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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: 1053430-CCC (Child Care Center) Investigator(s): Anna Parkin 651-431-6225 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was left alone outside on a playground for approximately 30 minutes. Date of Incident(s): December 3, 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 December 9, 2024; from documentation and video footage at the facility; and through four interviews conducted with a supervisory staff person (P), two facility staff persons (SP1 and SP2), and the AV’s family member (FM). According to the AV’s enrollment information, the AV was four years old and enrolled in the preschool B room at the time of the incident. The facility was located in downtown Minneapolis in an apartment building. The playground was surrounded by the apartment building and a parking garage on three sides, and a road on the fourth side. There was a sidewalk that led from the facility to a chain link fenced in toddler playground and then a chain link fenced preschool playground. The P provided the following information: · On December 3, 2024, at approximately 11:15 a.m., a community person (CP) who worked at the apartment building called and told the P that there was a child, later identified as the AV, alone and crying on the playground. The P ran outside and saw a security officer from the apartment building with the AV standing on the sidewalk between the preschool playground and the facility. · The AV was “pretty scared” and crying but the P did not see any injuries on the AV. The P took the AV inside to the preschool B room. SP1 and SP2 were doing group time with the other children and were not aware that the AV was outside on the playground. · The P asked SP1 and SP2 if they used the transition tracker when leaving the playground. SP1 said it was still inside the backpack so the P went and took out the transition tracker and it was “not filled out correctly” including missing a child’s name and blank spaces where SP1 and SP2 were supposed to check off when doing the name to face when coming inside from the playground. The P asked SP1 and SP2 why it was not filled out correctly and SP1 responded that they had not done a name to face during the transition inside. Video footage dated December 3, 2024, showed the following: · At 10:46 a.m., SP1 and SP2 had the children gather near the gate to the sidewalk. SP2 and one child walked out of the preschool playground and along the sidewalk. Approximately 30 seconds later, nine children started walking out of the gate and along the sidewalk holding onto the walking rope. SP1 was at the end of the line and an eleventh child walked behind SP1. · At 10:47:55 a.m., SP1, SP2, and the children were out of the view of the camera near the door to the facility. The AV was not visible in the footage camera footage until 10:48:14 a.m., when the AV ran to the gate. The AV stood or sat at the gate the whole time. · At 11:17:12 a.m., the security officer walked to the gate and opened it. The security officer took the AV’s hand and began walking along the sidewalk toward the facility. At 11:17:36 a.m., the P came into view, picked up the AV, and carried him/her inside. The AV had on a winter jacket with a hood. It was not visible whether the AV was wearing mittens. According to wunderground.com, On December 3, 2024, at 11 a.m., it was approximately 19 degrees Fahrenheit. SP1 provided the following information: · On December 3, 2024, SP1 and SP2 had 11 children including the AV outside on the preschool playground. Another child joined their group so there were 12 children including the AV outside. When a child was added to the room, SP1 “usually” wrote the child’s name on the name to face sheet but SP1 did not get a chance to write down the name because s/he had to assist two children with using the bathroom. When SP1 returned outside with the two children, it was time for everyone to go back inside. The children lined up at the gate and SP1 counted 11 children and thought they were “good” because SP1 forgot that a child had joined the group. · Once SP1, SP2, and the children were back inside the preschool B room, SP1 counted 11 children. SP1 and SP2 began group time with the children. Approximately 15 minutes later, SP1 saw the P carry the AV inside the room and was “confused” and “very shocked” because SP1 did not know the AV was left outside. The AV was crying but was not injured. · SP1 previously received training on the name to face sheet. A supervisory staff person gave a one-minute explanation on how to use the sheet and SP1 thought that s/he marked each child once during the transition even if they stopped and counted multiple times. SP1 stated that the name to face sheet was inside the backpack that SP1 carried inside and out. SP1 did not use the name to face sheet while outside at the gate because s/he was “dealing” with other children. SP1 thought SP2 did the name to face once they were inside because SP2 assisted the children with bathrooms while SP1 assisted other children but SP1 did not discuss name to face with SP2. SP2 provided the following information: · On December 3, 2024, at approximately 11 a.m., SP1 and SP2 were on the playground with 13 children including the AV. SP2 