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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: 800753-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, SP2, and SP3) knowledge or supervision for approximately two minutes. The AV was found by a community person (CP) and returned unharmed. Date of Incident(s): September 17, 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 27, 2024; from documentation at the facility and a recreation center video; and through six interviews conducted with the AV’s family member (FM), the CP, a facility supervisory staff person (P), and facility staff persons (SP1, SP2, and SP3.) The facility was located at one end of a community recreation center. Inside the recreation center was a walk way from the facility entrance to an exit door on the opposite end of the recreation center. Outside, above that door was a video camera. Outside the door was a sidewalk and to the right was a hotel and to the left was a facility playground, approximately 113 feet from the door. That sidewalk was lined with large shrubs and there was a slight turn in the sidewalk so the playground was not visible from the door. The playground was enclosed by a vertical wrought iron fence and gate, by an exterior wall of the building, and a brick fence. Next to the playground and gate was a driveway where family members parked when picking their child up from the playground. The driveway looped past the hotel front entrance and led to a large parking lot. On the other side of the playground was a parking lot and an assisted living facility. Beyond the parking lot and approximately 230 feet from the playground was a frontage road with a speed limit of 30 miles per hour. Beyond the frontage road and approximately 494 feet from the playground was a highway with a speed limit of 60 miles per hour. The playground was visible to passerby in the driveways and parking lots.
Facility documentation showed the AV was 20 months old and enrolled in a toddler “Duckling” classroom at the time of the incident. The CP provided the following information: · On the day of the incident, at approximately 5:15 p.m., the CP was at a driveway near the facility playground. The CP looked into the playground and “at first” did not see “anyone” and was going to leave but then s/he saw a “baby hand.” The CP parked his/her car, got out, and went to the playground. The playground gates were “wide open,” and s/he saw the AV “digging in the dirt.” There was no one else on the playground. · The CP got the AV and recognized that the AV was in the CP’s child’s class. The CP went in the back door of the recreation center and was inside “almost half way” to the facility on the walkway when s/he met up with “three” of the AV’s classroom staff persons and “five to seven” children. The CP asked the staff persons if they were “forgetting” someone. SP2 told the CP that s/he thought the AV had “previously” left. The CP then handed the AV over to the staff persons. · The CP waited at the facility and when s/he saw the FM with the AV, s/he told the FM that s/he had found the AV “alone” on the playground and brought the AV to his/her class. The CP told the FM to follow up with the facility. · The CP estimated that from the time the CP parked his/her car and picked up the AV to meeting up with the AV’s class, the AV was unsupervised for approximately five minutes. The FM provided the following information: · On September 17, 2024, the FM arrived at the facility and picked up the AV. As the FM and AV were leaving the facility, the CP approached the FM and told the FM that s/he found the AV on the playground with the gate open and brought the AV inside to his/her class who were in the recreation center. The FM did not “say much” to the CP and went to find the P. · The P told the FM that s/he saw the AV “come in” from the playground with the staff persons who were working in the AV’s classroom. The P told the FM that s/he would talk with the staff persons and “figure out” what had happened. · When the FM picked up the AV, the AV did not “seem upset.” That night the AV had a “hard time” going to sleep and the FM thought the AV “might” be anxious or worried about the incident. · Prior to this incident, the FM did not have concerns with the facility. Information obtained showed that there were initially 11 children, including the AV on the playground. One child left leaving ten children in attendance. SP1, SP2, and SP3 provided the following information: · On September 17, 2024, at approximately 5 p.m., SP1, SP2, and SP3 were on the playground with a group of children, including the AV. At some point, SP1 went inside and changed a child’s diaper and when s/he returned to the playground, SP2 told SP1 that there were ten children on the playground. SP1 stated s/he did not “look at the boards” to verify the number of children present. · SP2 stated that when SP1 came back to the playground, SP1 told SP2 that the P said to bring the children inside. SP2 began trying to line the children up by the gate by having them hold a rope. Then a family member came to pick up a child and SP2 had a conversation with him/her. When SP2 finished with that family member, s/he “resumed” his/her “responsibility” of lining up the children. · SP2 was at the front of the line, SP1 was at the middle of the line helping three children who were crying, and SP3 was at the end of the line holding a “bucket” that contained the classroom attendance boards. · SP3 stated that SP2 had one attendance board and s/he had two