|
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): Judith Schwanke/Brittany Dolen 651-431-4033 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left unsupervised in a classroom for approximately four minutes while the class transitioned outside. The AV was found by a staff person and rejoined the class outside. Date of Incident(s): October 25, 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 November 6, 2024; from documentation at the facility; and through five interviews conducted with the AV’s family member (FM), one supervisory staff person at the facility (P1) and three facility staff persons (P2, SP1 and SP2). This investigator observed the AV in the classroom but did not interview him/her due to his/her age. At the time of the incident, the AV was three years old and enrolled in the Preschool 2 classroom at the facility. On the day of the incident, there were twelve students in Preschool 2 including the AV, and SP1 and SP2 worked in the classroom. The Preschool 2 classroom was square shaped and had tables, chairs, toy/bookshelves, and a small sitting area with a couch. There was a bathroom with a half door and two toilets, lockers for the children’s storage, and four exit doors from the classroom. One door exited to the facility’s main hallway, one to the facility’s Preschool 1 classroom, one to the Preschool 3 classroom and one to a fenced in walkway which connected to the playground. Exits to the other classrooms as well as the main hallway had a childproof lock on the handle, and the exit to outside had an audible alarm when opened. The bathroom door did not have a childproof lock on the handle. The FM provided the following information: · The incident occurred on October 25, 2024. P1 contacted the FM at work immediately following the incident and informed the FM that the class had gone outside, and the AV was left in the classroom unsupervised for three to four minutes. The AV was “autistic and non-verbal” and was not supposed to be left alone. Due to the AV’s diagnosis, s/he was allowed to have his/her iPad at school. · The AV recently transitioned into the Preschool 2 classroom and was not familiar with staff persons. The AV was “kind of a loner” and did not like other children around him/her. The FM did not have significant concerns about the incident and s/he did not want the AV to go outside that day “because it was cold.” · The AV was not injured as a result of the incident. P1 provided the following information: · On October 25, 2024, from 10:36 a.m. to 10:40 a.m. the AV was left unsupervised in the classroom by SP1 and SP2. · P1 was at an out of office training on the day of the incident. P2 contacted P1 and told him/her that P2 was walking down the hallway and noticed the AV in the classroom, so s/he entered the classroom, looked around, and realized the AV was alone. P2 informed P1 that s/he brought the AV outside and told SP2 that the AV had been left unsupervised. · On October 30, 2024, P1 spoke with SP1 and SP2 regarding the incident. SP1 acknowledged not following the facility’s transition policy and stated there was “no excuse” for his/her breach of policy. SP2 did not take any responsibility and placed the blame on SP1. · P1 reviewed the video footage of SP1 and SP2 getting the class ready to go outside and saw the AV walk away from the class to the couch area. SP2 went outside first, followed by the children, and then SP1. P1 did not see the facility’s policies being followed in the following ways: SP1 and SP2 should have lined the children up on a walking rope, completed a name to face and documented it on a Daily Transition Tracker (a form used to document name to face checks) while in line in the classroom, and then once outside, completed and documented another name to face with the Daily Transition Tracker. · There was no Daily Transition Tracker for the day of the incident, and SP1 stated s/he threw them away at the end of the night, so they did not “start piling up.” · The AV had an Individual Childcare Program Plan (ICCPP) and was diagnosed with autism. The facility accommodated the AV’s needs by having snacks and a sippy cup available to him/her, and making the AV’s noise canceling headphones and iPad available to the AV. The facility received information regarding the AV’s diagnosis on July 19, 2024, and staff persons were trained on, read, and signed off on the AV’s ICCPP shortly after. · P1 said the AV was unsupervised for four minutes, and s/he knew this from viewing video footage. The AV was not injured as a result of this incident. P2 provided the following information: · P2 did not recall the date the incident occurred, but believed it was on or around October 23, 2024. · P2 walked by the door to the Preschool 2 classroom and noticed the AV in the classroom. P2 went into the room to say hello and realized the AV was alone. The AV “did not seem to notice” s/he was alone and was playing on his/her iPad. · P2 brought the AV outside, found SP2 and informed him/her that the AV was alone in the classroom. SP2 told P2 that SP1 was watching the AV. P2 then went inside and found SP1 on a FaceTime call in the breakroom. P2 asked SP1 if s/he knew the AV had been left unsupervised and SP1’s response was, “Oh shit.” P2 notified P1 of the incident following this conversation. · SP1 and SP2 should have used the Daily Transition Tracker in the classroom, completed a head count, used the walking rope at the door, and done a final sweep of the room prior to heading outside with the children. P2 reviewed the video footage and saw that neither SP1 or SP2 used the Daily Transition Tracker, walking rope, nor did a final sweep of the room before going outside. P2 was not able to find a Daily Transition Tracker for the day of the incident. · P2 said the