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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: 1081593-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 in a preschool room without two staff persons’ (SP1 and SP2) knowledge or supervision for approximately 18 minutes. Date of Incident(s): July 15, 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 25, 2024; from documentation at the facility; and through seven interviews conducted with two supervisory staff persons (P1 and P2) and five staff persons (P3, P4, P5, SP1, and SP2). Attempts were made via telephone and mail to contact the AV’s family member (FM), but those attempts were unsuccessful. The AV was three years old at the time of the incident and was enrolled in the preschool 2 classroom. At the time of the incident, it was the AV’s eighth day at the facility. The AV was not in attendance the day this investigator conducted the site visit. The facility provided care for infants through prekindergarten children and had an office by the front entrance. There were three preschool classrooms and one prekindergarten classroom. Past the door into the preschool 2 classroom on the wooden floor were three tables used for meals. To the left of the tables were the bathroom, a sink, and a diaper changing area with a sink. To the right was a carpeted area that had an area for group time. Next to the group area were toy shelves and small tables. At the back wall of the classroom were windows and in the middle of the back wall was a large motor play structure. Cots were placed on the carpet areas for nap time. Next to the group area was a door that led to the preschool playground. The preschool playground had a fence and a gate that led to the toddler playground, a bench, and a play structure. P5 said that on the day of the incident after snack time, s/he was taking out the trash from his/her classroom and “walked” through the preschool classroom because the trash can was located next to the preschool playground. As P5 walked through the preschool classroom, s/he saw the AV on a cot by the play structure. The AV was “just waking up” and was “not crying.” P5 helped the AV get his/her shoes on and asked the AV if there was “anyone else in the room?” The AV replied, “No.” P5 then brought the AV out to the preschool playground and asked P3, SP1, and SP2 if they knew the AV “was left inside.” P3 “blamed” SP1, SP1 “blamed” P3, and that SP2 “blamed [him/herself]” because s/he was “the last person in the room.” P5 then walked to the toddler playground and told P2 about the incident. P5 “thought” the AV was left alone for “10 minutes, maybe longer.” [Note: Although P5 stated that P3 was on the playground at the time of the incident, information from all other sources including video showed that P3 was not on the playground and left the classroom prior to them going outside.] P3 said that on the day of the incident s/he worked in the preschool classroom with SP1 until 3 p.m. There were approximately 16 to 18 children in the classroom, including the AV. At the end of nap time, prior to 3 p.m., P3 woke the children up and had them sit at the tables for a snack. The AV was still on his/her cot asleep next to the large motor structure. SP2 came into the classroom to replace P3, who was going to a different classroom for the rest of his/her shift SP2 went to the bathroom to help a child. P3 said s/he told SP1 that the AV was still asleep and that SP1 had to “wake up [the AV] in 5-10 minutes.” SP1 responded, “OK,” and then P3 left the classroom and went to the infant classroom and did not go to the playground. P3 said that s/he did not talk to SP2. P3 said that while s/he was the infant classroom another staff person came in and told him/her that the AV was left the preschool room by him/herself. P1-P5 provided consistent information that staff persons were trained to share classroom information such as the number of children in attendance when a staff person entered the classroom to relieve another staff person and staff persons were trained that the “last” staff person in the classroom during a transition was to “scan” the classroom to make sure there were no children left behind. Staff persons were to use the ProCare app and attendance sheets to complete a name to face attendance and the walking rope to make sure all the children were in attendance when transitioning to a new area. Staff persons were to count the children when they leave the classroom and when they enter a new area. The facility provided two videos of the preschool playground (video 1 was timestamped 3:11:10 to 3:11:48 p.m. and video 2 was timestamped 3:11:10 to 3:35:22 p.m.) and two videos of the preschool classroom (video 1 was timestamped 3:05 to 3:25:06 p.m. and video 2 was timestamped 3:25:06 to 3:37:47 p.m.). There was no audio and the videos provided the following information: · At 3:05 p.m., there were 19 children in the preschool classroom, 17 children at the tables eating snack, the AV on a cot next to the large motor structure, and a child that was in the bathroom that showed up later in the video. SP2 and P3 were standing near the tables and SP1 was sitting on a shelf that was on the carpet area.
