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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: 1089252-CCCC (Certified Child Care Center) Investigator(s): Danielle Morrison Minnesota Department of Children, Youth, and Families 651-539-8252 Suspected Maltreatment Reported: An alleged victim (AV) with a tree nut allergy was given a sandwich with a hazelnut spread on it. The AV had an allergic reaction 45 minutes later at home. Date of Incident(s): July 3, 2025 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 July 22, 2025; from documentation at the facility, and through four interviews conducted with two supervisory staff persons (P1 and P2), a facility staff person (SP), and the AV’s family member (FM). This investigator met with the AV, but s/he did not provide details for this investigation. The AV was five years old and enrolled in a summer program at the time of the incident. The AV had a tree nut allergy. It was the AV’s third day attending the facility. The facility’s Accident/Incident Report dated July 3, 2025, stated, “[The AV] didn’t have a snack, [the SP] had an extra snack and gave it to [the AV]. ([S/he’s] allergic to tree nuts.)” The AV’s Child Allergy Information Form dated May 27, 2025, showed the AV had an allergy to tree nuts (hazelnuts, walnuts, and pecans). The AV may experience itching, tingling, swelling of lips, itchy rash, vomiting, diarrhea, difficulty swallowing, shortness of breath, or wheezing. If the AV had those symptoms his/her EpiPen was to be administered, or a call made to 9-1-1. To avoid an allergic reaction, it was noted to check all food labels. The AV’s Child Care Center Medication Authorization forms dated May 27, 2025, showed the AV had an albuterol inhaler that was used as needed for wheezing and an EpiPen that was used as needed with one shot to the thigh for anaphylaxis. The facility’s Parent Handbook stated, “The [facility] encourages parents to send healthy snacks with your child each day. Time is given each morning and afternoon for children to enjoy a snack. Please note that some children have food sensitivities. You may be asked to limit certain types of snacks if it is known a child or team member in the program have such sensitivities.” The FM said s/he provided the AV’s lunch and two snacks each day the AV attended the facility. The FM said that on the day of the incident, which was the AV’s third day of attendance, the AV did not think s/he had an afternoon snack (it was at the bottom of his/her backpack), so the SP shared a snack with the AV. The SP was the AV’s “favorite person” and the SP made a “bad judgement call.” The AV’s older sibling approached the AV and SP and asked what the AV was eating and said the AV could not have that. The FM received a telephone call from the SP and was told that the AV had eaten part of a sandwich with a hazelnut spread and the SP had the AV’s “stuff” ready if needed. The FM went to the facility and brought the AV home. About 45 minutes later, the AV started wheezing, his/her eyes became itchy and puffy, and his/her stomach hurt. The FM administered the AV’s EpiPen and brought the AV to the emergency room where the AV received three additional unspecified medications. Multiple requests were made for the AV’s medical records, but as of the date this report was issued, the medical records were not supplied by the health care provider. P1, P2, and the SP provided the following consistent information: · On July 3, 2025, around 3:30 p.m., the AV’s group was eating snack. The AV approached the SP stating that s/he did not have snack. The SP knew that s/he was not supposed to give children snacks, but the SP did not want the AV to be hungry and the SP made a “bad judgement call.” · The SP provided the AV with a sandwich with a hazelnut spread. The AV unwrapped it and took a bite. The SP then realized the sandwich had tree nuts, so s/he called the FM, took out the AV’s medications, and monitored the AV until the FM arrived. The FM arrived within 5-15 minutes. · Staff persons went through allergy training every year at the beginning of the summer. This was the AV’s first or second week attending the facility. There was an allergy binder which listed all of the children’s allergies that was kept in the cafeteria. P1, P2, and the SP provided the following additional information: · The SP said s/he was getting ready to leave when the AV approached him/her saying s/he did not have a snack. The SP had two different sandwiches (one with peanut butter and one with a hazelnut spread) which s/he brought from home that s/he offered to the AV. The AV chose the sandwich with the hazelnut spread. · The SP said the AV’s older sibling was nearby and the SP asked him/her if the AV had any allergies. The AV’s sibling said tree nuts. The SP took the sandwich, threw it away, checked the label, and saw it had tree nuts. The SP did not remember if s/he had been trained on the AV’s allergies. · P1 and P2 were not at the facility on July 3, 2025. P1 said the SP called both P1 and P2 about the incident. P2 stated s/he spoke