|
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: 1059536-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was on a playground without staff person knowledge or supervision for three to ten minutes. Date of Incident(s): October 11, 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 October 29, 2024; from documentation at the facility; and through seven interviews conducted with a supervisory staff person (P1), five facility staff persons (SP1, SP2, SP3, SP4, and P2), and the AV’s family member (FM). The AV was 3 years old and enrolled in the Super Students (preschool) classroom at the time of the incident. At the time of the incident, SP3 was working with the Super Students class. This investigator met the AV, but s/he did not provide information relevant to this investigation. The facility was part of a community education advocacy program that provided services for families and was located in a residential neighborhood consisting of single-family homes. The community education advocacy program was located in a two-story building, and the facility had five classrooms for infants through pre-kindergarten aged children on the main level of the building. There was a playground on one side of the building with climbing structures and a large tree in the middle of it. There were two steps that led up to a landing connected to the building. On the landing there was a door which led into a main hallway and another door which led directly into a classroom. The playground was surrounded by a four-foot-high chain link fence with a gate leading toward the front of the building. There was a main road in front of the building that was approximately 25 feet from the fence. The speed limit on the road was 20 miles per hour. The facility’s Incident and Injury Report Form stated that on October 11, 2024, at 4:15 p.m., the AV was left on the playground when the rest of his/her group returned inside. P1 went outside and found the AV playing on the playground. The FM stated that on the day of the incident, s/he arrived at the facility and P1 told the FM about the incident before the FM even picked up the AV. The FM got the impression that the incident had happened just a few minutes before the FM arrived. P1 told the FM that the AV was “happy as can be” and was playing when P1 found the AV. When the FM saw the AV, the AV did not seem distressed. The FM had no prior concerns about the facility. P1 provided the following information: · On October 11, 2024, around 4:10 p.m., P1 was getting ready to leave the facility at the end of the day and saw SP1, SP2, SP3, and SP4 inside the building. When the weather was nice outside the groups combined outside at the end of the day. P1 made a comment to the staff persons about it being a nice day outside and wondered why they had come inside already. P1 did not remember exactly what was said about why the group was inside but thought that the children wanted water. · P1 then left the facility and saw another child’s family member walking toward the building so P1 stopped to talk to that family member. After three to five minutes, P1 and that family member were done with their conversation and P1 heard a noise coming from the playground, so P1 looked behind him/her and saw the AV skipping on the playground. P1 went in through the gate, checked the AV over for any injuries, and did not see anything. The AV laughed “the entire time.” · P1 brought the AV inside and went to the main lobby where SP1, SP2, and SP3 were waiting with the remaining children (P1 thought there were five children left at that time). P1 told SP1, SP2, and SP3 that the AV had been left outside. SP4 was not with the group and P1 did not remember if SP4 had left for the day or was in his/her classroom closing it down (cleaning and getting it ready for the next day). · Since it was close to the time the FM picked up, P1 stayed to have a conversation with the FM about the AV being left outside unsupervised. P1 said the FM understood the seriousness of what happened, and it was “scary” to hear, but that the FM “trusted” the staff persons and the AV appeared to be “okay.” · Staff persons were trained to scan the playground and know how many children were still in their care by using the Lillio app (an application used to track attendance and communicate with families). If a staff person left for the day, s/he was supposed to let the other staff persons supervising the group know who was left from his/her class outside. · When transitioning children from one location to another, staff persons were supposed to have one staff person in the front [of the line] and one staff person in the back [of the line], count before leaving an area, and count once they arrived to where they were going. · If staff persons were combined outside with their children and there was an infant child still present, the infant staff person was not responsible for the other children. P2 was sitting in the front lobby on the day of the incident, but did not remember what time it was. P2 said SP1, SP2, and SP3 were with a group of “maybe” four children. P2 did not remember if SP4 was with them or not. P2 checked the roster and noticed that the AV was not checked out but was not with the group. P2 asked if the AV had gotten picked up, and then P1 walked inside with the AV. P2 said the AV seemed “fine.” P2 did not recall if any staff person performed a name to face count to see who was there when the group came into the lobby. P2 did not know how long the AV was unsupervised. SP3 provided the following information: · SP3 did not remember the date of the incident but stated that it happened on a Friday afternoon. SP3, SP1, SP4, and another staff person (SP3 did not recall the