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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: 1088066-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) walked out the front door and was alone outside. Date of Incident(s): September 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 September 18, 2024; from documentation and video footage at the facility; and through five interviews conducted with two supervisory staff persons (P1 and P4), two facility staff persons (P2 and P3), and the AV’s family member (FM1). The AV was three years old, enrolled in the early preschool room, and began attending the facility a few days before the incident. Consistent information was provided that P2 and P3 were working in the early preschool room at the time of the incident. At the facility’s front entrance, there was a set of double doors that led into a vestibule, then a second set of double doors led into a lobby library. The vestibule had windows on all four sides. P1’s office was adjacent to the vestibule with a window between the two rooms. P1’s office also had windows to outside. The front door went out to a sidewalk and then a parking lot. The facility had businesses and houses surrounding it. The early preschool room was at the end of a hall that led from the library. P1-P4 provided consistent information that since the COVID-19 pandemic began, family members of children used an app to text the facility approximately five minutes prior to their arrival. P2 and P3 got the children ready and they watched as the children walked down the hall to the library, where either P1 or another supervisory staff person acknowledged the child. The children then waited in the library for their family members. Video footage (that did not include date and time) from the facility showed a family member (FM2) of another child (C) walked out the front door carrying the C. FM2 walked down the sidewalk to a parked car. Two seconds after the front door closed, the AV pushed the front door back open and walked outside. The AV took approximately three steps, stood on the sidewalk, and looked around. FM2 did not look back while placing the C inside his/her car. The AV stood on the sidewalk and approximately 42 seconds after s/he walked out the front door, the AV walked down the sidewalk and met FM1. FM1 walked the AV back inside the facility. P1 provided the following information: · On September 9, 2024, at approximately 4:50 p.m., P1 saw a text that FM1 was on his/her way to the facility. P1 used a walkie talkie to let P2 and P3 know to send the AV to the library. P1 heard P2 or P3 say that the AV was coming to the library but P1 did not see the AV. During that time, FM2 arrived at the facility, got the C, mentioned something unrelated to P1, and left the facility. · P1 sat at his/her desk and worked on attendance to see if a staff person could leave when s/he saw the AV and FM1 walk past the outside window back into the facility. P1 had not seen the AV enter the library or exit the front door so s/he was confused. · P1 asked FM1 what happened and FM1 said that the AV was outside. The AV did not have an injury and was smiling. P1 “immediately” went and looked at video footage of the incident and saved it. · P1 said the common practice at the facility was that children were sent to the library to await pickup, where P1 and sometimes other supervisory staff persons had a line of sight to the children. However, P1 had additional job duties that s/he also needed to complete and was unable to watch children who were waiting in the library at all times. Due to the difficulty with supervising children under this procedure, P1 had previously had “multiple” conversations with P4 about changing pick up procedures back to the procedures in place prior to the COVID-19 pandemic, when the family members picked up their children in the classrooms. P4 stated that family members preferred picking up children from the library, so the facility continued with that process until shortly after the incident. P1 assisted with supervising the children in the lobby, with backup or additional assistance from P4 and other supervisory staff persons when P1 was not in his/her office, or when it was “busier.” P1 denied that any staff persons had discussed concerns with the pickup procedure prior to the incident. FM1 stated on the day of the incident, s/he texted the facility to let them know s/he was on his/her way to get the AV. When FM1 walked around the corner of the facility s/he saw the AV standing alone approximately two to three feet outside the front door. FM1 “immediately” called to the AV who ran over. The AV did not have any injuries. FM1 and the AV walked back inside and spoke to P1 who was not aware that the AV had left the facility. FM1 was familiar with the change in pick up process during the COVID-19 pandemic because s/he had an older child who attended the facility. FM1 was “happy” that after the incident, the facility reverted to the previous procedures that required family members to pick up children in their classrooms. FM1 did not have any other concerns with the facility. According to the Supervision of Children policy, children were supervised “by sight and sound at all times.” According to the facility’s Drop Off/Pick Up policy, it was recommended that one family member dropped off and picked up children “when possible.” Family members were not allowed inside the facility for drop off/pick up and used curbside or “doorway drop off and pick up [sic]” to “limited unexpected contact” between family members and staff persons and maintain social distancing recommendations. Children were supervised “at all times” and no child was allowed to be unattended in the parking lot. Facility documentation showed that all staff persons interviewed for this investigation received training on the facility’s Supervision of Children policy, Drop Off/Pick Up policy, and the Maltreatment of Minors Act 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 stated that a child must have supervision at all times and that supervision was 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: Video footage provided by the facility showed that on September 9, 2024, the AV, who was three years old, walked out the front door and stood on the sidewalk for approximately 42 seconds without staff knowledge or supervision, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. When the AV left the facility without the knowledge or supervision of staff persons, the AV was exposed to dangers outside the facility including unknown community persons, the parking lot and street traffic. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health when reasonable 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 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. Consistent information was provided by P1-P4 and FM1 that it was the common practice of the facility to release the children from their respective room to the library area to wait for family members. This practice did not ensure that children were supervised at all times while they waited for pick up in the library, including when the incident occurred on September 9, 2024. Therefore, P1’s responsibility was mitigated and the facility was determined responsible for maltreatment of the AV. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 the facility was responsible did not meet statutory criteria to be determined as serious because the AV did not sustain an injury. 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. Shortly after the incident, the facility changed the pickup policy so family members picked up the children in their respective room. Action Taken by Department of Human Services, Office of Inspector General: On January 10, 2025, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. 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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