with the SP the following day and the SP let P2 know what happened. · P1 and P2 followed up with the FM and learned the AV had an anaphylactic reaction with heavy breathing. The FM gave the AV his/her inhaler and EpiPen and took the AV to the hospital. The facility’s Team Member Handbook stated, “Do not share lunch or snacks with the children,” and a section on preventing and responding to allergies stated: During the program registration process, parents/guardians are to submit documentation of any known allergies that their child may have. This information will appear on the child’s emergency form that needs to be kept with staff when on-site and off-site such as when on field trips. The allergy information must remain current in the child’s records and must include; • A description of the allergy, specific triggers, avoidance techniques, and symptoms of an allergic reaction. • Procedures for responding to an allergic reaction, including medications, dosages, and Dr.’s contact information. All staff at the site must be informed of a child’s current allergy information either annually and/or whenever a change has been made to a child’s allergy related information in a child’s record, staff must be informed. Documentation that staff were informed of the child’s current allergy information must be kept on site. A child’s allergy information must be available at all times including on site, when on field trips, and during transportation. Food allergy information must be readily available to staff in the areas where food is prepared and served to the child. Facility documentation showed that P1, P2, and the SP were each trained on the AV’s Child Allergy Information Form, and on the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute: Minnesota Statutes, section 142C.11, subdivision 4, states (in relevant parts) that: · Before admitting a child for care, the certified center must obtain documentation of any known allergies including a description of the allergy, avoidance techniques, and procedures for responding to an allergic reaction. · Staff persons must be informed of each child’s current allergy information at least annually and whenever a change is made. · Each child’s allergy information must be available to staff persons at all times. Conclusion: A. Maltreatment: Consistent information was provided that on July 3, 2025, the AV was at the facility and told the SP that s/he did not have a snack. Although the SP knew s/he was not supposed to share food with the children, the SP did not want the AV to be hungry. The SP gave the AV a sandwich the SP had brought from home that had a hazelnut spread on it, to which the AV was allergic. The AV’s sibling told the SP that the AV could not have the sandwich, so the SP took the sandwich back from the AV, checked the ingredients, called the FM, and gathered the AV’s inhaler and EpiPen in case the AV became symptomatic. The FM picked up the AV within 5-15 minutes. About 45 minutes later at home, the AV started breathing heavily and wheezing. The FM administered the AV’s inhaler and EpiPen and brought the AV to the emergency room. According to the FM, the AV received three additional unspecified medications at the emergency room. Given that the AV was provided a sandwich with tree nuts to which s/he was known to be allergic, and that the AV had an allergic reaction that required the use of his/her EpiPen and additional medical treatment, there was a preponderance of the evidence that there was a failure to protect the AV from conditions that seriously endangered the AV’s physical or mental health. It was determined that neglect occurred (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. The SP was responsible for the care of the AV at the time of the incident and provided the AV with a snack that contained foods the AV was allergic to. Facility documentation showed the SP was trained on the AV’s Child Allergy Information Form, on the Reporting of Maltreatment of Minors Act, and on facility policies that stated staff persons were not supposed to share food with children at the facility; and the SP acknowledged that s/he was not supposed to share his/her own food with children. The SP was determined responsible for the neglect of the AV. 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 Children, Youth, and Families for at least ten years after the date of the final entry in the report. Action Taken by Facility: Per Minnesota Statutes, chapter 142C, Certified License-Exempt Child Care Centers are not required to complete an internal review. The SP received corrective coaching from the facility. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: The Department of Children, Youth, and Families informed the Department of Human Services, Office of Inspector General, Background Studies Division that the SP was determined responsible for maltreatment. The determination that the SP is responsible for maltreatment 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 Children, Youth, and Families.
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