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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: 1115111-CCC (Child Care Center) Investigator(s): Judie Schwanke Minnesota Department of Children, Youth, and Families 651-539-8268 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) choked on a carrot while eating snack. Date of Incident(s): August 18, 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 August 28, 2025; from documentation at the facility and medical records; and through eight interviews conducted with the AV’s family member (FM), two supervisory staff persons (P1 and P2), and facility staff persons P3, SP1, SP2, SP3, and SP4. The AV was not interviewed because s/he was no longer enrolled at the facility on the day of the site visit. Facility documentation showed the AV was two years and four months old and enrolled in the Toddler 1 classroom on August 18, 2025. The following was observed during the site visit: · The facility had infant, toddler, and preschool classrooms, and a kitchen. The facility prepared snacks for the children and lunch was catered in by an outside vendor. · The Toddler 1 classroom was a large open space that had two tables with built in bucket seats. Near the tables was a countertop, a hand sink, and a small refrigerator. · On one wall of the Toddler 1 classroom was a First Aid poster that read, “Turn Over for Choking and CPR Instructions.” Instructions on the back of the poster directed staff persons to shout for help and start first aid for choking if a child could not breathe at all, a child could not cough or talk, or if the child turned blue. For children age 1 through 8 years old, if the child was conscious, call 9-1-1 and if the child was unable to breathe, cough, cry, or speak, staff persons were to perform the Heimlich maneuver. On the board was also a list of emergency phone numbers. · Posted above the Toddler 1 refrigerator was a four-week menu. The menu stated that when “fresh baby carrots” were served, staff persons were to “sub” canned carrots for infants and toddlers. This information was emphasized with highlighting in bright yellow, in addition to a yellow diamond shape with the word “CAUTION” written in capital letters. · In the facility kitchen there was a refrigerator and a shelving unit with canned fruits and vegetables, including canned sliced carrots. On a wall in the kitchen a four-week menu was posted that included breakfast, morning snack, and afternoon snack. This menu also stated that when “fresh baby carrots” were served, staff persons were to “sub” canned carrots for infants and toddlers. This information was also emphasized with highlighting in bright yellow, in addition to a yellow diamond shape with the word “CAUTION” written in capital letters. Facility staff persons used a group chat to communicate with each other. A photo of a daily sheet that was sent to the group chat for August 18, 2025, showed the morning snack was “carrots” (with no detail about whether carrots were raw, canned, etc.) and milk. The facility used an application to communicate with families. On August 18, 2025, at 10:30 a.m., an entry was made for the Toddler 1 family members that stated the morning snack was carrots, a donut hole, and milk. A Child Care Center Serious Injury & Death Reporting Form stated that on August 18, 2025, at 10:58 a.m., the AV choked on a carrot. A staff person removed the AV from the table and began attempting the Heimlich maneuver. The AV cried and asked for his/her “lovey” and “pacifier,” and his/her face turned “blue.” A staff person ran the AV “up front” and 9-1-1 was called. The AV’s breathing was “labored,” and the AV was “lethargic.” Emergency medical personnel arrived at the facility, administered oxygen, and transported the AV to a local medical facility. The AV had emergency surgery to remove two “large” pieces of carrot, one in each tube leading from his/her trachea to each lung. The AV’s medical records showed that on August 18, 2025, the AV was admitted to a local emergency medical facility with “shortness of breath and choking,” and was in respiratory distress. The AV was then transferred to a pediatric medical facility where s/he was admitted in “critical” condition due to an “airway obstruction.” The AV received emergency surgery to remove two pieces of carrot from the AV’s airway and lung. The AV remained stable overnight, and on August 19, 2025, the AV was discharged from the pediatric medical facility to home, with instructions