|
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: 1011385-CCC (Child Care Center) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised on the facility playground for approximately 15 minutes. Date of Incident(s): October 24, 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 1, 2024; from documentation at the facility; and through five interviews conducted with a facility supervisory staff person (P1), two staff persons (SP1 and SP2), the AV’s family member (FM), and a community person (CP). This investigator met the AV but did not interview him/her due to the AV’s age. The facility was located in an private elementary school and had multiple classrooms including a toddler room. The facility had a playground area that was not attached to the building. To access this area, staff persons exited the facility with the children and walked approximately 100 feet to the playground. There was a chain link fence with a gate surrounding the playground. When the playground was not being used, staff persons locked the gate with a padlock. The facility was located within a residential neighborhood with residential roads on two sides of the playground and an alley on another side. The playground was visible to passersby. The AV was approximately 17 months old at the time of the incident and enrolled in the toddler classroom. The Time Card Detail said that on October 24, 2024, there were ten children in the toddler classroom, including the AV. SP1 and SP2 worked in the toddler classroom. CP1 said that on October 24, 2024, around 3:20 or 3:30 p.m., CP1 was driving near the facility when s/he saw the AV in the corner of the playground, playing with leaves. The AV was not crying, seemed “calm,” and waved to CP1. CP1 was “worried” because s/he did not see anyone with the AV and it was “raining a little bit.” CP1 stopped his/her car, got out, and went to the playground but the gate was locked with a padlock. CP1 then told another community person (CP2) who was his/her family member and CP2 “ran” to one of the doors of the building to let someone know the AV was outside. An unknown person answered and said that the AV was from the facility. CP1 then saw another unknown person “run” to the playground to get the AV and then that person took the AV inside. CP1 then left without talking to any staff person. CP1 thought that the AV was unsupervised for approximately 10 to 15 minutes because another community person (CP3) who was CP1’s family member told CP1 that around 3:10 p.m., s/he saw the AV outside with his/her class. P1 provided the following information: · On October 24, 2024, around 3 p.m., P1 was in his/her office when s/he saw the toddler and preschool rooms go outside to the playground. At some point after, the classrooms came inside because it started to rain. Then, “shortly after,” a staff person from the school came into P1’s office asking for the playground key because the playground gate was locked and there was “still a toddler in the playground.” The school staff told P1 that an unknown person had knocked on one of the building’s doors to let the school staff person know the AV was outside. P1 did not know where the playground key was so P1 went outside and “climbed” over the playground fence to get the AV. During this time, SP2 ran outside with the playground key and then SP2 returned the AV to the classroom. · P1 thought that the AV was unsupervised for approximately five minutes based on when P1 saw the AV’s class return inside to when P1 was notified of the incident. · The AV was not injured and not crying. The AV was not wet so P1 thought the AV may have been “hiding” under playground equipment when the classrooms went inside. Potential risks to the AV being unsupervised included the AV falling and not having a staff person there to help him/her. The AV also could have climbed the fence to exit the playground. However, P1 had never seen the AV climb the fence. A community person also could have climbed the fence, similar to what P1 did, and accessed the AV. · SP1 and SP2 felt “really bad” and were “upset” regarding the incident. SP1 and SP2 told P1 that at the time of the incident, it started raining and they “rushed in” thinking they had everyone. Staff persons were trained to do head counts and document the counts on a dry erase board. SP1 provided the following information: · On October 24, 2024, at some point between 2 and 3:30 p.m., SP1 and SP2 took the toddler children outside. There were ten children in the classroom and SP1 and SP2 each had a buggy to bring the children outside, that held six children each. The preschool class was also outside. · After being outside for approximately 20 to 30 minutes, it began raining so SP1 and SP2 began “quickly” getting the children into the buggies to get them inside. During this, SP1 gathered what s/he thought was the “last kid” from the playground and then SP1 and SP2 brought the children in via the buggies. The preschool classroom also brought their children in at this time. As they were walking towards the building, SP1 “looked back” to ensure everything was picked up and did not see anyone, and then they went inside. · After approximately five to seven minutes of being inside, SP1 began looking around the classroom and did not see the AV. SP1 thought that the AV may have been with SP2 putting away the buggies. At the same time, a staff person (P2) from the preschool room came in with the AV and said that the AV was “left in the playground.” (Note: There was no other information that P2 returned the AV to the classroom.) · When the AV returned, s/he seemed “normal” and was not crying. There were no injuries to the AV. However, risks to the AV being unsupervised included the AV falling off playground equipment. · SP1 thought that the AV was unsupervised