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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: 830241-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that two alleged victims (AV1 and AV2) were on the playground without staff person knowledge or supervision for 17 minutes. Date of Incident(s): September 5, 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 17, 2024; from documentation at the facility; and through six interviews conducted with a supervisory staff person (P1), three facility staff persons (SP, P2, and P3), AV2’s family member (FM), and a community person (CP). (Note: P3 was also AV1’s family member). This investigator also reached out to an additional staff person (P4) by email, telephone, and mail to request an interview, but P4 did not provide information to this investigator. AV1 was 35 months old and AV2 was 32 months old, and both were enrolled in the Early Preschool classroom at the time of the incident. The facility was a stand-alone building and had two infant classrooms, three toddler classrooms, three preschool classrooms (Early Preschool, Preschool, and Pre-kindergarten), and a school aged classroom. Along one side of the front (east) side of the building were three exterior doors leading from an infant classroom, the Early Preschool classroom, and the Preschool classroom. There was a sidewalk that led from these doors to the preschool playground and toddler playgrounds at the north end of the facility grounds. The playgrounds and sidewalk were surrounded by a six-foot chain-link fence with a gate that led to a sidewalk near the facility’s front entrance. There was a four-foot chain link fence with a gate separating the two playgrounds. The facility shared a parking lot with other businesses on the front (east) side of the building, there was a main road along the north side with a posted speed limit of 50 miles per hour, and there was another parking lot with businesses on the back (west) side of the building. The facility’s Incident Report stated that on September 5, 2024, at 5 p.m., AV1 and AV2 were unattended on the playground for 17 minutes. The FM received a telephone call from the facility the day after the incident and was told that AV2 and another child were on the playground unattended for 17 minutes. The FM was told that staff persons did not follow the right protocol. The FM had no prior concerns. During his/her interview, the CP said that on an unknown date around 4 or 5 p.m., the CP left the facility with his/her children. As the CP left the parking lot in his/her vehicle, the CP thought s/he saw some children on the playground alone. The CP pulled over and turned back into the parking lot and saw two children on the playground with no staff persons present. The CP got out of his/her vehicle and approached P3 who was outside the building and the CP told P3 what s/he saw. P3 provided the following information: · On the day of the incident, P3 brought one of his/her own children to P3’s vehicle and was returning back to the facility when a vehicle rushed into the parking lot and the CP stepped out stating that there were two children outside. At first P3 did not think anything of that because it was outside time, and then the CP explained there were no staff persons outside. · P3 went to the side gate of the playground and saw AV1. P3 brought AV1 to the Preschool classroom door, just as P4 opened the door looking concerned and P4 asked, “How long [AV1] had been out there.” P3 stated that s/he just found out. P3 left AV1 with P4 and went to get AV2, who had gone to the toddler playground side. P3 brought AV2 inside and then left with AV1. It was not until later that night when it “hit” P3 that AV1 was unsupervised on the playground. · P3 stated that neither AV1 nor AV2 were crying, they were just playing “nonchalantly.” P3 was told by P1 that AV1 and AV2 were outside for 17 minutes. · P3 was trained to transition children from one location to another by lining them up before leaving the original location, calling a child’s name from the Face to Name Transition Sheet, placing a checkmark next to a child’s name as they passed through each door, and circling the checkmarks upon arrival at the destination. P2 provided the following information: · On the day of the incident, P2 was working in the Early Preschool classroom toward the end of the day. Around 4 or 4:30 p.m., P2 transferred his/her children, including AV1 and AV2, outside to the SP who was outside with the Preschool classroom. P2 told the SP the names of the children P2 was transferring to the SP while the SP wrote them down. P2 then went to work in the Pre-kindergarten classroom. · Around 5 p.m., P2 brought the Pre-kindergarten class to combine with children in the Preschool classroom where the SP was already inside. P4 joined them there and then the SP left the facility for the day. · P4 checked Sprout (an application to track children’s attendance) because the SP was “not good” with computer stuff (P2 gave an example of children still marked present on Sprout who were actually no longer in the classroom). P4 noticed that AV1 and AV2 were marked present on Sprout but were not in the classroom, just as P3 brought them into the classroom. AV1 was a bit dirty from playing in the dirt and AV2 was crying a little when s/he first came inside but calmed down once P3 held AV2 on his/her lap. · P2 was trained to conduct a face to name check every time the class lined up, moved from one location to another, or went through a doorway. Staff persons should put a check by each child’s name on the Face to Name Transition Sheet when they lined up, then upon arrival at the destination, put a circle around the checkmark for each child they saw there. P1 provided the following information: · On September 5, 2024, around 6:10 p.m., P1 was in his/her office when P4 entered and told P1 that s/he noticed AV1 and AV2 unattended on the playground. P4 told P1 that P2, P4, and the SP combined in the Preschool classroom at the end of the day and that the SP left at 5:08 p.m. P4 and P2 were playing with the remaining children when P4 saw AV1 through the window. P4 went to the door just as P3 got AV1 off the playground and gave AV1 to P4, then P3 went to the other playground to get AV2. · P1 then called his/her supervisor to have them obtain video footage. P1 reviewed the video footage the next day and saw the SP on the playground, standing under an awning. The SP called the children over but did not perform a name to face check. There were four “stragglers” including AV1 and AV2. Two of the “stragglers” followed the SP into the Preschool classroom but AV1 and AV2 remained on the playground. AV1 unlatched the gate between the playgrounds, then AV1 and AV2 went into the toddler playground. After about 17 minutes, AV1 saw P3 and ran over to the front gate. P4 opened the door from the Preschool playground and P3 handed AV1 to P4 and then P3 went to get AV2 from the toddler playground. · Staff persons were