last remembered seeing the AV playing on the playground. SP1 and SP2 had the children line up at the gate. SP2 did not count the children, use the name to face sheet, or do a final sweep prior to leaving the playground. SP2 was not aware if SP1 used the name to face sheet. · When SP1, SP2, and the children got inside, SP1 and SP2 did not use the name to face sheet. SP1 and SP2 assisted the children with getting their outside clothes off and SP2 started group time with the children. During that time, the P carried the AV inside the room who was crying but did not have any injuries. SP2 said that the AV was alone outside for approximately 20 minutes. The FM was told about the incident that day and after s/he picked up the AV, the FM asked the AV about the incident. The AV cried and told the FM s/he was “alone” on the playground. The AV said that the security officer came and got him/her from the playground and the AV then went inside the facility. The FM did not see any injuries on the AV. According to the facility’s Safety and Supervision Policies: · All children were within sight and sound “at all times.” Staff persons focused their attention on supervising the children and “always” knew the exact number of children they were responsible for and where they were at all times. · Playground supervision was part of staff person’s daily routine and was met with the “same enthusiasm and diligence” as any other area of the facility. According to the Transition Policy: · Before any transitions occur in the day, staff persons ensured that all children were accurately listed on the transition tracker and signed in on the facility app. · Staff persons placed a rope in a line on the floor. Staff persons then called each child by name to hold onto the rope and placed a “X” by each child’s name on the sheet. Once the name to face was completed, staff persons counted the children on the rope to ensure all children were accounted for. · All staff persons then verbally confirmed with each other that the number counted was the same as on the sheet. · The staff person at the end of the line “must sweep” the area to ensure that all children were accounted for before closing the door. Once staff persons arrived at the new location, staff persons placed a “X” by each child’s name when they let go of the rope. According to the Daily Tracker Information Posting: · Staff persons added each child’s first and last name to the sheet. Staff persons used a “X” when children arrived and left for the day. · Any time the group left one area to transition to another, staff persons were required to perform name to face when leaving a space and again when arriving. At any areas along the way that could cause a “disruption,” such as a great room or playground, staff persons stopped and counted the children to ensure the number of children was accurate and each child was accounted for. · Staff persons added the number of “X”’s for each transition and wrote the number in the total box. Staff persons then initialed after the total. Facility documentation showed that all staff persons interviewed for this investigation, including SP1 and SP2, received training on the facility’s Safety and Supervision Policy, Transition Policy, Daily Tracker Information Posting, and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, stated that a child must have supervision at all times and that supervision was defined as occurring when 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. Conclusion: A. Maltreatment: Consistent information was provided that on December 3, 2024, the AV was left alone on the preschool playground unsupervised without staff persons knowledge or supervision for 30 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 stated s/he counted the children, SP1 forgot that a child joined the group and therefore his/her count was incorrect. In addition, SP1 stated s/he did not do a name to face count of the children. SP2 stated s/he did not count the children, do a name to face count of the children, nor do a sweep of the playground when they left. Neither SP1 nor SP2 were aware that the AV was alone on the playground. Given that the AV was four years old, it was unlikely that the AV would be able to provide for him/herself in an emergency and staff persons were not aware that the AV was outside on the playground in the event of an emergency. In addition, being alone outside for approximately 30 minutes in 19 degrees Fahrenheit exposed the AV to dangers including the weather and community persons. 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. 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 AV at the time of the incident and were trained on the facility’s Safety and Supervision Policy, Transition Policy, Daily Tracker Information Posting, and the Reporting of Maltreatment of Minors Act. SP1 and SP2 were each responsible for 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 for which the AV did not sustain an 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. SP1 and SP2 no longer worked at the facility and the remaining staff persons received additional on transitions. 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 March 7, 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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