to Face policy. SP1 no longer worked at the facility. 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 disqualification. The determination that SP1 was responsible for maltreatment is subject to appeal. SP2 was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that SP2 was responsible for maltreatment and the disqualification of SP2 are each subject to appeal. On January 9, 2025, the facility was issued a Correction Order for the violations 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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