to follow up with the AV’s primary care provider later that week. The FM provided the following information: · On August 18, 2025, the FM received a phone call and was told that while the AV was eating snack s/he choked. A staff person performed the Heimlich maneuver twice, and did not see any food come out. The AV cried and turned “blue,” so 9-1-1 was called and emergency medical services was at the facility tending to the AV. · The FM drove to the local emergency medical facility and met the AV there. The AV’s oxygen levels were initially “okay” but then “declined,” and the local emergency medical facility did not have the “capabilities” to treat the AV, so the AV was transferred to the pediatric medical facility. The AV’s health further declined there, and the AV was sedated. A surgery was performed, and two carrot fragments were removed from the AV’s airway. The AV was kept overnight for monitoring and sent home the next day. As of August 27, the AV 2025, was doing “well.” · Prior to August 18, 2025, the FM had received pictures of the AV eating meals at the facility that showed cooked diced carrots on the AV’s plate. · Prior to August 18, 2025, the FM did not have concerns with the facility. According to the United State Department of Agriculture (USDA) Food and Nutrition Service, children under the age of four were at a high risk of choking while eating. Young children were still learning how to chew food properly, and often swallowed food whole. To make eating safer for young children, “hard food, like carrots,” should be cooked until they were soft enough to be pierced with a fork. To avoid choking hazards, tube-shaped food such as “raw carrots” should not be served or should be cut into short “short strips.” Food served to young children should be cut into pieces no larger than one half inch. The following is a summary of information about the incident provided during interviews with P1, P2, P3, SP1, SP2, SP3, and SP4: Regarding snack preparation for August 18, 2025: · Information was consistent that the morning snack for August 18, 2025, was prepared in advance by SP1 on August 15, 2025. · SP1 stated that prior to August 18, 2025, s/he usually gave the Toddler 1 classroom canned carrots for snack. SP1 stated that on the afternoon of August 15, 2025, s/he prepared the morning snack for August 18, 2025. SP1 said that on August 15, 2025, s/he was “pretty sure” s/he asked P2 if s/he should prepare raw or canned carrots for the Toddler 1 classroom, and P2 told SP1 to prepare raw carrots. SP1 prepared and delivered whole, raw baby carrots to the Toddler 1 classroom refrigerator. SP1 stated the carrots were the size of a “Jolly Rancher” or a “little bigger.” · P2 stated that s/he was not at the facility in the afternoon of August 15, 2025. · P3 stated that on August 15, 2025, s/he was a facility “closer.” P3 asked SP1 if s/he could prepare snack and SP1 told P3 that s/he knew how to do it. P3 gave SP1 the counts for the next day and asked SP1 if s/he knew what snack to prepare. SP1 told P3 that s/he did know what snack was supposed to be and then prepared the snacks and distributed them to the classrooms. Regarding serving snack to the Toddler 1 classroom on August 18, 2025: · P1 stated that on the morning of August 18, 2025, s/he sent a picture in a group chat of the daily sheet showing that the morning snack was “carrots.” P1 stated that day, the children in the Toddler 1 classroom were served “whole” raw baby carrots. · SP3 usually worked in a classroom with children younger than the Toddler 1 classroom children. On August 18, 2025, SP3 worked in the Toddler 1 classroom. That morning s/he looked at a picture of a daily sheet that had been sent as a picture in a group chat. The daily sheet showed that morning snack was carrots with ranch dressing. The sheet did not specify if the carrots were to be cooked or raw. SP3 took a bag of “hard,” raw baby carrots out of the classroom refrigerator and sat it on a counter and then put out enough small trays for each child. Then SP2 came into the classroom and SP3 left the classroom for a short break. · On August 18, 2025, SP2 was in the Toddler 1 classroom to give SP3 a ten-minute break out of the classroom. SP2 stated that snack was already in the Toddler 1 classroom, and s/he passed out two or three, two-inch raw baby carrots to each child. SP2 did not recall if s/he had ever given the Toddler 1 classroom raw carrots prior to August 18, 2025. SP2 stated that as the children ate