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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: 1037325-CCC (Child Care Center) Investigator(s): Judith Schwanke/Kimberly Anderson 651-431-4033 Suspected Maltreatment Reported: It was reported that a pitcher of bleach water solution was accessible to the preschool children and that three alleged victims (AV1, AV2 and AV3) drank water from the pitcher. Date of Incident(s): December 14, 2022 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 January 12, 2023; from documentation at the facility; and through 10 interviews conducted with a facility management person (P1), staff persons (P2, SP1, and SP2), AV1, AV2, AV3, and AV1’s-AV3’s family members (FM1, FM2, FM3 respectively). Facility enrollment records show that at the time of the incident, AV1 and AV3 were four years old and AV2 was five years old. AV1, AV2, and AV3 were enrolled in the facility’s preschool program. The facility was a preschool facility and cared for children ages three through five. There were two classrooms, and a small hallway. Off the hallway was a bathroom and storage area that contained art supplies and cleaning chemicals. In the classroom, on a small, low table, was a tray that contained a small pitcher with water and paper drinking cups for the children to serve themselves. Near this small table were two larger, rectangular tables where the children ate their lunch. The facility’s Incident/Injury Report Forms for AV1, AV2, and AV3 each stated that on December 19, 2022, AV1, AV2, and AV3 poured themselves some water and took a sip. The water was a bleach water solution used for cleaning. SP1 contact the local poison control center and was instructed to give AV1, AV2, and AV3 water and crackers. P1’s interview and written documentation provided the following information: · On December 19, 2022, P1 was working from home when SP2 notified him/her that at approximately 9:45 a.m., a small pitcher was “accidentally” filled with a water and bleach solution and AV1, AV2, and AV3 ingested a small amount of the bleach and water solution after pouring the solution from the pitcher into small paper cups. · AV1-AV3 noticed the water tasted “strange” and notified a SP3, who smelled and tasted the water and realized it was bleach water. SP1 called Poison Control and followed their guidance, which was to encourage AV1, AV2, and AV3 to drink water and eat crackers. · P1 called FM1, FM2, and FM3 and told each about the incident, and then emailed all other enrolled families about the incident. · P1 said that the incident occurred because the bleach solution had been mixed in and was still in a plastic jug with the original factory label of “spring water.” After the incident, the plastic jug’s “spring water” label was removed and properly labeled with the correct contents. FM1, FM2 and FM3 each stated that they were notified by the facility that their child had ingested the bleach solution. AV1, AV2 and AV3 were given water and crackers and did not get sick after ingesting the bleach solution. Neither FM1, FM2, nor FM3 had concerns with the facility. AV1 stated the water that s/he drank was “soapy” water and it tasted “yucky.” The water pitcher was sitting out and someone decided to drink it. AV2 stated that s/he drank water that SP2 provided and it tasted “weird” and s/he did not like it. AV2 only drank the “bad water” once and it did not make him/her sick. AV3 stated s/he had two sips of “poison water” from a cup and told staff persons it was “not good.” SP1, SP2, and P2 provided the following consistent information: · On December 19, 2022, SP1 mixed a bleach solution, used for cleaning, in the plastic jug labeled spring water and then filled four spray bottles of the solution for classroom sanitizing. The remainder of the solution was left in the jug. The jug was on a counter in the storage area, near a bin that was the “mixing station.” · A small pitcher of water was provided for the children who then served themselves when thirsty. Typically staff persons refilled the pitcher from the tap when it was empty. AV1 and AV3 wanted water to drink but the water pitcher was empty. SP2 went into the storage area and filled the water pitcher from the jug labeled spring water. SP2 had never filled the pitcher from a plastic jug before this incident. · SP1 was on the classroom carpet playing with children and P2 was seated at the rectangular table furthest from the small table where the pitcher of water had been placed. AV1 and AV3 drank the water from the pitcher and said it tasted “gross.” SP2 thought the children just preferred the tap water over the “spring water” and dumped out the contents of the pitcher and filled it with water from the tap. AV2 drank water from the pitcher after the bleach solution had been