AV was unsupervised for four minutes, from 10:36 a.m. to 10:40 a.m., and s/he knew this because s/he viewed the video footage. The AV was not injured as a result of this incident. SP1 provided the following information: · The incident occurred on or around October 23, 2024, at around 10:30 a.m. · The morning of the incident was “very hectic” and most of the morning SP1 and SP2 were over ratio because another staff person was late, so they had to combine with another classroom. When SP1 arrived that morning around 7:30 a.m., there had been no Daily Transition Tracker completed. SP1’s focus was on calming the children down because they were all “very emotional and energetic.” SP1 completed a Daily Transition Tracker later that day but threw it away. SP1 was not aware that the Daily Transition Trackers needed to be turned in at the end of the day. · At one point, SP2 brought ten children to the Preschool 1 classroom and returned to the Preschool 2 classroom around 10:20 a.m. SP1 said that at this time s/he was “really overwhelmed” and the children were “constantly crying and fighting.” SP1 wanted to get the children outside so they could “be free and run.” · SP1 was employed at the facility for six years and knew the proper transition procedure because it was a part of the facility’s policy. SP1 stated “I didn’t do [the transition according to policy] and I should have. I should have taken a breath and put [the children] first.” SP1 should have lined all the children up, given them the walking rope, completed a name to face and counted all the children before going outside. However, when the incident occurred, SP1 and SP2 did not use the walking rope, did not complete a name to face, and did not do a final sweep of the room. · The AV was new to the room, and s/he did not seem to want to interact with the rest of the class. SP1 tried to involve the AV in activities with the class, but the AV often separated him/herself. · SP1 was told by P1 that the AV was unsupervised for four minutes. The AV was not injured as a result of this incident. When the AV returned to the group after the incident “s/he was normal”, had his/her iPad and kept to him/herself. SP2 provided the following information: · On or around October 23, 2024, sometime between 9 and 10 a.m., the AV was left alone in the classroom. · On the day of the incident, a staff person from another class was late, so the children from two classrooms were combined. SP2 stated, “It was crazy.” · SP2 and SP1 brought sixteen children outside. SP1 was still in the classroom when SP2 went outside with the children. SP1 followed the group outside, but then went back inside and left SP2 outside alone for twenty to thirty minutes. SP2 stated s/he was often left alone with the children. SP2 usually counted the children and gave them the walking rope prior to walking outside, but that day s/he did not because s/he “did not have time.” One child opened the door, and SP2 did not want the children to be unsupervised outside so s/he left with some of the children and SP1 was behind him/her in the classroom. · SP2 completed the Daily Transition Tracker once outside and stated s/he was trained on how to complete transitions at new staff person training. SP2 said s/he tried to count the children but did not specify where s/he was when s/he tried to count them. · SP2 was trained to have the children take the walking rope, complete a name to face and all walk together from place to place during transitions. · SP2 thought the AV was left unsupervised for five to six minutes. When the AV was brought outside after the incident, s/he was on his/her iPad and was not upset. The AV was not injured as a result of this incident. The facility provided three video segments from different locations in the facility. The video was time stamped and did not have audio. The videos provided the following information: · At the beginning of the video, SP1 came out of the bathroom into the classroom, and SP2 was sitting in the classroom. There were twelve children in the classroom playing independently. · At 10:27:33 a.m., SP1 left the classroom for approximately two minutes. During this time SP2 was in the room with the children, however, at 10:28:58 a.m., SP2 also left the classroom for approximately 30 seconds and returned with multiple jackets in his/her hands. · From the time the video began until 10:29:02 a.m., the AV played with his/her iPad at a shelf. At 10:29:09 a.m. the AV moved to a long table near the bathroom remained there for approximately three minutes. · At 10:31:43 a.m., SP2 left the classroom until s/he returned at 10:32:06 a.m. with another child. While SP2 was out of the classroom, SP1 was on his/her telephone, walking away from the children. · At 10:32:11 a.m., SP2 was near the door to outside helping children get ready to go outside. At this time, SP1 walked across the classroom, picked up a pair of shoes and sat with the AV at the table. · At 10:32:24, SP1 put the AV’s shoes on for him/her. When finished, SP1 stood up, tapped the AV on the head and took the iPad from the AV. SP1 walked away and the AV followed, took the iPad back from SP1, and stood briefly with a group of children near the door to outside. · At 10:33:31 a.m. the AV appeared upset by another child trying to touch his/her iPad and the AV moved to a play area, still near the other children. The AV remained there for approximately one minute, then moved to a shelf of toys, and at 10:36:07 a.m. the AV moved to the couch in the sitting area and sat down. During this time, SP2 sat near the door, facing the other children with his/her back to the AV and SP1 stood near the bathroom, facing the children. · At 10:34:20, another individual, later identified as another child’s caseworker, entered the