their snack, SP3 came back into the classroom and SP2 left the classroom. Later, s/he talked with a management staff person and was told that a child had choked on carrots and had surgery but was “doing okay.” · SP4 stated that on August 18, 2025, at about 10:20 a.m., SP4 was in the Toddler 1 classroom with SP3 and 13 children, including the AV. SP2 passed out “hard” baby carrots, donut holes, and milk to the children for snack. Initially, SP4 stated that s/he saw the raw baby carrots before SP2 passed them out to the children. However, during a follow up conversation, SP4 stated that s/he did not “realize” the toddler children were given the raw baby carrots until they were “crunching away” on them. Regarding the AV choking and facility staff persons’ response: · SP3 stated that when s/he arrived back in the Toddler 1classroom after his/her break, the children were eating snack. SP3 put his/her things away and stood between the two tables and heard the AV cough. SP3 walked over to the AV and saw carrots coming out of his/her mouth. SP3 then lifted the AV out of the bucket seat and placed the AV on the floor. The AV was still “choking,” and his/her face turned red. SP3 stated that both s/he and SP4 tried to “tap” the AV on his/her back, then SP3 “hit” the AV’s back with his/her hand. SP3 stated the hit was not “hard” but was not “soft” because s/he “knew” the hit had to be hard enough to “get something to come out” of the AV. SP4 then picked up the AV and also hit the AV on his/her back, then SP4 took the AV out of the classroom. When SP4 returned to the classroom, s/he told SP3 that 9-1-1 had been called for the AV. · SP4 stated that as the children finished eating snack, s/he helped a child wash his/her hands at the handwashing sink near the tables. SP3 returned to the classroom and SP2 left the classroom. SP4 saw the AV’s face turn “bright red” and s/he asked SP3 to “pat” the AV on his/her back. SP3 patted the AV on his/her back and the AV spit out carrots. SP4 then asked SP3 to take the AV out of his/her seat and bring him/her to SP4. SP3 lifted the AV out of his/her seat and then brought the AV to SP4. SP4 “grabbed” the AV, rolled him/her over, bent down, and patted the AV’s back three or four times. The AV started to cry and SP4 asked the AV if s/he was “okay.” SP4 saw that the AV was “lethargic.” The AV turned blue and asked for his/her pacifier. SP4 gave the AV his/her pacifier and then carried the AV to the facility office. P2 called 9-1-1 and SP4 left the AV in the office and returned to the classroom to retrieve the AV’s “doggy.” When SP4 walked back to the office, emergency medical services walked in the facility door. SP4 stayed up front to answer questions and when the AV was being taken out of the facility, SP4 returned to the Toddler 1 classroom. · P1 stated that at approximately 10:30 a.m., SP4 brought the AV into the office and “explained what happened” to the AV. SP4 was not sure if the AV choked on a carrot and the AV turned “blue.” The AV was crying, his/her breathing was “labored,” and the AV was blue. P1 laid the AV on the floor on his/her side, and after seven seconds, P2 stepped out of the office and called 9-1-1. P2 also called the FM and talked with him/her and shortly after, emergency medical services arrived at the facility. The AV and P1 were transported to the local emergency medical facility. P1 waited there until the AV’s family members arrived and then P1 returned to the facility. · P2 stated that on August 18, 2025, s/he was in the facility office with P1 when SP4 brought the AV into the office. SP4 told P1 and P2 that the AV was “not breathing,” and was “turning different colors.” The AV was placed on the floor on his/her back and then P1 tried to have the AV sit up. Sitting up did not help the AV so P1 laid him/her back down on his/her back. P2 then stepped out of the office and called 9-1-1. · P1 reviewed video footage from August 18, 2025, and saw that SP4 performed an “infant Heimlich” maneuver “once” on the AV. P1 did not think the Heimlich maneuver was performed “very well,” as SP4 “patted” the AV’s back and “hugged” the AV with one hand. · SP3 stated that neither s/he nor SP4 performed the Heimlich maneuver. SP3 “thought” that first aid for a choking victim was “just to hit” the victims back to dislodge the food. Regarding training for snack preparation: · P1 stated that staff persons who prepared snack were trained by shadowing other staff persons and were trained to look at the snack