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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: 1001324-CCCC (Certified Child Care Center) Investigator(s): Thomas Nixon Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was unsupervised in a classroom for 21 minutes without two staff persons (SP1 and SP2) knowledge. Date of Incident(s): July 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 August 8, 2024; from documentation at the facility; and through seven interviews conducted with the AV’s family member (FM), three supervisory staff persons (P1- P3), and three staff persons (P4, SP1, and SP2). The AV was three years old at the time of the incident and was enrolled in a preschool classroom. The FM said the AV was “curious and clever” and liked to read books, look at birds, and spend time with his/her family. The facility was located in a corner of a strip mall that included various stores and restaurants. The strip mall was surrounded by a sidewalk, parking lots, and a driveway. Across the parking lot and driveway at the northeast corner of the building was the facility playgrounds. The preschool classroom was at the northwest corner of the facility. The classroom had two ceiling mounted video cameras facing into the classroom for opposite corners. The cameras did not record audio. On the exterior wall were three windows and a door to the sidewalk outside, driveway, and parking lot. The classroom had four additional doors, two to the pre-k classroom, one to the twos classroom, and one to a bathroom. SP1 provided the following information: · On an unknown date, SP1 was scheduled to work from 8:30 a.m. to 5 p.m. It was a “field trip” day with outside programs at the facility for children to participate in. The day was “busy” and “hectic” as children were transferred in and out of the combined preschool and pre-k classroom to attend the other programming. The face to name sheet was “just scribbled” due to the continued rotation of children in and out of the classroom. · Between 10:30 and 11 a.m., SP1 and SP2 took between 17 to 20 children outside to the playground. SP1 thought the toddlers might have been on the other playground as well. While on the playground, P4 brought the AV to the playground and took a different child out. · SP1 did not recall if s/he added the AV to the sheet, if s/he asked SP2 to add the AV, or if P4 added the AV to the sheet. SP1 thought s/he and SP2 possibly “just got distracted” and the AV was not added to the classroom face to name sheet. · While on the playground, some children who had accidents, some got injuries that bled, and some needed to use the bathroom. SP1 and SP2 then took turns bringing groups of six children inside to use the bathroom. At one point, SP1 told SP2 s/he planned to take a group of children inside to use the bathroom. Because there was only one paper with the name to face, SP1 left it on the playground with SP2 because that was where a majority of the children were. · As SP1 and the children left the playground, SP1 counted the children, including the AV, “just in my mind.” SP1 thought there were “six or seven” children in the group. SP1 walked with the children across the street and into the facility. SP1 did not recall what door they used to enter. SP1 said that as they entered the facility, s/he did another headcount. · In the classroom, some of the children used the bathroom while others played. The AV was last to use the bathroom and SP1 entered the information into a tracking app the facility used to record some daily activities. · SP1 then called out for the children to come to the door to go back outside. Several children played behind a shelf near the door and SP1 completed a headcount “in my head” of the children. SP1 then opened the door and the group exited to the sidewalk. SP1 thought s/he saw the AV walk out the door. SP1 said s/he “just kept going and assuming I had all the count and everybody.” Once they were outside on the playground, SP1 did not recount the children.” · SP1 thought the group remained on the playground for another 10 to 15 minutes. When it was time to go in, SP1 and SP2 gathered the children, looked around the playground to ensure everyone was present, and completed a name to face count. At that time, SP1 counted 20 children. The group exited the playground, walked across the parking lot, and stood near the classroom external door where they again counted 20 children before going inside. · As they stood at the door, SP1 saw the AV looking out the window of the classroom at the group. SP1 entered the classroom, went the AV, gave him/her a hug and apologized and “consoled” the AV. The AV was “not crying” and looked like s/he was “just waiting [his/her] turn” for something. The AV was not injured or wet and there were no issues with the AV. SP1 asked the AV if s/he was “scared,” and the AV said, “A little.” · SP1 “felt bad” and told SP2, “I forgot a child.” At that time, P4 was also in the classroom so SP1 also told P4 about what happened. · SP1 then counted the children and there were 21 instead of the 20. SP1 then reviewed the name to face sheet and saw that the AV’s name was crossed off and was assigned to a toddler room. · SP2 or P4 then brought the AV to the toddlers classroom next door to ensure and maintain ratios. SP1 then left the classroom and told P3 what about the incident. · SP1 