boards in the “bucket.” “Outside the gate,” SP2 counted nine children and said they were “missing” a child. SP2 asked SP3 to check for the missing child. SP3 “turned” to go look for a child and “right away” SP2 said that one child left, and they had the right number and told SP3 to “come back.” SP3 stated that his/her whole body did not get a foot back into the playground when SP2 told him/her to “come back.” SP3 did not shut the playground gate as s/he left the playground. · SP2 stated that when s/he counted nine children, SP1 also said s/he counted nine children. SP2 thought it “seemed” like the right number because one child left with a family member. SP2 “trusted” SP1 and they “all” recounted and counted nine children. · SP1 stated s/he did not know how many children were outside and took SP2’s “word” for how many they should have. · The group then left the gate area and walked on the sidewalk toward the recreation center doors. SP1, SP2, and SP3 each stated that the group was outside near the doors when the CP met up with them with the AV. SP2 “thought” that the AV had been with the group and had fallen “behind” and “apologized” to the CP. The CP told SP2 that the AV was in the playground “by the fence.” SP2 apologized again. Then SP2 said the children’s names and “counted” the children “immediately.” The group continued to walk to the classroom and once inside the classroom, SP2 called the children’s names and did “another count.” · SP2 stated s/he was not trained on the name to face attendance procedure but saw other staff persons do so. SP2 stated that when the group left the playground, “someone” should have looked at each child and counted them. SP1, SP2, and SP3 all needed to be “on the same page” with the number of children present. SP2 stated that the AV was in a “blind spot” by the “fence in back” on the playground and s/he did not realize the AV was there so s/he “miscounted” the number of children before leaving the playground. SP2 estimated the AV was unsupervised between 15-20 seconds based on where the group was when the CP caught up with them. · SP1 was trained to “check” the clipboards to know how many children were present and s/he “should have” used the list and taken more time to ensure all the children were in line. SP1 stated that the AV was unsupervised for “less than a minute” because the group did not walk far before the CP caught up with them. · SP3 stated s/he was trained to complete “name to face before transitioning anywhere.” On the day of the incident, name to face attendance was not taken as the children left the playground and s/he did not say anything to SP2 because SP3 was “in a rush.” SP3 stated the AV was unsupervised between one and two minutes based on the time the group left the playground and when the CP brought them the AV. · SP1, SP2, and SP3 stated that while the AV was unsupervised, s/he could have left the playground, a community person could have gone into the playground, or the AV could have fallen and gotten hurt. Video dated September 17, 2024, from 4:59 to 5:01 p.m. did not contain audio. The video showed SP2 stepping into camera view walking backwards on the sidewalk toward the recreation center doors. SP2 held onto a rope and was followed by six children holding loops on the rope. SP1 was next as s/he held the hands of two children and another child held the hand of one of those children. SP3 walked behind SP1 and carried a clear bin with items inside. SP2 walked out of camera view as SP1 and SP3 turned back toward the playground and the CP walked up behind them, carrying the AV. SP1 let go of one child’s hand and the CP handed the AV to SP1. Then the CP picked up his/her child and walked away from the group out of camera view. SP1 and SP3 then walked toward the recreation center door and out of camera view and the video ended. The P provided the following information: · On September 17, 2024, at approximately 5:50 p.m., the P was in the facility office when the FM came to the office and told the P that the CP had “stopped” the FM in a facility hallway and told the FM that s/he had found the AV “on the playground.” The P told the FM that s/he was “not aware” of the incident and that s/he saw the AV “walk into” his/her classroom with the group at approximately 5:05 p.m. The P told the FM that s/he would follow up with the staff persons who were working with the AV at that time and would get back to him/her. · The P then called SP2, who had left the facility, and asked SP2 about the incident. SP2 told the P that when they transitioned out of the playground, SP2 completed a “head count” and counted nine children. SP2 told SP1 and SP3 that there should be ten children but SP1 said that another child had been picked up so there should be nine children present. The group then continued to walk on the sidewalk toward the recreation center doors. “Before” the group entered the doors, the CP met them. The CP had the AV and asked SP1, SP2, and SP3 “if they were forgetting someone.” SP2 told the CP that s/he “thought” the AV was with the group and “thanked” the CP. · SP2 told the P that s/he completed a “head count” as children went through the gate but did not complete name to face attendance at that time because they “forgot” to do it. SP2 told the P that the attendance sheets were in a “bucket” with SP3. · The P then called the FM and left a voicemail regarding the incident and that s/he would follow up with him/her again. · The P stated that as children walk through the playground gate, the staff