menu and serve what was on the menu. P1 did not know why the menu was not followed by SP1 on August 15, 2025. · P2 stated s/he trained staff persons, including SP1 and SP2, on the “snack process.” P2 trained staff persons that preschool aged children and older were served raw baby carrots and children younger than preschool were served canned carrots. P2 stated this was also listed on the menu in the kitchen. P2 stated s/he was not aware that the menu specifically listed canned carrots as a substitution for raw baby carrots for infants and toddlers. P2 stated s/he knew that facility policies stated that the facility followed USDA guidelines but P2 did not know what the guidelines were. · SP2 stated that SP4 trained him/her on how to prepare and pass out snacks based on what the menus showed and that children younger than preschool should not be given raw baby carrots for snack. · SP1 stated that P2 taught him/her how to prepare snack. P2 taught SP1 to read the menu and gather the right amount of snack for a classroom, place the snack on a cart, walk the cart to each classroom, and then put the snack in the classroom refrigerator. SP1 did not “believe” s/he read USDA Food and Nutrition Guidelines as part of his/her training. · SP2 stated s/he “thought” s/he had four weeks of training to work in the kitchen and was supported “every week” until s/he felt “confident” with his/her duties. SP2 did not read USDA Food and Nutrition guidelines as part of his/her training. · Prior to August 18, 2025, SP3 had never prepared snack and did not recall any training regarding what food children should and should not be fed. SP3 did not know that children in the Toddler 1 classroom should not be fed raw baby carrots. SP3 did not feel his/her training was adequate and if all the staff persons knew that the AV should not be fed raw baby carrots, this incident would not have happened. · Prior to August 18, 2025, SP4 had prepared snacks for classrooms. S/he used the daily “sheet” from facility management persons and the menu to know what to prepare. SP4 did not know if s/he had given the Toddler 1 classroom raw baby carrots for snack prior to August 18, 2025. SP4 trained other staff persons how to prepare and pass out snack. SP4 was not “sure” what the training stated regarding serving toddlers baby carrots. SP4 “believed” that prior to August 18, 2025, the toddlers were given canned carrots and “maybe” one other time had raw baby carrots. Regarding common practice for snack preparation and serving: · P1 stated that prior to August 18, 2025, the menu with the substitution for raw carrots was in place but it was not a “set rule.” P1 stated that s/he felt that two- and one-half year-old children could have raw carrots and there was not a set age for giving children canned carrots versus raw carrots. However, the Toddler 1 classroom children were not “typically” served raw carrots and on August 18, 2025, the classroom should not have received raw carrots. P1 “thought” that August 18, 2025, was the first day that the Toddler 1 classroom ever received raw baby carrots for snack. · Prior to August 18, 2025, P2 was not aware of any other time the Toddler 1 children were given raw carrots for snack. · P3 stated that if a classroom was given the wrong snack, a staff person should return the snack to the kitchen and grab the correct snack. Staff persons could also ask P1 or P2 what the children should eat. P2 trained P3 how to prepare and pass out snack. P2 brought P3 into the kitchen and showed him/her the monthly menu and how to check which classrooms received fresh or canned fruits and vegetables. P3 was trained to give the Toddler 1 classroom canned fruits and vegetables. · SP2 stated his/her normal duties were to “dish out” food to every classroom at the facility. Each morning, a facility management person sent a “morning message” in a group chat to the staff persons that listed what snacks and meals were for the day. In addition, menus were posted in the kitchen and in classrooms. Prior to August 18, 2025, SP2 saw the menu in the kitchen and some snacks were baby carrots. SP2 did not recall seeing on the menu that infants and toddlers should not get raw baby carrots and that raw baby carrots should be substituted with canned diced carrots for infants and toddlers. When SP2 gave classrooms carrots for lunches, the carrots were cooked. · SP3 stated s/he never prepped snack or passed snack out to classrooms. The facility provided two video segments from the