name but likely SP2 based on SP3’s description and information from other staff persons) were outside on the playground. SP3 told SP1 and SP2 that s/he was going to go inside to close down SP3’s classroom. SP3 did not recall if SP4 was outside at that time as SP4 was getting ready to leave for the day. · SP3 took about ten minutes to close down his/her classroom and was going to rejoin the group outside and noticed that they had come inside, so SP3 joined them in the front lobby. P2 was sitting up front and P2 said, “I think we are missing a child.” P2 grabbed the tablet and started looking through the list when P1 walked in with the AV saying the AV had been left on the playground. SP3 said the AV seemed “fine.” · SP3 used a tablet to keep track of his/her class but at the time of the incident s/he did not know that s/he could also see the other classes on the tablet. SP3 stated there were only four children enrolled in his/her class and that SP3 counted the children anytime they traveled anywhere. When groups combined outside, SP3 liked to say out loud how many children were present from each class and the total number of children, then to count down when children left. · On the day of the incident when SP3 went inside s/he did not tell the other staff persons which of SP3’s children s/he was leaving outside because when the staff persons were on the playground together at the end of the day, they were “all responsible for all of the children” no matter which age group the children were in. SP4 provided the following information: · On the day of the incident around 4 p.m., SP1, SP2, SP3, and SP4 were outside with a group of children. SP4 went inside to close down his/her classroom for the day, leaving SP1, SP2, and SP3 outside with the group of children including the AV. It was the end of SP4’s shift so after s/he finished in his/her classroom, SP4 went back outside to see if the other staff persons needed anything before SP4 left. When SP4 went back outside, SP1 and SP2 were the only staff persons outside, as SP3 had gone inside to close down his/her classroom. · SP4 thought there were between five and seven children left at that time and SP1 stated it was getting “a little cold,” so SP4 offered to help SP1 and SP2 get the children inside. SP4 said the staff persons called the children over to the door and SP2 went in through the door first. SP4 stated that staff persons “usually” called children by name, but that day that “clearly that wasn’t the case” as the AV was left outside, and the children were not counted before going inside. SP4 thought the staff persons just “rounded the kids up” and they walked inside that day. · SP4 did not think the children were counted once the group was inside. SP3 returned to the group after closing down his/her classroom and then SP4 left for the day. SP4 did not find out until the next day that the AV was left outside. SP4 was not sure if SP1 or SP2 was working with infants that afternoon, but said that whoever was not working with the infants was responsible for the AV. · SP4 was trained to count children during transitions to know how many children went outside and how many returned inside. SP4 said that staff persons used a tablet to see which children were still checked in at the end of the day, but when the groups were combined outside, SP4 said it was “easier” to ask other staff persons which children they brought outside instead of using the tablets. · SP4 said it was about ten minutes from when the group came inside to when SP4 left for the day as SP4 got picked up and waited for his/her ride, however it was possible the AV was found outside by P1 before SP4 left the facility grounds. SP2 provided the following information: · Around 4 p.m. on the day of the incident, SP2 was outside with SP1, SP4 and a group of children (SP2 thought “maybe” there were nine children including the AV). SP3 had gone inside to close down his/her classroom. SP2 remembered seeing the AV by the tree on the playground. SP2 stated that SP3 did not tell SP2 how many children s/he was leaving on the playground when SP3 went inside. · SP1, SP2, and SP4 called the children over to the door to go inside. The group all went inside together and went to the front lobby where SP3 rejoined the group. SP2 did not provide information about whether the children were counted at any point(s) during the transition. In the front lobby, P1 told the staff persons it was early to be out front. As the group was up front, P2 noticed on the app that the AV was still checked in but not with the group. P1 then brought the AV back to the group and stated that s/he found the AV outside playing on the playground. SP2 said the AV had a “neutral face” when SP2 saw the AV. · SP2 said s/he was trained to use the Lillio app to see which children were still present and which children had been checked out for the day. When coming inside, staff persons “tried” to do a headcount. · SP2 was not sure how long the AV was without supervision. SP1 provided the following information: · SP1 did not remember the date of the incident but stated that it was a Friday afternoon. SP1 brought the infants outside a little before 4 p.m. SP2 closed down the infant classroom and came outside. Two infants left while the class was outside with the other children, so SP1 told SP2 to help the other staff persons (SP3 and SP4) supervise their children, since there was only one infant left. · SP1 brought the one infant inside with him/her to grab cups and water for the group and then they returned to the group outside. SP3 went in to close down his/her classroom and then returned back outside with the other staff persons to bring the children inside. When the group went