said that when leaving the classroom to return to the playground, “I believe [the AV] was behind a shelf… I didn’t look behind the shelf where kids were playing… I said everyone come… a bunch of heads pop up and walk out the door. I did a count, mostly she went right back sitting down trying to hide.” SP1 said s/he, “Apparently closed the door on [the AV] when I was walking out the door or [s/he] was hiding or walking slow.” SP2 provided the following information: · On an unknown date, sometime between 10 a.m. and 10:45 a.m., SP2, SP1, and “likely” 20 children went outside. SP1 and SP2 did a name to face count when they left the classroom. SP2 said the AV was with the group while they were outside. · SP2 said s/he did not know SP1 was taking a group of children inside to use the bathroom. SP2 “had no clue” who was with SP1, how many children SP1 had with him/her, or when SP1 took them inside. SP1 “just went” and SP2 did not see the group leave. · When SP2 saw SP1 and the children return to the playground, SP2 did not think that SP1 did a name to face. After SP1 and children returned to the playground, they were outside another five to ten minutes before they lined up to go back inside. · Once the children were lined up, SP1, who had the name to face sheet, was to do the name to face count, while SP2 looked around the playground to make sure there were no children. SP2 did not recall if s/he heard SP1 complete the name to face before the group left. SP2 thought it was likely not done because SP1 would have realized then that the AV was not with the group. SP2 said s/he did not complete a headcount of the children before they left the playground. · The group left the playground, walked across the parking lot, and lined up against the wall to start the process of going into the building. SP2 held the door open while SP1 stood in the doorway to call the children inside. When the classroom door was opened, SP1 and SP2 saw the AV standing in the classroom at the window. SP2 had not seen the AV from outside through the window. · The AV appeared to be “fine,” was not crying or injured, but was “confused.” SP2 was “in shock” and asked if the AV was left inside. SP1 acknowledged so and said, “I messed up.” The AV asked SP1 and SP2, “Why did I get left inside?” and “[SP1] left me inside.” SP2 asked the AV is s/he was okay, and the AV responded s/he was “fine.” · SP1 then left the classroom presumably to tell P3 about the incident while SP2 read the children a book. The AV appeared “good” and was back to his/her “old self” the rest of the day. P1, P2, P3, and P4 provided the following information: · On the morning of July 24, 2024, P3 was working while P1 and P2 were at a conference. That day, the facility hosted both a Soccer Shots and a science program and the children were rotated in and out of classrooms throughout the day. P3 tracked and coordinated the children’s placements and participation in the events. · P4 was on the toddler playground and saw SP1 take children inside to use the bathroom and then return to the playground. P4 did not see SP1 complete a name to face count of the children when s/he returned to the playground. At some point after, SP1 was with the AV and told P4, “I left [the AV] in the classroom by accident.” P4 saw that the AV was “a little red in the face.” P4 asked the AV what happened, and the AV said that s/he “was in the classroom.” P4 asked if a teacher was with him/her and the AV said, “No.” The AV “seemed fine” the rest of the day and “played regularly” and “was not distressed.” · Around 11 to 11:30 a.m., P3 was in the kitchen to prepare food for the children when SP1 came in. SP1 said s/he brought “a few” of the children in to use the bathroom and the AV “got left in the classroom for five minutes.” P3 stated s/he was told by SP1 it was discovered the AV was not with the group when they “got back out to the playground that [the AV] was left inside” and told SP2 about it. Once it was realized the AV was not with, SP1 immediately lined up the children and they went back inside to the classroom. (Note: SP1 and SP2 denied learning the AV was not with the group while they were on the playground.) · Later when P3 was delivering lunch, s/he saw the AV who “seemed fine” and answered questions from P3 about his/her day. P3 and the AV did not talk about the AV being left alone in the classroom. · After learning of the incident, P2 called SP1, who said s/he “got overwhelmed and did not count… [and] did not do the face to name.” P1 also talked to SP1 about the incident. SP1 told P1 that s/he went into the classroom with six children, including the AV and when they left the classroom, SP1 thought the AV was “right behind them or right in front of them” as they left. SP1 “knew it was wrong.” · Around 1:30 p.m., P3 called the FM and was told about the incident. · P1 said a name to face or headcount was to be done at “every transition… every threshold is our policy.” When a staff person went with a group of children out of a classroom it was to be done “at the door” and once again at the place of arrival. The face to name documents for the day of the incident were requested; however, the facility was not able to locate them. A video camera was located in the ceiling corner of the preschool classroom and provided a view of the exterior door to the playground, the classroom