Toddler 1 classroom and the facility office. The classroom video was dated August 18, 2025, and time stamped but did not contain audio. The office video was not dated or time stamped and did not have audio. The videos provided the following information: o At 10:32 a.m., SP2, SP3, SP4, and 14 children, including the AV, were in the classroom. The AV’s back was to the classroom camera. SP4 stood near one of the tables and the children were all seated in buckets seats at the tables. SP2 and SP3 stood next to each other at a counter with small paper trays and a bag of baby carrots. SP4 walked over to the counter, SP3 walked away, and SP2 put on a pair of food service gloves. SP4 walked away and sat in a chair between the two tables. SP2 cut open the bag of carrots and placed them in the trays. SP2 then pointed to the trays and appeared to ask SP4 a question. SP4 walked over to the counter area and appeared to talk with SP2. SP2 continued to put food into the trays and SP4 sat in the chair between the tables. o At 10:34 a.m., SP2 gave the AV his/her tray of snack. After SP2 gave each child a snack tray, s/he took milk out from the refrigerator and poured small plastic cups of milk for each child and passed them out. During this time, SP4 got up from the chair and walked around the table area and returned to the chair. o At 10:40 a.m., SP2 collected trays from children who were done eating snack and SP4 was bent over the counter where the snack was prepared. o At 10:41 a.m., SP4 swept under the tables and SP2 stood near the refrigerator. The AV lifted his/her snack tray, and it appeared that the tray was empty. SP4 took the AV’s tray, appeared to talk with the AV, and then went back to sweeping. o At 10:43 a.m., SP3 and SP4 moved around the tables and picked up trays. SP3 returned to the classroom and then SP2 exited the classroom. o At 10:44 a.m., SP4 picked up a child and set him/her down on the floor. That child ran behind the AV and SP4 followed the child. SP3 stood near the AV’s table. The AV put his/her left hand up to his/her mouth and then turned toward the camera to look in the child’s direction. The AV’s face was red. The AV turned back to the table, and SP4 and the child walked to the sink. SP3 turned his/her back to the AV’s table and appeared to talk with SP4. The AV turned toward the camera again, and his/her face was red. Then the AV turned back to the table and his/her left hand was at his/her face and his/her head and upper body swayed to his/her right. SP3 turned back to the table and looked at the AV. SP3 stood on the opposite side of the table from the AV, leaned forward and patted the upper part AV’s back with his/her right open hand. SP4 turned to look at SP3 and the AV. SP3 patted the AV’s back again and turned to look at SP4. SP3 turned back to the AV and then patted his/her back again. SP3 stopped and took a step back from the table and watched the AV. SP3 then stepped up to the table again and patted the AV on his/her back. While s/he patted the AV, the AV slouched forward and placed his/her chest and head on the table. SP3 patted the AV again and then walked around the table so s/he was behind the AV. o At 10:45:45 a.m., SP3 lifted the AV out from his/her bucket seat and placed the AV on the floor. SP4 turned around from the sink and the AV walked to SP4. SP4 knelt alongside the AV. SP3 walked and stood between the camera and the AV. o At 10:46 a.m., SP4 stood and lifted the AV. SP4 held the AV facing him/her and patted the AV’s back with his/her right hand. The AV turned in SP4’s arms and SP4 knelt again. The AV’s legs straddled SP4’s left leg and SP4 held the AV around his/her chest using his/her left hand and patted his/her back with his/her right hand. The AV slid off SP4’s leg and SP4 pulled the AV back to him/her with his/her left arm and patted the AV’s back with his/her right hand. SP3 then knelt in front of the AV and the AV bent forward on SP4’s leg. SP3 held the AV’s head between his/her hands and looked into the AV’s mouth. The AV flailed and SP3 let go of the AV’s head. The AV turned his/her head to look at SP4 and appeared to go limp. SP4 stood up with the AV and the AV’s head wobbled. SP4 walked over to the counter and picked up an item and placed it in the AV’s mouth. SP4 looked at the AV and the AV’s head wobbled again. o At 10:47:04 a.m., SP4 then carried the AV and walked out the classroom door and the classroom video ended. There was no footage of back blows or abdominal thrusts performed