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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: 801675-CCC (Child Care Center) Investigator(s): Tessa Ripka/Danielle Morrison Minnesota Department of Children, Youth, and Families 651-539-8252 Suspected Maltreatment Reported: It was reported that a staff person (SP) administered an epinephrine injection (EpiPen) to an alleged victim (AV) without an allergy or a prescription for an EpiPen. Date of Incident(s): September 25, 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 October 6, 2025; from documentation at the facility and the AV’s medical records; and through five interviews conducted with four facility staff persons (P1, P2, P3, P4), and the AV’s family member (FM). This investigator made attempts to interview the SP by phone, email, and mail, but attempts were unsuccessful. Due to the AV’s age s/he was unable to provide any information. The AV was 24 months old at the time of the incident and enrolled in a toddler classroom. P1-P4 and the internal review provided the following information: · On September 25, 2025, P1 and P2 worked in the AV’s classroom and had the class outside on the playground. At approximately 5:30 p.m., P2 noticed a dime size red bump on the AV’s forearm and asked P1 if it was a bee sting. P1 thought it did look like a bee sting. P2 said that s/he believed the AV was allergic to bees because P4 said that a “few weeks ago.” · P1 said that the AV had red and white bumps that they then noticed on the AV’s face and legs that “kept getting worse.” P2 said that s/he noticed red raised dots larger than a “pencil mark” on the AV’s palms and on both knees. P1 and P2 said the AV was not having trouble breathing and did not appear to have any other symptoms of an allergic reaction. · P2 brought the AV inside and talked with P3. P3 saw redness and minor swelling on the AV’s arm approximately the size of a quarter but no hives or other signs of a reaction (breathing problems, swollen eyes, lips turning color). P3 told P2 to call the FM and notify the SP for assistance. The SP was the designated person in charge at the facility at the time of the incident. · P2 said that s/he and the SP were “panicking.” The SP began to look for the AV’s medication, but s/he could not find an EpiPen or any allergy paperwork. · The SP decided to administer another child’s prescribed EpiPen because the SP believed the AV was having an allergic reaction. P2 did not remember any conversation about calling 9-1-1 before or after the injection was given. · The FM arrived shortly after and was “angry” and “confused.” The FM said the AV did not have a bee allergy although another family member did. · P4 was not at the facility at the time of the incident. A few weeks prior to the incident, the AV’s family member told P4 that there was a beehive out in the parking lot. The family member was concerned because s/he was allergic to bees. The family member said that s/he did not know if his/her children were allergic to bees as well as they had not been stung. · P4 said that other staff members knew about this conversation and thought it may have created confusion about whether the AV was allergic to bees. P4 looked at the AV the following day and saw spots that looked like hand, foot, and mouth disease on the AV’s body. The AV’s sibling had hand, foot, and mouth recently, but it had not been noticed on the AV prior. The spots were small and white and almost looked like pimples. · If a child had an allergy there was a sheet that was posted on the wall in the classroom with the child’s name and it said EpiPen next to it, if they had one prescribed. If a child did not have an allergy and had a suspected allergic reaction, staff person called 9-1-1, called the child’s parents, and monitored the child. Under no circumstances did staff persons give medication to a child that was not prescribed for them. The SP declined to interview with this investigator but provided the following information through the facility internal review: · At approximately 5:30-5:40 p.m., P2 came down the stairs carrying the AV saying that the AV had been stung by a bee and was allergic. The SP noticed small skin-colored dots on the AV’s legs but no swelling, redness, or breathing issues. The SP asked where the AV’s allergy forms, and EpiPen were located but P1 and P2 did not know. · They went to the classroom to look for the forms. P2 “insisted” that the AV was allergic to bees and said that a family member told this to P2 a “few days ago.” The SP asked where the allergy medication was and P2 opened the cupboard and said there was not an EpiPen or allergy paperwork for the AV. · Since P1 and P2 said that the AV was allergic to bees and because of the appearance of the AV’s legs, the SP administered another child’s EpiPen to the AV. The SP said s/he did not contact the FM or call 9-1-1 after administering the injection. The AV did not have any breathing difficulties and cried after the injection. The FM said that on September 25, 2025, when s/he arrived at the facility s/he was told that the AV was stung by a bee and was given an EpiPen 20 to 30 minutes prior. The AV was not allergic to bees and did not own an EpiPen. The AV experienced a seroma (fluid that forms under the skin) where the EpiPen was given and had some heart palpitations and anxiety from the injection. The AV had previously had hand, foot, and mouth and the staff persons thought that those spots were hives and that the AV was going into anaphylactic shock. The FM was not sure why the facility did not call 9-1-1 or the FM if they believed this. The AV’s medical records showed that on September 27, 2025, the AV was seen in an emergency department for pain and swelling at the September 25, 2025, epinephrine injection site on his/her left thigh. The AV was diagnosed with seroma without signs of infection. No treatment was ordered. The Individual Food Allergies sheet posted in the classroom included three children with allergies. The AV was not listed on this sheet. The AV was listed on a Special Food Needs sheet posted below that showed 12 children and their specific food need/preference. The facility’s policies stated that a list of children with their specific allergies was posted in all classrooms and in the kitchen with the children’s pictures. EpiPens were kept in the classroom using a “safety sack” for storage with the medical information for the child. All staff persons were trained on individual allergies. No medication was administered to any child without specific written instructions from the child’s parent and authorized health professional. Medication was administered only to the person for whom it was prescribed. The Family Handbook stated that families were expected to notify the facility regarding children’s food or environmental allergies and provide the facility with a detailed individual allergy action plan signed by the child’s physician. A list of the child’s allergies with their pictures was posted in all classrooms throughout the facility. Staff persons were trained to consult as