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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: 1089379-CCCC (Certified Child Care Center) Investigator(s): Kimberly Anderson Minnesota Department of Children, Youth, and Families 651-539-8226 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) was given another child’s prescription medication. Date of Incident(s): July 23, 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 27, 2025; from documentation at the facility; and through three interviews conducted with facility staff persons. Attempts to reach the AV’s family member (FM), the AV, and a staff person (SP) for information related to the incident were made via telephone and US mail. The requests were unsuccessful. The facility provided care to school-aged children in an elementary school building. The facility provided children with choice-based programming which allowed the children to explore, create, and grow.
The AV’s enrollment file showed that the AV was nine years old at the time of the incident and that the AV did not take any medications at the facility. The facility’s written documentation, interviews with facility management persons (P1 and P3) and a staff person (P2) provided the following information: · On July 23, 2025, the FM reached out to P1 to let him/her know that earlier that day, the AV was “mistakenly” given another child’s medication (later identified as methylphenidate, commonly used for treatment of attention deficit disorder). · The next day, P1 spoke to the AV at the facility. The AV told P1 that when the SP called him/her down to the office, the SP asked for his/her first name and then gave the AV a pill that was “small, little, white and round.” The AV told P1 that after the AV swallowed the pill, the AV went into the hallway with P2 and told P2 that that pill was not for him/her. · P2 stated that after the AV told him/her that s/he was not supposed to take medication at the facility, P2 asked the SP to double check if the AV was supposed to have medication and the SP said that s/he had the right child. · P1 reviewed the facility’s video footage and saw that the AV was called to the SP’s office at approximately 3:30 p.m. to receive medication. A few minutes after the AV left the office, a child (C) with the same first and last initials and a first name that was only one letter different than the AV’s walked into the SP’s office. · P1 and P3 each stated that the SP was a “substitute” at the facility on July 23, 2025, and that the SP “normally” worked at another site location. · The SP told P1 and P3 that a few minutes after the AV came into his/her office, s/he discovered that the C had the same initials and similar first name as the AV was supposed to receive the medication. The SP told P3 that s/he did not give the medication to the AV. · P1 and P3 reviewed the controlled medication count log and saw an entry signed by SP, dated July 23, 2025, at 3:34 p.m., indicating that the C’s medication was “wasted” due to being dropped on the floor. · The C’s Medication Record showed that the C’s medication was methylphenidate, 5 milligrams (mg) to be administered at 3:30 p.m. The SP documented in the Medication Record that s/he administered the medication to the C on July 23, 2025. A picture of the medication showed a clear baggie with the C’s first and last name, his/her grade, and the type of medication. · The facility’s Controlled Medication Count for the C stated that on July 23, 2025, the C’s pill count decreased by two. At 3:30 p.m. one pill was “wasted” due to being dropped on the floor, and another was administered to the C as needed that day. · There was no information from P1, P2, or P3 indicating that the AV had any side effects from taking a medication that was not prescribed to him/her or that the AV required medical care as a result of the incident.
The facility’s Administration of Medication and Over the Counter Products policy and training stated that only staff persons trained to administer medications were allowed to administer medication to children. Staff persons were to give medications after determining that they had the right student, right drug, right dose, right time, and right route. Staff persons were to record the administration on the child’s administration card. The facility’s personnel files showed that the SP was trained on the facility’s policies and procedures and the Reporting of Maltreatment of Minors Act prior to the incident. P1, P2, and P3 were each trained on the Reporting of Maltreatment of Minors Act prior to the incident.
Conclusion: Information was provided that on July 23, 2025, the SP administered methylphenidate, a prescription medication to the AV that was not prescribed to the AV. The SP was a substitute at the facility on the day of the incident, and the C and the AV had the same initials and first names that were one letter different. Although the SP told P1 and P3 that s/he did not administer the medication to the AV, the AV told the FM and P2 that s/he received medication that s/he was not supposed to take. In addition, the C’s Controlled Medication Count showed that on the day of the incident, the C’s pill count decreased by two. The SP’s administration of the C’s prescription medication to the AV subjected the AV to the risk of medication reaction or side effects. In addition, by concealing the misadministration of methylphenidate to the AV from the AV’s caregivers, the SP further increased the risk to the AV, as the AV’s other caregivers were not aware that the AV had taken the medication and were therefore unable to seek medical advice and/or monitor the AV for concerning symptoms. 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. The SP’s actions of not ensuring the right student were determined to be a nonmaltreatment mistake for the following reasons: 1) The SP had not been determined responsible for a similar incident that resulted in the finding of maltreatment; 2) The SP had not been determined to have committed a similar nonmaltreatment mistake under this paragraph; 3) The AV did not sustain an injury as a result of the incident; 4) Except for the period when the incident occurred, the facility and the SP were in compliance with all licensing and certification requirements relevant to the incident; and 5) This clause was not applicable because the facility was not licensed under Minnesota Rules, chapter 9503. The nonmaltreatment mistake to the AV by the SP 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 Children, Youth, and Families for a period of five years. 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 as a nonmaltreatment mistake. The Office of Inspector General notified the SP 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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