trained to conduct name to face checks at each door, place a check mark when they left a destination, another checkmark as they entered a new location and finally once at the final destination circle the checkmarks after completing another name to face check. The SP provided the following information: · On an unknown date, the SP was outside on the playground with a group of children when P2 came out with all of his/her children and stated s/he was taking two children from the SP and leaving three children for the SP. P2 dropped off his/her clipboard with the Face to Name Transition Sheet and “was gone” before the SP finished checking the children in and out, so the SP tried to “update the Face to Name Transition Sheet the best s/he could.” · About ten minutes later the SP brought the children inside. The SP did not remember what steps s/he took that day to bring the children inside but stated that s/he did not think s/he walked around the whole playground to ensure all of the children were there. · Once inside, P2 and another staff person (the SP did not remember who) were already in the classroom. The SP received a call from the front office saying that s/he could go home for the day. The SP gave his/her clipboard with the Face to Name Transition Sheet on it to P2 and the other staff person, who looked it over and said the SP could leave. · The SP left and then later that evening, s/he received a telephone call from P1 stating that the SP was “basically” on investigation and Human Resources was looking into it. P1 did not provide much detail, but the SP heard from other staff persons through telephone calls and text messages that two children, who the SP said were not on the SP’s Face to Name Transition Sheet, were left on the playground when the SP brought the children inside. · The SP was trained to transition children from one location to another by calling the children over and walking around the playground to make sure children were not in a “blind spot” under the awning in the back corner. Next, the SP called a child’s name and saw his/her face as the child walked by the SP. Once inside, the SP did not have the children sit down, but “visually [went] through the sheet and [saw] them” and then marked them off again to document that the children were in the building. The SP used a checkmark when the children walked past him/her and then made little circles once in the room when s/he saw the children. The facility’s Face to Name Transition Sheet for September 5, 2024, showed AV2 and two other children (not AV1) marked as moved to the Preschool classroom at 4:15 p.m. and two other children were marked as moved to pre-k at 4:15 p.m. For the 5 p.m. transition time in from the playground, AV2 had a checkmark by his/her name, but no child had a circle. The facility’s Face to Name Procedure for transitions was: · Line children up for the transition, confirm you have seen the child’s face and said their name by putting a check mark in the row associated with their name before leaving. · Once the child has arrived to the new location, confirm you have seen the child’s face and said their name by putting a circle around the check mark The facility’s Child Supervision Procedure stated, “Staff persons must position themselves and move throughout the playground, so all children are visible at all times.” The facility’s Risk Reduction Plan stated, “Classes are required to count their [children] throughout the day. Classes are required to do a name to face roll call for every transition they make.” Facility documentation showed that P1, P2, P3, P4, and the SP were each trained on the facility’s Risk Reduction Plan, Child Supervision Procedure, and the Reporting of Maltreatment of Minors Act. This investigator was able to view video footage from four camera angles from the time of the incident. The video footage was consistent with the information provided by P1. This investigator also observed that AV1 initially went with the SP when the SP waved the children over to go inside, but then AV1 ran back toward the playground and the toddler gate. The video footage confirmed that the SP did not walk around the playground to ensure s/he had all of his/her children before bringing them inside. Relevant Rule and/or Statute Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, states 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: Consistent information was provided that on September 5, 2024, AV1 and AV2 were on the preschool playground with the SP and other children. When the SP and the rest of the class went inside, AV1 and AV2 remained outside. Video footage showed AV1 and AV2 were without staff person supervision for approximately 17 minutes, which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules part 9503.0045, subpart 1, item A. Although AV1 and AV2 were not harmed during the incident, given that while they were on the playground they were exposed to community dangers because of the transparent design of the fence, and that staff persons were not there to intervene in the event of an injury or emergency, there was a preponderance of the evidence that there was a failure to supply AV1 and AV2 with the necessary care and a failure to protect AV1 and AV2 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. 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. AV1 was not listed on the Preschool classroom’s Face to Name Transition Sheet for September 5, 2024, and the SP stated that P2 was unclear on which children were joining the SP’s class and on which children P2 was taking with him/her which may have contributed to AV1 being left off the Face to Name Transition Sheet. However, the SP was the person who wrote the names down on the Face to Name Transition Sheet, and although AV1 was not on the sheet, AV2 was on the sheet and still did not make it into the classroom. The SP also did not walk around the playground to ensure all of the children were accounted for, despite being trained to do so. The SP was responsible for the supervision of AV1 and AV2 at the time of the incident and had received training on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. The SP was responsible for maltreatment of AV1 and AV2. 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 the SP was responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and AV1 and AV2 did not sustain any injuries. 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 their policies and procedures adequate, but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was 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 the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On February 5, 2025, the facility was issued a Correction Order for the violation outlined in this report, for not maintaining state mandated ratios, and for a background study violation for failure to update a study after a legal name change. 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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