between five to seven minutes. SP1 did not think it was longer because they had just returned to the classroom, the toddler children were still in the process of taking off their coats, and SP2 was still putting the buggies away when the AV was returned. · SP1 and SP2 were both responsible for supervising the children. Staff persons typically did a head count during transitions, including when leaving the playground and returning to the classroom. However, on the date of the incident, this was not done due to the rain and everyone “rushing.” SP1 also said that s/he did not do a head count because s/he was “pretty new.” SP2 provided the following information: · On October 24, 2024, around 3 p.m., SP1 and SP2 were outside with the toddler children when it began raining “out of nowhere.” SP1 and SP2 began getting the toddler children in the “buggies” as “quickly as possible” but the children were “all running around.” The preschool classroom was also outside, and the preschool staff persons also began getting their children ready to go inside. Once SP1 and SP2 got the toddler children into the buggies, SP2 “assumed” all the children were present but did not “double check.” However, SP2 “briefly looked” at the two buggies and thought that all the “seats were filled in” that were “supposed to be.” SP1 and SP2 then brought the children inside. · About five minutes after getting inside, while SP2 was in the hallway assisting the children with getting their jackets off, SP2 realized that s/he did not see the AV. SP2 realized this because the AV wore a “bright” colored jacket which SP2 did not see. SP2 then looked in the preschool room to see if the AV was there but SP2 did not see the AV. At the same time, an unknown staff person from the elementary school came and told SP2 that another person found the AV outside. SP2 than ran outside and saw P1 walking with the AV towards the building. The AV was not crying and was not wet. Because the AV was not wet, SP2 thought that the AV might have been in one of the playground tunnels. · SP2 said that the AV was unsupervised between five and ten minutes. Risks to the AV being unsupervised included the AV falling off playground equipment. Additionally, the playground gate was typically locked after the classrooms used it, and SP2 thought one of the preschool staff persons locked it on the date of the incident, prior to coming inside. The AV was not able to exit the playground due to the lock. · SP1 and SP2 were both responsible for the supervision of the AV. SP2 was trained to do a head count and document the count prior to going inside and typically did so but did not on the date of the incident because s/he was on “autopilot.” SP1 and SP2 both felt “awful” about the incident. The FM said that P1 notified him/her of the incident “right away.” The FM did not have any concerns with the facility. According to www.wunderground.com, on October 24, 2024, at the time of the incident the temperature outside was 56 degrees Fahrenheit with “precipitation.” The Risk Reduction Plan said that there was a “busy” road next to the facility. The children were to always be in the fenced in playground or in a line with staff persons or buggy while outside. The Staff Handbook said that children were to have “constant” supervision from staff persons. While on the playground, staff persons were to always know how many children were in their care. Children were to be counted when going inside. Facility documentation showed that P1, SP1, and SP2 received training on the facility policies and procedures, including the Risk Reduction Plan and on the Reporting of Maltreatment of Minors Act. Relevant Rules and Statutes: 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: On October 24, 2024, SP1 and SP2 were on the playground with ten children, including the AV. When SP1 and SP2 brought the children inside, the AV was left outside on the playground unsupervised between 5 and 15 minutes which was a violation of Minnesota Statutes section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although SP1 and SP2 each provided information that they “quickly” gathered the child to go inside because it began to rain, neither counted the children and the AV, who was 17 months old, was left unsupervised on the playground which was visible from passerby’s and therefore, exposed the AV to community dangers. Given the AV’s age, it was unlikely that the AV would have been able to provide for him/herself in an emergency and staff persons would not have been able to respond in the event of an emergency and/or intervene if necessary. Therefore, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and/or protect the AV from conditions 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. SP1 and SP2 were each responsible for the care and supervision of the children, including the AV. SP1 and SP2 received training on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. SP1 and SP2 were 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. SP1 and SP2 were each responsible for a single incident of maltreatment for which the AV did not sustain a serious injury. 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 determined that policies and procedures were adequate but not followed at the time of the incident. Following the incident, staff persons were retrained on the supervision of children. Additionally, P1 planned to go into each room more frequently to ask staff persons how many children were in their care. There were no similar prior incidents. 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 24, 2025, the facility was issued a Correction Order for the violation outlined in this report. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal. 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.
|