person “leading the group” should look at the “attendance sheet,” say each child’s name “out loud,” “visually” see each child, and then place a check mark next to the child’s name in a column on the attendance sheet. · Based on the information provided by SP2, the P estimated that the AV was unsupervised between one and two minutes. An unnamed facility document for the day of the incident, showed that children from the “Ducklings” classroom transitioned to the playground at 3:58 p.m. and there was no information when the children left the playground to transition back to the classroom. The facility’s Supervision of Children policy showed that “all children” were in sight and hearing of staff persons at all times. The facility’s Name to Face policy showed that staff persons used the name to face attendance form as children arrived at the facility, as the class transitioned to any location outside of the classroom, and when children departed the facility. Name to face attendance required that staff persons read the name of a child, either out loud or silently, visually located that child, and then checked off that child’s name on the form. The P, SP1, SP2, and SP3 each received training on the Reporting of Maltreatment of Minors Act and the facility’s Supervision of Children and Name to Face policies. 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: On September 17, 2024, at approximately 4:55 p.m., the AV was left on the playground for less than two minutes without staff persons’ knowledge or supervision which was inconsistent with the facility’s Supervision of Children policy and was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. SP1, SP2, SP3, and a group of children, including the AV were on the facility playground. When it was time to go inside, SP2 lined the children up at the playground gate. Some children held a rope and SP1 held the hands and assisted other children. SP2 said that as they left the playground, SP2 counted nine children and told SP1 and SP3 that they were missing a child. SP1 told SP2 that a child left and there should be nine children. SP2 was at the front, SP1 was in the middle, and SP3 was at the end of the line as they walked the children to the recreation center. During this time, the CP arrived, saw the AV alone and entered the playground. The CP picked up the AV and carried him/her out of the playground. Although the CP stated s/he met up with SP1, SP2, SP3, and the other children inside the recreation center about halfway to the facility, information provided by SP1, SP2, and SP3 was corroborated by the video which showed that the CP met them outside on the sidewalk near the recreation center door and that they had not yet transitioned inside. Minnesota Statutes, section 260E. 30, subdivision 3 states that rather than making a determination of substantiated maltreatment by an individual, the commissioner of human services shall determine that a nonmaltreatment mistake was made by the individual. A nonmaltreatment mistake occurs when: (1) at the time of the incident, the individual was performing duties identified in the center's child care program plan required under Minnesota Rules, part 9503.0045; (2) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; (4) any injury to a child resulting from the incident, if treated, is treated only with remedies that are available over the counter, whether ordered by a medical professional or not; and (5) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing requirements relevant to the incident. Consistent information was provided that although staff persons counted the children as they left the playground, they counted nine when they had ten children. Within one to two minutes, the CP found the AV on the playground and brought the AV to the group who were still outside on their way to the recreation center door. SP1’s, SP2’s and SP3’s actions or conduct were determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, SP1, SP2, and SP3 were performing job-related duties. The children were counted and they communicated the numbers although inaccurate. In addition, the group had not yet transitioned inside and were within approximately 100 feet of the playground; (2) SP1, SP2, and SP3 each had not been determined responsible for any previous nonmaltreament mistake under this paragraph; (3) SP1, SP2, and SP3 each had not been determined responsible for any previous incident that resulted in a finding of maltreatment; (4) The AV was uninjured and did not require medical care after the incident; and (5) Except for the period when the incident occurred, the facility and SP1, SP2, and SP3 were each in compliance with all licensing requirements relevant to the incident. The nonmaltreatment mistake to the AV by SP1, SP2, and SP3 was not maltreatment. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but not followed by SP1, SP2, or SP3. All staff persons at the facility were retrained on the facility’s policies and procedures. Action Taken by Department of Human Services, Office of Inspector General: SP1, SP2, and SP3 were each not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which SP1, SP2, and SP3 were each responsible met the criteria to be determined a nonmaltreatment mistake. SP1, SP2, and SP3 were each notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP1, SP2, and SP3 were responsible might not be considered a nonmaltreatment mistake. On January 24, 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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