area, bathroom entrance, and partial view of the hallway with the twos’ classroom and hallway door on either end. The video recording, was 59 minutes and 59 seconds, started at 10:15 a.m. and ended at 11:15 a.m., and contained no audio. The video recording showed the following: · At 15:47, the exterior door opened and six children, which included the AV, and SP1 came into the classroom. The children used the bathroom while SP1 monitored the classroom. · At 21:32, the children, including the AV, start to head towards the outside door, SP1 walked towards the outside door, and the children gathered near the outside door. · At 21:48, the AV went to the window to the right of the door. SP1 looked the opposite direction to his/her left. · At 21:53, SP1 turned to face the children to his/her right toward the direction of the AV. · At 21:55, SP1 opened door and children begin to exit. · At 21:58, SP1 exited the door and held it open as a fifth child left. The AV remained at the window. · At 22:04, the door closed. The AV was still in the classroom and walked towards the door and then back to the window. · From 22:04 to 42:42, the AV remained in the classroom and looked around the room, shook his/her arms, shuffled his/her legs and feet, jumped up on and down, had his/her mouth open looking around the room possibly crying or calling out, bounced up and down, walked off camera, walked to look at the outside door, went to a shelf and back to the window, walked across the room to the hallway door area off camera, returned back on camera to walk towards the Twos classroom door area off camera, returned back to the hallway door area off camera, and returned to the window. · At 42:43, the outside door opened and SP1 stood in the doorway as children entered. · At 43:02, SP2 entered the classroom followed by SP1. SP1 looked towards the AV. The FM was notified the day of the incident and was told the AV was in the classroom alone for five minutes. The AV “seemed fine” and was not affected by the incident. The FM checked the AV for any injuries and/or bruises, and none were found. A few days later, P1 called the FM and said that after s/he watched the camera footage, the AV was in the classroom unsupervised for approximately 20 minutes. While the FM was concerned about the incident, s/he was overall happy with the facility and the AV continued to attend. According to the facility’s Face to Name Procedure, the Face to Name Transition Sheet was to be kept current at all times and was to be used when children arrive or leave a classroom and transitioning from one location to another. According to the facility’s Child Supervision Procedure, children must be supervised, in the direct line or sight and within earshot of a staff member at all times. Facility documentation showed that SP1, SP2, P2, P3, and P4 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A, state 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: Information including video was consistent that July 24, 2024, around 10:30 to 11 a.m., the AV was left unsupervised in the preschool classroom for approximately 20 minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision 18, and Minnesota Rules, part 9503.0045, subpart 1, item A. Although the AV was not injured, given the AV was three years old and unsupervised for approximately 20 minutes inside the classroom without staff persons knowledge, 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 in the classroom and would not have been able to intervene in the event of an emergency. 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 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 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 working in the classroom on the playground at the time of the incident and were trained on the Reporting of Maltreatment of Minors Act and on the facility’s policies, including those regarding the supervision of children, prior to the incident. At one point, SP1 took a group of children, including the AV, into the facility to use the bathroom. Although SP1 said s/he told SP2, SP2 stated that s/he was not aware that SP1 took children inside to the bathroom. Regardless of whether SP2 knew that SP1 took some children inside, when SP1 left the playground, SP1 became the sole staff person responsible for the supervision of the children in his/her care which included the AV. SP2 remained responsible for the supervision of the children on the playground. When the group was done inside, SP1 left the classroom and returned to the playground leaving the AV unsupervised in the classroom. SP2 was on the playground and had no reason to believe that SP1 would have left any child in the classroom unsupervised. Therefore, SP2’s responsibly was mitigated and SP1 was 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 was 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 determined that the facility’s policies were adequate, but were not followed by the staff persons. All staff persons at the facility were retrained on the face to name procedure. SP1 no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 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 disqualification. The determination that SP1 was responsible for maltreatment is subject to appeal. On May 2, 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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