in the classroom. o In the office video, P1 and P2 sat across from each other at a desk. SP4 carried the AV into the office. SP4 walked to the side of the desk and knelt on the floor and as s/he did so the AV’s head fell back. SP4 placed the AV on the floor and talked with P1I. P1 left his/her chair and joined the AV and SP4 on the floor. A filing cabinet and binder obstructed the camera view of the AV, P1, and SP4. After seven seconds, P2 stood up and left the office. P2 returned to the office and held a phone to his/her ear. SP4 appeared to talk with P1 and made motions with his/her hands near his/her neck. P2 left the office and P1 grabbed a phone off the desk. P2 returned to the office and placed his/her phone on the desk and stood behind SP4. SP4 stood and walked out of the office. SP4 returned to the office with a small stuffed dog and then exited the office. SP4 returned with tissues and handed them to P1 and then exited the office. P2 used his/her phone and appeared to take a picture of the AV. The video ended before paramedics arrived. A recording of the 9-1-1 call showed that a staff person (later identified as P2) told the 9-1-1 operator that the AV was “losing color” in his/her face and was “having issues breathing.” P2 told the operator that the AV was awake and “fully active.” P2 went on to say that the AV was crying and “struggling to breathe.” The 9-1-1 operator told P2 that help was on the way and P2 told the operator that s/he would be waiting up front and the call ended. The facility had a Complete First Aid Pocket Guide in the facility’s first aid pack, which provided the following information: · The most common object that caused an airway obstruction was food, and children under the age of five were most at risk for choking. · Signs of choking included clutching throat and/or chest, difficulty in breathing, coughing, wheezing, red face initially, then turning pale or blue, and a reduced level of consciousness. · The first aid treatment for choking was the delivery of back blows and abdominal thrusts. The facility’s Childcare Program Mission and Program Plan stated that children in the toddler program were served meals and snacks that were posted on menus in the kitchen and on their website. The facility’s Risk Reduction Plan stated that staff persons responsible for food preparation “must” follow all USDA guidelines when preparing food. The facility’s Food Handling & Preparation Guidelines stated that meals and snacks met USDA requirements and food items served were age appropriate and cut into small pieces to avoid choking. Foods for toddlers were one half inch or smaller. Staff persons sat with children during meal and snack times. Facility documentation showed that P1, P2, P3, SP1, SP2, SP3, and SP4 each received training on the facility’s policies including the facility’s Childcare Program Mission and Program Plan, Risk Reduction Plan, Pediatric First Aid and CPR, and the Reporting of Maltreatment of Minors Act prior to the incident. Relevant Rules and Statutes Minnesota Rules 9503.0145 subpart 4, item D states that the license holder must provide or ensure the availability of program staff who are seated with the children during meal and snack times.
Conclusion: A. Maltreatment: SP1 stated that on August 15, 2025, s/he asked P2 if s/he could prepare and distribute raw baby carrots to the Toddler 1 classroom. However, P2 said s/he was not at the facility that afternoon. P3 stated that on August 15, 2025, SP1 told him/her that s/he knew how to prepare snack, and that prior to August 15, 2025, SP1 had prepared snack 30 to 40 times. On August 15, 2025, SP1 placed a bag of whole, raw baby carrots in the Toddler 1 classroom refrigerator for morning snack on August 18, 2025. On the morning of August 18, 2025, SP3 removed the baby carrots from the Toddler 1 refrigerator and placed them on a counter. SP2 then entered the classroom and SP3 left the classroom for a brief break. SP2 placed the baby carrots into trays and passed the trays out to the children. SP4 stood near the counter as SP2 placed the carrots into the trays. SP2 handed out the trays to the children, including the AV’s tray which s/he gave to the AV at 10:34 a.m. SP4 then sat with the children during the first part of snack time. When SP3 returned to the classroom, SP2 left the classroom. Neither SP3 nor SP4 sat with the children for the remainder of snack time, which was a violation of Minnesota Rules 9503.0145, subpart 4, item D. Both SP3 and