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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: 1012986-CCC (Child Care Center) Investigator(s): Van Mulheron Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left on the playground without two staff persons’ (SP1 and SP2) knowledge or supervision for approximately nine minutes. Date of Incident(s): July 16, 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 31, 2024; from documentation at the facility and through seven interviews conducted with two supervisory staff persons (P1 and P2), four staff persons (P3, P4, SP1, and SP2) and the AV’s family member (FM). The AV was 20 months old at the time of the incident and was enrolled in a toddler classroom. The facility was a standalone building located in an area with shared driveways and parking lots with a fast-food restaurant, a gas station and two beauty school buildings. Directly in front of the building was a parking lot and a sidewalk. In front, on one side of the building was an enclosed trash area and then the toddler playground. The toddler playground was surrounded on three sides by fencing and on one side by the facility. A sidewalk was between the trash enclosure and playground. The sidewalk also went behind the trash enclosure and led to two doors to the building and two gates to the toddler playground. The toddler classroom door was a third door but the only door that opened directly onto the toddler playground. A wrought iron vertical fence ran along the sidewalk and a chain link fence along the other two sides. Behind a portion of the chain link fence were trees and a grassy field. There was a gate in the chain link fence that led onto the preschool playground. The toddler playground had a play structure with a slide in the middle and behind the play structure was a playhouse. In addition, there were various large motor toys such as cars and sees saws. The playground was visible to passersby in portions of the parking lot and driveway. The entrance to the facility had an office and past the office was a large motor room. To the rear of the large motor room was a hallway that led directly to the toddler classroom. The toddler classroom had an exterior door that led to the playground. The door had an alarm sounded when the door was open. There was a button above the door to turn the alarm off. The FM said that the morning after the incident, when s/he dropped off the AV at the facility, s/he was told about the incident. P2 and P3 told the FM that the AV was left unsupervised for approximately 10 minutes. The FM said that s/he had no prior concerns. P1-P4 provided the following information: · On July 16, 2024, P4’s car was parked in front of the toddler playground and at approximately 5 p.m. when s/he was leaving the facility for the day, s/he “heard crying” as s/he approached the trash enclosure. P4 walked past the trash enclosure, looked onto the toddler playground, and saw the AV “crying” at the toddler door. P4 then “ran” past a lawn service person (LP) at a gate to the toddler playground and into the playground. P4 picked up the AV and carried the AV into the toddler classroom, which was empty, and then they walked to the large motor room, where the AV’s classroom was. P4 handed the AV to SP1 and told SP1 that the AV was outside. SP1 and SP2 appeared “shocked” and did not say anything. P4 left the large muscle room and went to the office, told P3 about the incident, and then left the facility. Prior to leaving, P4 was outside with his/her class which was the same time as the toddler class was outside, so P4 thought the AV was outside alone for “10 minutes.” · After P4 left, P3 went into the large motor room and spoke with SP1 and SP2. P3 asked SP1 and SP2, “How did this happen?” and SP1 and SP2 replied, “We don’t know. We have no idea how this could have happened.” P3 then asked SP1, “Did you sweep the playground?” SP1 replied, “No,” and that s/he “did not know why” and that “it had been a day.” SP1 was holding the AV and the AV appeared “calm” and “happy” but SP1 appeared “upset” and SP2 was “in tears” and “very emotional” about the incident. P3 “looked” at the AV and did not see any injuries. · At approximately 5 p.m., P4 text P3 about the incident and P3 called him/her. The next day, P2 spoke with the FM and told the FM the AV was left outside for approximately 9 to -10 minutes. P2 spoke to SP1 and SP2 separately and each said that the toddler class was outside until the LP came. They asked the LP to complete the preschool playground first and then SP1 and SP2 brought the children to the toddler door to go inside. At that time, each saw the AV by the door with the other children. SP2 began to count the children by tapping them on their heads and as SP2 was counting, s/he saw a child near the slide and told SP1. SP1 walked over