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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: 1025811-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), who was allergic to dairy products and eggs, was served a cookie by a staff person (SP1), which caused the AV to have an allergic reaction that required medical attention. Date of Incident(s): December 2, 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 December 15, 2025; from documentation at the facility and medical records; and through four interviews conducted with the AV’s family member (FM), a supervisory staff person (P), and two facility staff persons (SP1 and SP2). This investigator spoke with the AV, but s/he did not provide information pertinent to this investigation. The facility was located in a community church and had preschool classrooms, including the preschool 3 and 4 classrooms. A hallway outside of the preschool classrooms was utilized as a cafeteria with tables, where meals and snacks were served. The preschool 4 classroom was rectangular with tables, chairs, toy shelves and toys. On one wall there was a shelf with binders and a clipboard. On December 15, 2025, (the day of the site visit) the AV’s allergy plans were on the clipboard on the shelf. Facility documentation showed the AV was three years old and enrolled in the facility’s preschool 3 classroom on December 2, 2025. The AV’s Individual Childcare Program Plan (ICCPP/allergy plan) showed the AV was allergic to dairy, eggs, tree nuts, and peanuts. The facility received allergen free meals from their food vendor and “all ingredient labels” were to be checked for allergens before serving food to the AV. Staff members were to sit next to the AV to prevent cross contamination from other children sharing their food with the AV. Exposure to the AV’s skin or ingestion by the AV of these allergens caused an allergic reaction that included itching; tingling or swelling of the lips, tongue, or mouth; hives; rash or swelling of the face or extremities; nausea; difficulty swallowing; shortness of breath or wheezing; weak or fast pulse; low blood pressure; fainting; and anaphylactic shock. If the AV ingested any of these items, the facility was to administer 5 milliliters of Benadryl and closely monitor the AV for breathing changes, rash, or vomiting. If the AV had any of those symptoms within 30 minutes after ingesting the allergen, the facility was to administer the AV’s epinephrine auto injector (EpiPen) and then call 9-1-1, and then call the FM. The facility’s Child Care Center Serious Injury and Death Reporting Form stated that on December 2, 2025, at 11:10 a.m., staff persons “accidentally” gave the AV a cookie containing dairy. The AV took the “tiniest” bite of the cookie before staff persons realized what happened and took the cookie away from the AV and cleared the cookie from the AV’s mouth. Staff persons administered 7.5 milliliters of Benadryl and called the FM. The AV sat on a staff person’s lap. After approximately 30 minutes, the AV’s breathing slowed and s/he went “limp.” The AV’s EpiPen was administered and 9-1-1 was called. The FM stated it was hard to keep the AV safe because of his/her allergies. Prior to enrollment at the facility, s/he provided a form to the facility regarding the AV’s allergies. On December 2, 2025, SP1 called the FM and said that SP1 gave the AV a cookie that contained the AV’s allergens and that the AV took a bite of it. The AV developed a “rash” around his/her mouth. The FM told SP1 that typically if the AV symptoms were going to “ramp up” it would happen within 20 to 30 minutes after eating an allergen. The FM told SP1 to monitor the AV, let him/her know if there were any changes, and if the AV had trouble breathing, SP1 should administer the AV’s EpiPen. Approximately 22 minutes later, the FM received a phone call from SP1 who told the FM that the AV was having trouble breathing and SP1 gave the AV his/her EpiPen and had called 9-1-1. The FM then drove to an emergency medical facility and met SP1 and the AV there. The AV was monitored at the emergency medical facility and then sent home. The FM stated that s/he felt “fortunate” to have SP1 care for the AV and prior to December 2, 2025, the facility had been “great” with the AV’s allergies. The AV’s medical records dated December 2, 2025, stated that when the AV was admitted, s/he was awake and alert and his/her breathing was “easy.” A “couple” of rash spots were noticed on the AV’s right upper and lower lip. The AV was given an oral dose of Famotidine and an oral dose of Dexamethasone. According to mayoclinic.org, Famotidine was a histamine blocker that decreased the amount of acid produced by the stomach and Dexamethasone was cortisone-like prescription medication used to treat inflammation from