SP4 had their backs turned to the AV when the AV’s face turned red. SP3 heard the AV cough, went to him/her, and patted his/her back. SP3 lifted the AV out of his/her bucket seat and the AV walked to SP4. SP4 patted the AV’s back. The AV then became “lethargic” and turned blue. SP4 gave the AV his/her pacifier and carried the AV to the office. In the office, P1 attended to the AV and P2 called 9-1-1. The 9-1-1 operator told P2 that help was on the way and did not advise that staff persons attempt back blows or the Heimlich maneuver. Paramedics arrived at the facility and transported the AV to a nearby emergency medical facility where his/her oxygen levels declined. The AV was then transported to a pediatric medical facility where s/he was admitted in “critical” condition. The AV underwent emergency surgery to remove two pieces of carrots that were blocking his/her airway and lung. According to the facility’s policies, meals and snacks met USDA requirements and food items served were to be age appropriate and cut into small pieces to avoid choking. Foods for toddlers were to be cut into pieces that were one half inch or smaller. Staff persons were also to sit with children during meal and snack times. USDA guidelines stated that children under the age of four were at a high risk of choking while eating. To make eating safer for young children, “hard food, like carrots,” should be cooked until they were soft enough to be pierced with a fork. To avoid choking hazards, tube-shaped food such as “raw carrots” should not be served or should be cut into short “short strips.” Food served to young children should be no larger than one half inch. Given that the children in the Toddler 1 classroom, including the AV, were served whole, raw baby carrots, a known choking hazard for toddler age children, for snack; and that the AV choked on the carrots, was in “critical” condition, and had to have two pieces of carrot surgically removed from his/her airway; there was a preponderance of the evidence that there was a failure to provide the AV with necessary care required for the AV’s physical health when reasonably able to do so; 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): 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. On August 15, 2025, SP1 prepared and delivered the whole raw baby carrots to the Toddler 1 classroom refrigerator. On August 18, 2025, SP3 removed the raw baby carrots from the Toddler 1 classroom and placed them on the counter. SP2 placed the baby carrots in trays and passed them out to the children, including the AV. SP4 stood near SP2 as s/he placed the carrots in the trays and watched the children eat the carrots. Although SP1 prepared and delivered the whole raw baby carrots to the Toddler 1 classroom, SP1 did not tell SP2, SP3, and SP4 to disregard training they received or the posted menu, and SP1 was not responsible for the direct care of the children on August 18, 2025. Therefore, SP1’s responsibility was mitigated. SP2, SP3, and SP4 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies including the Risk Reduction Plan and Childcare Program Mission and Program Plan, and on Pediatric First Aid and CPR. SP2 and SP4 each stated that P2 provided them with additional training on snack procedures. Given that SP2, SP3, and SP4 were each responsible for the direct care of the AV and each played a role in serving whole raw baby carrots to the AV and other children in the Toddler 1 classroom; that they received relevant training; and that the facility’s menu postings clearly stated toddlers were to be served canned carrots as a substitute for raw carrots, SP2, SP3, and SP4 were each determined responsible for the maltreatment 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: The facility completed an internal review and determined that their policies and procedures were adequate, and the center’s approved menu and age-appropriate food policy was not followed. Staff persons were retrained on age-appropriate food preparation and a menu compliance chart. 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 SP2, SP3, and SP4 were each determined responsible for maltreatment. The determination that SP2, SP3, and SP4 were each responsible for maltreatment is subject to appeal. On March 11, 2025, the facility was issued a Correction Order for staff persons not seated with children while the children ate. 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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