to get the child and when SP1 returned to the group, SP1 asked SP2 how many kids they had and SP2 said they had nine which was the number they had. The group then went inside through the toddler room and to the large motor room. SP2 said that while they were outside, “a few” of the kids were “crying” because they were “scared” of the leaf blower and wanted to go inside. Neither SP1 nor SP2 realized the AV was outside until P4 came into the large motor room with the AV. · P2 said that SP1 was “really distraught” and said s/he had an “off day” and “had a bad day.” SP1 also told P2 that s/he that “everything [s/he] normally did, [s/he] did not do” at the time of the incident. SP1 “did not recount the kids” and “did not sweep the playground” to check for children. SP2 told P2 that it was a “chaotic” day and that s/he “did not recount the kids” when they were inside. · Staff persons were to use the walking rope when transitioning children between locations and were to count and complete a name to face of the children to ensure all children were accounted for prior to leaving the classroom and again when reaching their destination. Staff persons were also trained to complete a sweep of the playground or classroom to make sure no children were left behind. · P1 and P2 had no prior concerns about SP1 or SP2. The facility provided two videos of the playground, two videos of the toddler classroom, and one video of the large motor room. The playground video 1 was timestamp from 4:50 to 5 p.m. and video 2 was timestamped 4:57 to 5:07 p.m. (Note: Due to the angle of the camera, the storage bin and the area in front of the gate to the preschool playground was not visible.) The toddler classroom video 1 was timestamped from 4:55 to 4:56 p.m. and video 2 was timestamped from 5:04:42 to 5:04:46 p.m. and the large motor video of the room was timestamped 5:02:52 to 5:05:29 p.m. (Note: due to the angle of the camera the hallway to the toddler classroom was not in view). The videos showed the following: · At 4:53:36 p.m., SP1 walked toward the preschool playground gate followed by the AV and out of view of the camera. SP2 was near the toddler door and then walked toward the play structure. · At 4:54:38 p.m., SP1 reappeared on camera near the sidewalk made a motioned for SP2 to go to the toddler door. (Note: The AV did not appear on camera at that time with SP1.) · At 4:54:50 p.m., SP2 walked to the toddler door while SP1 held a child on the sidewalk. The children began to walk to the door and another child was in a car next to the slide. · At 4:55:03 p.m., SP2 opened the door and turned off the door alarm. · At 4:55:26 p.m., SP1 put the child on the sidewalk and waved the other child in the car over to the door as SP2 let the nine children inside the classroom and then entered the classroom followed by SP1. SP2 then led the nine children to the large motor room followed by SP1. · At 4:58:55 p.m., the AV appeared on camera on the sidewalk and then again walked out of view of the camera. · At 5:00:07 p.m., the LP walked into view of the camera onto the sidewalk next to the trash enclosure blowing the leaves, then walked behind the trash enclosure, and then walked back out to the parking lot. · At 5:01:36 p.m., the AV appeared on the sidewalk next to toddler door and looked in the direction of the parking lot and the LP. · At 5:02:44 p.m., the AV stepped backwards and out of view of the camera and then reappeared by the classroom door and tapped on the door. · At 5:03:59 p.m., P4 walked past the trash enclosure to his/her car. The LP came into view behind P4 and walked onto the sidewalk next to the enclosure. At the end of the trash enclosure, the LP looked toward the AV and then walked through the first gate to the playground. · At 5:04:14 p.m., P4 walked back on the sidewalk and then ran to the toddler playground, ran past the LP at the second gate and then to the AV, who was out of view of the camera. · At 5:04:34 p.m., P4 opened the classroom door, entered the classroom, and then walked to the large motor room. SP1 and SP2 provided the following information: · On July 16, 2024, at approximately 3:30 p.m., SP1, SP2 and 13 children, including the AV, went outside to the toddler playground. While the class was outside some children went home leaving 10 children in attendance. The LP came to the toddler playground but said that s/he would come back to blow leaves off the playground so SP1 and SP2 decided to go into the large motor room to finish their large motor time. SP1 and SP2 then called all the children to the door. · SP1 said that the AV was next to him/her and holding his/her hand as SP2 stood next to the door and counted the children. As SP2 counted the children SP1 saw a child by the standing by a car, so s/he let go of the AV’s hand and “put [the AV] by the door,” and then