different conditions, including allergies. The AV was observed for two hours and then discharged to his/her home with a prescription for oral Prednisolone. According to mayoclinic.org, Prednisolone was a cortisone-like steroid used to treat inflammation from different conditions, including allergies. The following is a summary of information about the incident provided during interviews with the P, and SP1 and SP2: · The P stated that the AV was enrolled in the Preschool 3 classroom and on December 2, 2025, the Preschool 3 and Preschool 4 classrooms were combined. “Usually” there was no food in the classrooms and the children ate breakfast, lunch, and snack in the lunchroom. The AV sat in the same spot for every meal and a staff person sat next to him/her for every meal. · SP1 stated that on December 2, 2025, s/he and SP2 decided to give the children a “special treat.” SP1 took pumpkin “cut out” cookies out of the freezer. At approximately 10:40 a.m., SP1 handed out cookies to the children. The cookies were homemade and were left over from a fall event. After s/he gave the AV a cookie, SP1 took two steps forward, and then remember the AV should not have the cookie. SP1 took two steps back to the AV, who had already taken a “small” bite of the cookie. SP1 put his/her finger into the AV’s mouth and swept out “mushed up tiny bits of cookie.” SP2 left the classroom to get the P. SP1 called the FM and grabbed the AV’s bag that contained Benadryl and the EpiPen. SP1 initially gave the AV 5 milliliters of Benadryl and in talking with the FM, the FM instructed SP1 to give the AV 2.5 additional milliliters of Benadryl to the AV so SP1 did. The FM told SP1 to watch the AV and if s/he had any reaction, SP1 should administer the AV’s EpiPen. The AV then sat on SP1’s lap and they read stories. After approximately 20 minutes, the AV became “lethargic,” had “shallow breaths,” and had a “rash” around his/her mouth. SP1 asked the P to take the children out of the classroom and then SP1 called 9-1-1. SP1 administered the AV’s EpiPen into the AV’s left thigh. The AV then started to cry “a little” and his/her breathing returned to normal. SP1 ended the call with 9-1-1 and called the FM. SP1 carried the AV to the front door and waited for an ambulance to arrive. When it arrived, they both were transported to the local emergency medical facility. The AV was monitored at the medical facility and sent home with a steroid. · SP1 stated s/he was trained on the AV’s allergy plan and knew that a staff person was to sit with the AV at mealtimes. SP1 did not know why s/he or SP2 did not sit next to the AV on December 2, 2025. · SP2 stated that on an unknown date, SP2 and SP1 decided to give the preschool children a treat and SP1 retrieved cookies from a facility freezer that were left over from a holiday party. SP1 placed the cookies on a classroom shelf until they were served. The children sat at two tables in the Preschool 4 classroom and SP1 began to hand out cookies before SP2 noticed s/he was doing so. SP2 was across the table from the AV and noticed “right away” that the AV got a cookie and took the cookie away from him/her. SP2 told SP1 that the AV was not supposed to have the cookie, and they both saw a bite mark out of the AV’s cookie. SP1 removed some cookie from the AV’s mouth. SP1 gave the AV a dose of Benadryl and SP2 went and found the P and brought him/her to the classroom. SP2 then took some children out of the classroom to use the bathroom. When SP2 walked the children back to the classroom, the P was walking out of the classroom with the rest of the children, except the AV. · SP2 was trained on the AV’s allergy plan and knew staff persons were supposed to sit next to the AV when s/he ate. The facility’s Procedures for administering first aid for a child experiencing an Allergic Reaction stated that before admitting a child for care, the facility obtained documentation of any known allergy from the child’s medical professional. That information was kept in the child’s records and used to develop an ICCPP. All staff persons that provided care to a child with an ICCPP were “familiar” with the procedures for treating a child known to have allergies, identified the child by sight, and followed the procedures in the ICCPP. The ICCPP was to be available at all times and in the area where food was prepared and served. In the event of an exposure, a facility staff person gave antihistamine, notified a family member immediately, and if symptoms progressed used EpiPen and called 9-1-1. Staff members monitored children and followed instructions given by 9-1-1. The facility’s Parent Handbook stated that the facility provided breakfast at 8 a.m., lunch at 11:30 a.m., and for preschool aged children, an afternoon snack at 2:30 p.m. Family members of