classroom, and talked to SP1. · At 10:36:28 a.m., SP2 went outside followed by nine children and the caseworker. At 10:36:41 two other children left the room and at 10:36:46 SP1 left the room carrying a blanket and clipboard. Neither SP1 nor SP2 used a walking rope, completed a name to face, or completed a sweep of the room before leaving the room with the children. The AV was still sitting on the couch when SP1 and SP2 left the classroom. · From 10:36:46 to 10:39:50, the AV sat alone on the couch, playing his/her iPad. · At 10:39:50 a.m., P2 entered the classroom. P2 looked around, checked the bathroom, and then walked to the AV. P2 took the AV’s hand and walked him/her outside with the rest of the class at 10:40:21 a.m. When P2 arrived outside, SP2 was near the door to the Preschool 3 classroom. P2 walked past SP2, out of sight of the cameras and SP2 followed. The AV walked towards the playground with his/her iPad. According to the facility’s Safety and Supervision Policy, children were discouraged from opening doors. This policy also stated that all children must be within sight and sound at all times, and that staff persons should always know “the exact number of children they were responsible for, their names, and where they were at all times.” Each staff person was responsible to complete a Daily Transition Tracker which required them to mark an “x” when a child arrived or left for the day. Information posted in the classroom indicated that any time a group of children transitioned from one space to another, staff persons performed the appropriate transition steps when leaving and arriving at each space. Staff persons were expected to add “x’s” for each transition and write the total number of children present in the “total” box. These trackers were to be signed and turned in at the end of the day and kept for one month before being thrown away. The facility’s Transition Policy stated that staff persons should use the following steps when transitioning from one area to another, and that prior to any transitions occurring, they must ensure all children were accurately listed on the tracker form and signed in on ProCare (an application used to track attendance). The first step was to place the New Horizon Academy approved walking rope(s) on the floor and then call each child by name, one by one, to grab a loop on the rope. As each child grabbed the rope, staff persons placed an “x” by their name on the Daily Transition Tracker. Once a name to face was completed, a full count of the children on the rope was completed. This step could not take place before the name to face. Staff persons would then verbally confirm with each other the number of children counted and that it matched the number on the Daily Transition Tracker. They then did a sweep of the area to ensure that all children were accounted for, walked to their destination, and completed another name to face once they arrived at their new location. Facility documents showed that P1, P2, SP1 and SP2 were trained on the facility’s policies, including the facility’s Safety and Supervision Policy, Transition Policy, 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 “supervision” means a program staff person was 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 were required to be supervised at all times. Conclusion: A. Maltreatment: Consistent information was provided that on October 25, 2024, the AV was left in the classroom without the knowledge or supervision of SP1 or SP2, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Minnesota Department of Human Services, and, a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP2 said that s/he did not have time to count the children before leaving the classroom because a child opened the door and started going outside before s/he could do so. However, video footage showed that SP2 led children outside, and SP1 followed, before either completed a count of the children, a name to face, or a sweep of the room. Eleven children went outside with SP1 and SP2, but the AV was left behind in the classroom. SP1, SP2, and all other sources acknowledged that the facility’s transition policy was not followed during the incident. Given that the AV, who was three years old, was in the classroom without the knowledge or supervision of staff persons for approximately four minutes, and that staff persons were unable to intervene if the AV injured him/herself or in the event of an emergency or other hazards, 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 were 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. On the day of the incident, SP1 and SP2 were each responsible for the supervision of all the children in the Preschool 2 room, including the AV. Both SP1 and SP2 transitioned children outside without following the facility’s transition policy, and as a result, SP1 and SP2 failed to notice the AV did not go outside with the rest of the group. SP1 and SP2 each received training on the facility’s policies, including the Safety and Supervision Policy and Transition Policy and the Reporting of Maltreatment of Minors Act, prior to the incident. Therefore, SP1 and SP2 were each determined 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 found that policies and procedures were not followed by SP1 or SP2. SP1 was retrained in Safety and Supervision and Transition policies, and all staff persons received additional transition and supervision training from the facility on November 12, 2024. The facility also updated the AV’s ICCPP, and staff persons who worked directly with the AV were re-trained on the updates. SP1 received corrective action from the facility, and SP2 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 17, 2025, 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.
|