inside, SP1 went inside first with the infant s/he had. SP1 said each class “usually” counted their own groups, but that day SP1 did not hear anyone counting. SP1 said it was around 4:10 p.m. and they went to the front lobby area to wait for families to pick up. P1 said that SP4 left as s/he was done working for the day. P1 asked why they were inside so early and SP1 told P1 it was because SP1 did not feel well. · P1 left the facility and went outside to speak with a parent. At that time someone asked about the AV (SP1 did not remember who asked), and SP1 said s/he had not seen the AV all day as the AV was not in the classroom SP1 worked in and SP1 had not checked the Lillio app. SP2 stated s/he saw the AV behind the tree. P1 then came inside with the AV saying s/he found the AV outside on the playground. · SP1 said that staff persons counted which children they had at the end of the day and that the AV was in SP3’s class. SP1 said the facility used the Lillio app, but SP1 did not hear any staff persons counting the children during the transition from the playground to the lobby on the day of the incident. · SP1 thought the AV was outside for five to ten minutes. The facility’s Risk Reduction Plan stated, “Children are counted before leaving an area and when they arrive. [Staff persons] are positioned in the front and back of the line to ensure children are transitioned safely. Facility documentation showed that P1, P2, SP1, SP2, SP3, and SP4 were each trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Rules 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: Consistent information was provided that on October 11, 2024, SP1, SP2, SP3, and SP4 were outside on the playground with all of the children still at the facility, including the AV. At some point while the group was outside, SP3 went inside to close down his/her classroom and did not inform SP1, SP2 and SP4 of how many children s/he was leaving under their supervision on the playground. The AV was one of those children. SP2, SP3, and SP4 stated that SP3 did not return outside before the group went inside. Around 4:10 p.m., SP1, SP2, and SP4 brought the children inside. SP3 then rejoined the group in the front lobby, and SP4 left for the day. P1 commented that the group was back inside early before s/he left for the day. Once outside P1 stopped to speak with a family member and after that conversation P1 found the AV on the playground. P1 checked the AV over for injuries, did not see anything, and then P1 brought the AV inside. Information provided was the AV was outside on the playground by him/herself for approximately three to ten minutes which was a violation of Minnesota Statutes, section 245A.02, subdivision, 18, and Minnesota Rules part 9503.0045, subpart 1, item A. Minnesota Statutes, section 260E.30, subdivision 3 states that rather that 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; (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. Regarding SP3: (1) at the time of the incident, SP3 was performing duties identified in the center’s child care program plan; (2) SP3 had not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; (3) SP3 had not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years;
(4) There were no injuries to the AV as a result of this incident; and (5) except for the period when the incident occurred, the facility and SP3 were in compliance with all licensing requirements relevant to the incident. Regarding SP2 and SP4: A. Maltreatment: Information was consistent that SP1, SP2, and SP4 brought the children inside and did not perform a headcount before leaving the playground or once arriving in the front lobby. Although there was no apparent harm to the AV, while the AV was alone on the playground staff persons were not present in case of an emergency, and the design of the facility fence meant the AV was visible to 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 and 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 stated that s/he was supervising an infant at the time of the incident, and P1 and SP4 each said that if an infant was still present at the end of the day, the staff person supervising the infant was not responsible for the other children. Therefore, SP1’s responsibility was mitigated. SP2 and SP4 were responsible for the supervision of the AV at the time of the incident and had been trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. SP2 and SP4 were each 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 SP2 and SP4 were responsible did not meet statutory criteria to be determined as recurring or serious as it was a single incident, and the AV 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 staff persons. SP1, SP2, SP3, and SP4 were all retrained on the facility’s policies. Action Taken by Department of Human Services, Office of Inspector General: SP2 and SP4 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 and SP4 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 SP2 and SP4 were each responsible for maltreatment is subject to appeal. SP3 was not determined as a perpetrator of maltreatment of the AV because the Department of Human Services found that the incident for which SP3 was responsible met the criteria to be determined a nonmaltreatment mistake. SP3 was notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which SP3 is responsible might not be considered a non-maltreatment mistake. During the course of the investigation, it was determined that one background study violation occurred. On May 9, 2025, the facility was issued a $200 fine for the background study violation. The Order to Forfeit a Fine is subject to appeal. On May 9, 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.
|