children with allergies were required to fill out a form and have the form signed by a medical professional. The facility posted pictures of children with allergies, listed the allergies, and offered “alternative” foods to meet nutritional requirements. The facility’s Staff Handbook stated that the facility was a “nut-free” facility, and staff persons were to check “all labels” for allergens, including dairy, peanuts, tree nuts, and eggs. The facility’s Risk Reduction Plan stated that children with known allergens had the allergen and ICCPP posted for all staff persons to have access to it. All staff persons were introduced to the child with allergies and trained on the child’s ICCPP. All snacks brought into the facility were store bought and checked for peanut, tree nut, dairy and egg warnings before being served to children. Facility documentation showed that the P, SP1, and SP2 each received training on the facility’s Risk Reduction Plan, the facility’s Procedures for administering first aid for a child experiencing an Allergic Reaction, Parent Handbook, Staff Handbook, and the Reporting of Maltreatment of Minors Act prior to the incident. The P, SP1, and SP2 each received training on the AV’s ICCPP/allergy plan prior to December 2, 2025. Relevant Rules and/or Statutes: Minnesota Rules, part 9503.0145, subpart 5 states in part that the license holder must provide for a child’s dietary needs prescribed by the child’s source of medical care. A license holder serving a child who has a prescribed diet must keep the diet order and its duration in the child’s record. All staff designated to provide care to the child must be informed of the diet order. Conclusion: A. Maltreatment: Consistent information was provided that the AV was allergic to peanuts, tree nuts, eggs, and dairy and on December 2, 2025, the AV was served a homemade cookie and experienced an allergic reaction. SP1 and SP2 realized immediately after the AV took a single bite of the cookie, took the cookie away from the AV, and SP1 used his/her finger to sweep any cookie out of the AV’s mouth. SP1 then gave the AV Benadryl, called the FM, and SP2 went for help. The FM told SP1 that the AV’s reactions typically worsened within 20 to 30 minutes. SP1 sat with the AV on his/her lap and after approximately 25 minutes, SP1 noticed the AV became lethargic and was having trouble breathing. SP1 administered the AV’s EpiPen, called 9-1-1 and called the FM. The AV was transported to the local emergency medical facility where s/he was given an oral histamine blocker and an oral cortisone-like medication used to treat inflammation. The AV was observed and released after approximately two hours with an oral steroid prescription. Given that all snacks brought into the facility were to be store bought and were to be checked for peanut, tree nut, dairy and egg warnings before being served to children; that SP1 served the Preschool 3 classroom children, including the AV, home-made cookies without a label; and that the AV had a reaction that required his/her EpiPen and medical care, including a prescription medication; there was a preponderance of the evidence that there was a failure to supply the AV with necessary care and a failure to protect the AV from conditions that seriously endangered his/her 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; and a 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. SP1 and SP2 were each responsible for the care of the AV at the time of the incident and decided to give the children a “treat” of homemade cookies from the freezer. Although SP2, along with SP1, decided to give the children a treat, and was in the classroom at the time of the incident, SP1 passed the cookies out to the children, including the AV, before SP2 was aware that s/he was doing so. As soon as SP2 noticed that the AV had the cookie, s/he intervened to protect the AV. Therefore, SP2’s responsibility was mitigated. Given that SP1 passed out the homemade cookies to the AV without checking for allergens, and that SP1 was trained on the AV’s ICCPP/allergy plan, the Reporting of Maltreatment of Minors Act, the facility’s Risk Reduction Plan, the facility’s Procedures for administering first aid for a child experiencing and Allergic Reaction, Parent Handbook, and Staff Handbook, SP1 was determined responsible for 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 inadequate and only “partially” followed. The facility updated their policies to reflect that homemade food items were not allowed and retrained staff persons on their policies. 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 SP1 was determined responsible for maltreatment. The determination that SP1 was 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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