· At 3:05:25 p.m., P3 walked to the diaper area and began to pack a bag. (Note: P3’s head was not in view of the camera.) SP2 walked to a table on the carpet and sat facing the children eating snack. · At 3:06:41 p.m., P3 walked out of the classroom. · Between 3:08:40 and 3:11:14 p.m., SP1, SP2, and the children engaged in various classroom activities including cleaning up from snack and picking up a cot. A backpack with the walking rope was on a hook near the playground door. At no point during this time did SP1 or SP2 go over to the AV’s cot. · At 3:11:14 p.m., SP1 was standing at the playground door, when P4 opened the playground door and spoke with SP1. Then 15 children walked out onto the playground followed by SP1. SP2 was standing by a table with three children and the AV was still lying on his/her cot. · Between 3:11:14 to 3:12:16 p.m., SP2 was at the snack table with three and the AV was still asleep on his/her cot. SP1 stood between the building and the side jumping house and then walked between the front of the jumping house and the play structure. · At 3:12:16 p.m., SP2 walked to the playground door with one child, opened the door, and the child walked out onto the playground and the SP2 returned to help the two children at the snack table. · At 3:13:13 p.m., the AV sat up on his/her cot. A child was sitting at a table stood up and appeared to be pointing at the AV. The child then went to the sink and washed his/her hands. The second child who had washed his/her hands, walked to the playground door. · At 3:13:51 p.m., SP2 opened the playground door and exited the room onto the playground with two children. SP2 then re-entered the classroom, looked behind the backpack that was on the hook, and then returned to the playground closing the door. The AV remained sitting on his/her cot. SP2 then walked by and spoke with SP1 near the jump house and then toward the play structure and out of view of the camera. (Note: Neither SP1 or SP2 carried an iPad or attendance forms with them and there were no signs that SP1 or SP2 counted the children once they were on the playground at any time.) · At 3:15:55 p.m., SP2 reappeared between the play structure and building holding three bottles of water, SP2 walked over and handed a bottle of water to SP2 and P4, and then walked over to the fence. · At 3:25:17 p.m., a parent walked into the classroom from the hallway door and then exited onto the playground. · At 3:31:43 p.m., P5 entered the classroom with a trash bag. P5 walked to the AV, put the AV’s shoes on, and then they walked to the playground door. · At 3:32:44 p.m., SP2 was at the jump house when P5 opened the playground door with the AV. P5 appeared to be talking and SP2 walked to the preschool door and spoke with P5 before P5 walked away to the trash can. SP2 then walked towards the play structure followed by the AV. SP1 was not in view of the camera. SP1 provided the following information: · On an unknown date, SP1 was working with two staff persons whose names s/he could not remember (later identified as P3 and SP2) and nine children, including the AV. After nap and snack time was finished, SP1 prepared to take six children out the playground, and SP2 took two kids to the bathroom and the AV was on his/her cot. SP1 said s/he told P3, “There is still a baby on the cot, you got to wake [the AV] up, change [the AV], and then bring [the AV] outside.” SP1 then walked outside and onto the playground with six children. SP1 later said that P3 was the staff person who helped the children in the bathroom and SP2 was the one s/he told to wake up the AV. · After the children were done in the bathroom, SP2 came out to the playground with two children. SP1 said that when SP2 came out SP1 and SP2 “talked” but not about the AV and SP1 and SP2 did not count the children when SP2 arrived on the playground. Approximately 20 minutes later, a staff person who SP1 could not recall came out to the playground alone and asked SP1 where P3 was. The staff person then said that “[P3] left a baby in there.” SP1 later said that when the staff person came out s/he said, “You all know you all left [the AV] in the room.” SP1 replied, “I did not leave [him/her] in the room. I was already outside so the last two teachers that was in the room left [the AV].” · SP1 said that s/he was not “aware” when the AV came outside, that another unknown staff person brought the AV outside, and that the AV was “doing [his/her] own thing.” · SP1 said that s/he was “half trained” on how to supervise children and was not trained on how to transition children, how to keep track of attendance, how to use the walking rope, or how to count children. SP1 said s/he knew how to transition children and s/he “figured out” how to transition children as s/he had used the ropes with other staff persons and the children held the rope when walking out of the building and because s/he “had been working with kids for a long time.” SP1 said that s/he did not do so the day of the incident because s/he had “six children” and “they minded me and listened to me.” SP2 provided the following information: · On the date of the incident at 3 p.m., SP2 was moved to work in the preschool classroom. SP2 entered the classroom and counted 15 children sitting at the tables and eating snack. SP2 did not talk to P3 and neither P3 nor SP1 told him/her that the AV was still sleeping before P3 left the classroom. SP2 was told that “children should not sleep past 2:45 p.m.” so when SP2 entered the classroom s/he “figured … all the children were all up for snack, then these were the kids that were there.” SP2 continued to help the children clean from snack and when there were only three children left at the table, SP1 took 12 children to the playground door, opened the door, and let them “run” outside to the jump house followed by SP1. SP2 did not see SP1 take the walking rope and did not hear SP1 count the children. SP2 remained inside and helped three children clean up from snack and then they all went outside to the playground. SP2 said that s/he did not complete a head count of the children when s/he arrived on the playground and that s/he spoke with SP1 briefly but not about the children. · Approximately 10 to 15 minutes later P5 came outside with the AV and said, “Here is [the AV], who was in the room with [him/her]?” SP2 replied, “I was with [P3] earlier, but nobody told me.” SP2 