appropriate to avoid the potential of exposing children to substances to which they have known allergies. The facility’s Incidents policy stated that if a child required emergency medical attention, staff persons should call 9-1-1 and contact the child’s family members when necessary. Manufacturer information for the epinephrine injection pen (EpiPen) stated that epinephrine was a prescription medication used for the emergency treatment of allergic reactions. Whenever epinephrine injection was used, including in the event of accidental injection, the person injected should, “Get emergency medical help right away.” Video footage showed on September 9, 2025, P1 and P2 were on the playground at 5:15 p.m. Some parents came to pick up children while the other children including the AV continued to play on play structures around the playground. At 5:18 p.m., the AV ran to P2 and gave P2 a hug. The AV continued to play on and around P2’s lap. At 5:25 p.m., P2 appeared to start looking over the AV’s body especially at the AV’s arms. At 5:26 p.m., the AV got off P2’s lap and went to say goodbye to a child that was leaving and then returned to P2’s lap. The AV repeatedly got off SP2’s lap and then “jumped” back to P2’s lap while P2 would catch the AV. At 5:28 p.m., P2 looked at the AV’s arms again and appeared to talk with P1. P2 scooted close to P1 who was also sitting on the ground and appeared to show P1 the AV’s arms. The AV then got up and played. At 5:31 p.m., P1 and P2 took the children including the AV inside. P1 took the children back to the classroom while P2 went into an infant room carrying the AV and talked with some staff (likely P3) before finding the SP and talking with the SP. They both exited the classroom. P2 was still carrying the AV and the SP arrived at the toddler classroom at 5:34 p.m. and started looking through a locker and a cupboard. At 5:37 p.m., the SP took something out of the cupboard (likely the EpiPen). This is when the SP likely administered the EpiPen to the AV, but this was blocked from the camera view. P1 left the classroom and the SP and P2 appeared to be trying to calm the AV down. At 5:40 p.m., P1 set the AV down on a chair at a table and put out a snack for the AV and three other children. At 5:42 p.m., the SP and P1 came back into the classroom as the FM arrived. At 5:43 p.m., the FM and another family member entered the facility. At 5:46 p.m., the FM and another family member arrived in the classroom and talked with the SP and P1 until they exited the classroom at 5:50 p.m. Facility documentation showed that staff persons, including the SP, were trained on the facility’s policies and the Reporting of Maltreatment of Minors Act.
Conclusion: On September 25, 2025, P1 and P2 alerted the SP that they believed the AV had been stung by a bee while they were outside on the toddler playground. They believed that the AV was allergic to bees after noticing marks on the AV’s arms and palms. There was no documentation at the facility showing that the AV had a bee sting allergy. The SP administered another child’s prescription EpiPen to the AV and did not call 9-1-1 or the FM. When the FM arrived at the facility to pick up the AV approximately six minutes later, s/he was informed that the EpiPen had been used on the AV. Two days later, on September 27, 2025, the AV was seen in an emergency department for pain and swelling at the injection site. No treatment was ordered. Facility information and policies stated that no medication was to be administered to any child without specific written instructions from the child’s parent and an authorized health professional. Medication was to be administered only to the child for whom it was prescribed. The facility’s Incidents policy stated that if a child required emergency medical attention, staff persons should call 9-1-1 and contact the child’s family members when necessary. In addition, manufacturer’s information for the EpiPen stated that whenever epinephrine injection was used, including accidental injection, the person should, “Get emergency medical help right away.” Giving the AV, who did not have a documented allergy, another child’s prescription EpiPen; and not seeking emergency medical attention for the AV afterward; seriously endangered the AV’s physical health. In addition, the AV developed pain and swelling at the injection site that lasted at least two days. However, Minnesota Statutes, section 260E. 30, subdivision 3, states that rather than making a determination of substantiated maltreatment by an individual, the commissioner of children, youth, and families shall determine that the individual made a nonmaltreatment mistake. A nonmaltreatment mistake occurs when: 1) the individual has not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; 2) the individual has not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; 3) 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; 4) except for the period when the incident occurred, the facility and the individual providing services were both in compliance with all licensing and certification requirements relevant to the incident; and 5) at the time of the incident, the individual was performing duties identified in the licensed center's child care program plan required under Minnesota Rules, part 9503.0045. This clause applies only to child care centers licensed under Minnesota Rules, chapter 9503. It was determined that the SP’s actions were a nonmaltreatment mistake for the following reasons: 1) the SP had not been determined responsible for a similar incident that resulted in a finding of maltreatment for at least seven years; 2) the SP had not been determined to have committed a similar nonmaltreatment mistake under this paragraph for at least four years; 3) the AV did not sustain any injury as a result of the maltreatment which required treatment; 4) except for the period when the incident occurred, the facility and the SP were both in compliance with all licensing and certification requirements relevant to the incident; and 5) at the time of the incident, the SP was performing duties identified in the licensed center’s child care program plan. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Children, Youth, and Families for a period of five years. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. All staff persons were retrained on Allergy Prevention and Response Policies and Medication Administration Policies. The SP no longer worked at the facility. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: The SP was not determined as a perpetrator of maltreatment of the AV because the Department of Children, Youth, and Families found that the incident for which the SP was responsible met the criteria to be determined a nonmaltreatment mistake. The SP was notified by the Office of Inspector General that any future incident of possible neglect of an alleged victim for which the SP is responsible might not be considered a nonmaltreatment mistake. 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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