poured out and the pitcher was refilled with tap water but not rinsed. Because the children kept talking about the water, P2 smelled the water and tasted it. P2 whispered to SP2 the water was bleach water. SP2 ran to the storage area, grabbed the plastic jug labeled spring water, and came back into the classroom and asked SP1 about the contents of the jug. SP1 confirmed it was bleach water. SP2 told SP1 that some of the children may have drank the bleach solution. · SP1 immediately called Poison Control. Poison Control asked SP1 the ages of the children who ingested the solution and the percentage of the solution. Poison Control then instructed SP1 to give the children either crackers or toast and “a lot” of water. · P2 found crackers for the children to eat while SP1 started a drinking “contest” with AV1, AV2, and AV3 and they all began to drink tap water. Each drank two full eight-ounce cups of water and SP1 encouraged the AVs to make cracker towers and eat crackers. The AVs were encouraged to eat as many crackers as they wanted. SP1 and P2 monitored each for any adverse reactions and saw none. The facility’s Risk Reduction Plan stated cleaning supplies will not be accessible to children and separate storage areas will be provided for cleaning products and the storage areas will be locked at all times. Facility records showed that prior to the incident, SP1, SP2, P1 and P2 had been trained on the facility’s Risk Reduction Plan and the Reporting of Maltreatment of Minors Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes, section 245A.66, subdivision 2, paragraph (e), and Minnesota Rules, part 9503.0140, subpart 17, stated that the facility’s risk reduction plan that will prohibit the accessibility of hazardous items to children and that poisonous chemicals, including household supplies, must be stored out of the reach of children. Conclusion: On December 19, 2022, SP1 mixed a bleach solution, used for cleaning, in the plastic jug labeled spring water and then filled four spray bottles of the solution for classroom sanitizing. The remainder of the solution was left in the jug on the storage area counter near a bin that was the “mixing station.” Later, SP2 poured water from the jug into a small pitcher and placed the pitcher in the classroom for children’s consumption. The water in the jug was a bleach solution used for cleaning, but not properly labeled. AV1, AV2, and AV3 drank a small amount of the bleach solution which was a violation of Minnesota Statues, section 245A.66, subdivision 2, paragraph (e) and Minnesota Rules, part 9503.0140, subpart 17. SP1 contacted poison control immediately and SP1 and P2 followed the instructions by providing the AVs with tap water to drink and crackers to eat. Neither AV1, AV2, nor AV3 had adverse reactions to drinking the bleach solution. Minnesota Statute 260E.30, subdivision 3, paragraph (b), clauses (1-5) states that a “Nonmaltreatment mistake” means:
(1) At the time of the incident, the individual was performing duties identified in the center’s child care program plan required under Minnesota Rules, part 9503.0045; (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 individuals providing services were both in compliance with all licensing requirements relevant to this incident. Although SP1 mixed a bleach solution in a jug labeled spring water and did not relabel the jug and SP2 filled a water pitcher for the AVs from that jug, SP1’s and SP2’s actions or conduct was determined to be a nonmaltreatment mistake for the following reasons: (1) At the time of the incident, SP1 and SP2 were performing job related duties. (2) Neither SP1 nor SP2 had not been determined responsible for any incident that resulted in a finding of maltreatment. (3) SP1 and SP2 had not been determined to have committed a nonmaltreatment mistake under this paragraph. (4) Poison Control directed that AV1, AV2, and AV3 drink a lot of water and eat crackers. Neither AV1, AV2, nor AV3 had effects from drinking the bleach solution. (5) Except for the period when the incident occurred, the facility, SP1 and SP2 were in compliance with all licensing requirements. The nonmaltreatment mistake regarding AV1, AV2, and AV3 by SP1 and SP2 was not maltreatment. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years. Action Taken by Facility: The facility conducted an internal review and found their policies were adequate but not followed. The facility has retrained staff and discontinued the use of the small pitcher of water. The facility now has a large water cooler with a spigot that the children use for drinking water. Action Taken by Department of Human Services, Office of Inspector General: On February 22, 2023, 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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