said that s/he was “shocked” when s/he heard the news. P5 then called P2 over from the toddler playground and told P2 about the incident. · After the incident, SP1 told SP2, “[P3] knew that the child was sleeping, but [P3] leapt out of the room so fast” and P3 “was trying to deal with other kids.” · When SP2 saw the AV outside, the AV was “okay”, “happy”, and “had no tears.” The AV stood by the jump house for a few minutes and then went and played on the play structure. · SP2 said that when s/he was hired s/he “was not trained” on how to complete a transition from the classroom to the playground but when SP2 worked with other staff persons they took the lead and SP2 followed their instructions. SP2 helped in multiple classrooms and each classroom had a different way to transition children to their playgrounds. · SP2 said that s/he was trained to complete a head count of the children to make sure a classroom was empty. SP2 said that neither s/he or SP1 did a head count of the children when s/he and SP1 were on the playground. P1 and P2 provided the following information: · P1 and P2 provided conflicting information on when they were told that the AV was left alone. P1 said that s/he was in the office with P2 when P5 came in and said that s/he found “a child sleeping on their cot” “alone” in the preschool 2 room. P2 then left the office and went to the preschool room. · P2 said that s/he was on the preschool playground talking with SP2 when P5 came up behind him/her and said, “there was a child left alone in preschool.” P5 was walking the garbage through the classroom and found the AV alone and then said to P2, “[s/he] is out here now” and pointed to the AV. P2 then went into the office and told P1 about the incident. · P1 and P2 then spoke to SP1, SP2, and P3. o SP1 said that P3 “did not tell [him/her] that [the AV] was there” before P3 left the classroom and P3 “did not get [the AV] up.” SP1 took the first group of children outside. When P1 asked SP1 about the AV, SP1 replied, “[s/he] was wondering where the baby was” and that s/he “never thought to look for that missing child.” o SP2 said that when s/he entered the classroom to take over for P3, s/he was “never given communication” about the number of children in the classroom or that the AV was still asleep on the cot. SP2 was “mortified” about the incident and that s/he “had no idea there was a child over there.” o P3 said that prior to leaving the preschool classroom s/he “tried” to wake up the AV but the AV was not ready to get up. P3 said s/he told SP1 and SP2 that the AV was still on his/her cot before s/he left the classroom. · P1 called the FM 30 to 40 minutes after the incident and told the FM about the incident. The FM was “concerned” and “very quiet” but did not “seem angry or upset.” · P1 and P2 watched the video and provided information that was consistent with the aforementioned video. P1 and P2 did not see SP1 or SP2 count the children or see SP2 scan the classroom for any additional children. P4 said on the day of the incident there was a jump house on the preschool playground and s/he had 8 to 9 children outside using it. P4 walked to the preschool door and saw SP1 with “a group of children.” P4 was not sure if the AV was in that group. P4 asked SP1 to either wait to go outside or to make sure that his/her children stayed out of the jump house so that P4’s children would have their turns. The preschool children then pushed the door open and entered the playground. SP1 followed the children, did not speak with P3, and then walked over and sat on a bench. P4 and his/her classroom left the playground 5 to 10 minutes later. P4 did remember if SP2 had come onto the playground before s/he left the playground. 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, “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, “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, and 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 15, 2024, the AV was left unsupervised in the preschool room for approximately 18 minutes 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 by P5 who was walking through the classroom to go to the trash outside. Although the AV was not injured, the AV was three years old and alone in the classroom without staff knowledge. Given the AV’s age it was unlikely that the AV would be able to provide for him/herself in an emergency and no staff persons were aware that the AV was in the preschool classroom in the event of an emergency and would not have been able to intervene to protect the AV. Therefore, there was a preponderance of the evidence that 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 when reasonably 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/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 each responsible for the care and supervision of the AV at the time of the incident. SP1 knew that the AV was asleep on his/her cot prior to going outside and although SP1 said that s/he told either P3 or SP2 to wake up the AV and bring him/her outside, once the entire group was outside, SP1 did not ensure that all the children were outside. Although SP2 stated s/he did not know the AV was sleeping and thought that all of the children were up from nap, SP2 did not complete a scan of the classroom before s/he went to the playground and that s/he did not speak with SP1 until P5 came outside and said that the AV “was in the room.” Therefore, 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 but not followed by SP1 and SP2. SP2 received additional training on the facility’s Safety and Supervision policy. SP1 no longer worked at the facility. 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 26, 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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