walked over to get the child. When SP1 returned to the door s/he asked SP2, “How many do we have?” and SP2 replied, “Nine.” SP1 said, “Okay” and then SP1 and SP2 walked through the toddler classroom and into the large motor room. SP1 said that s/he did not “confirm” the count and did not walk around the playground check and confirm if any child was still there. · SP2 said s/he saw the AV when the children were lining up. The AV was on the sidewalk near the door before SP2 opened the door. SP2 said that some children began “to cry” so s/he opened the door, turned off the alarm, and began to “count” the children. SP2 counted eight children and then s/he saw a nineth child sitting in a car by the slide. SP1 walked over to the child and brought the child to SP2. SP1 asked SP2, “Do we have nine?” and SP2 replied, “Nine, we are good.” SP2 then led the class inside the toddler class and then to the large motor room followed by SP1. · SP1 said that after “five or six minutes” in the large motor room, SP1 and SP2 began “to count” the children and realized they “were missing one.” Then P4 entered the room with the AV and said, “You forgot [the AV] outside.” SP1 replied, “Oh my gosh,” “this has never happened before,” and “I don’t know how it happened.” SP1 said that the AV “was crying” and SP2 said that the AV had a “serious” face. SP1 held the AV until the AV felt better. · SP1 and SP2 said that they were trained to use the walking rope when transitioning children to another area and to complete a name to face of the children on the iPad before leaving an area. SP1 and SP2 said that on the day of the incident they “did not do a name to face before going outside or coming inside” and that they did not complete a sweep of the playground to check for any missing children. The facility’s Safety and Supervision policy stated that “all children must be within sight and sound at all times” and “always know the exact number of children you are responsible for … and where they are at all times.” The facility’s Transition Policy stated that, “The children should line up on the rope if going to the large muscle room or playground. Staff persons are to count the number of children lined up. Complete a name to face count … prior to leaving your current location. Do a sweep of the classroom … while the children are lined up on the rope prior to leaving the location. Count the number of children and complete a name to face count when they enter the transition classroom, large muscle room, or playground. The facility’s Risk Reduction Plan stated that, “When transition [sic] from one area to another, children will form a line using a walking rope. Staff will call the children by name to hold on to the walking rope. Staff will use face to name every time the rope is used. One staff will be at the front of the line and one staff will be at the back of the line. Staff will count the number of children transitioning to ensure all children are present.”
Facility records showed that P1-P5, SP1, and SP2 were trained on the facility’s Safety and Supervision policy, Transition Policy, Risk Reduction Plan, 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 16, 2024, the AV, who was 20 months old, was left outside unsupervised for nine minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP4 heard “crying” when s/he was leaving the facility for the day and the saw the AV alone crying at the toddler room door. The AV was not injured. Although the AV was in a fenced in playground, given that the AV who was 20 months old was left for nine minutes alone on the playground and that the playground was outside visible to passersby and the LP, 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 Safety and Supervision policy, Transition Policy, and Risk Reduction Plan. SP1 and SP2 were responsible for the care and supervision of the children in the toddler classroom, including the AV. SP1 and SP2 counted the children prior to leaving the playground but did not complete a name to face count or sweep the playground and they did not count the children when they reached the large muscle room. SP1 said that after “five or six minutes” in the large motor room, SP1 and SP2 began “to count” the children and realized they “were missing one,” when P4 walked in with the AV. However, according to video the AV was alone for nine minutes on the playground before s/he was found by P4. 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 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 their policies and procedures were adequate and not followed by SP1 and SP2. SP1 and SP2 received additional training on the facility’s Transition policy. 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 January 16, 2025, 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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