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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: 1093042-CCC (Child Care Center) Investigator(s): Judith Schwanke Minnesota Department of Children, Youth, and Families 651-539-8268 Suspected Maltreatment Reported: It was reported that an alleged victim (AV) had a capsule in his/her mouth and chewed on it. Date of Incident(s): October 9, 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 23, 2025; from documentation at the facility; and through six interviews conducted with a supervisory staff person (P1), facility staff persons (P2, P3, P4, and the SP), and the AV’s family member (FM). Facility documentation showed the AV was nine months old and enrolled in the infant classroom on October 9, 2025. Due to his/her age the AV was not interviewed for this investigation. The facility was a stand-alone building with several rooms including a staff person break room and an infant classroom. The break room had lockers with locks and was down a hallway from the infant classroom. Upon entering the infant classroom from the hallway, there was a kitchen area with highchairs on a tiled floor and a “First Aid & Meds” box installed on a wall out of the reach of children. Just beyond the highchairs was a carpeted area with toy shelves, toys, and low chairs for the infants. The FM provided the following information: · On October 9, 2025, after 12 p.m., P1 called the FM and told him/her that “around noon,” the AV had found a capsule in the infant classroom and put the capsule in his/her mouth. P1 had already contacted Poison Control and was told that the AV would be “okay,” because the capsule had not “dissolved” in the AV’s mouth. · The FM was a medical professional and asked what type of capsule the AV had in his/her mouth. P1 told him/her that the capsule was Hydroxyzine, but s/he did not know the milligrams. The FM “knew” that capsule had multiple uses including as an antihistamine, for anxiety, pain, and sleep. If the AV did ingest any of the capsule, s/he would be “sleepy.” (Note: according to www.mayclinic.org/drugs, Hydroxyzine was a medication to help control anxiety and tension, produce sleep before surgery, and to relieve symptoms of allergic conditions. Adult dosage was 50 to 100 milligrams and children under six years of age dosage was 50 milligrams in divided doses.) · After the phone call, the FM picked up the AV earlier than usual. The AV was “happy” and the FM did not notice any changes in the AV. The FM monitored the AV that evening and throughout the night and the AV was “happy.” The FM did not notice any change in the AV’s demeanor, reactions, or emotions. The FM did not seek any medical care for the AV. · Prior to October 9, 2025, the FM did not have concerns with the facility. P1, P2, P3, and P4 provided the following consistent information: · On October 9, 2025, P2, P4, the SP, and the AV were in the infant classroom. P3 went into the infant room to give the SP a break, and the SP left the classroom. · P4 stated that between 10:30 and 11:30 a.m., the AV was seated on the floor near a highchair and approximately two feet away from a shelf and was moving his/her mouth. P4 saw something “green” on the AV’s lip. P4 went to the AV and put a finger in the AV’s mouth and found that the AV had a “capsule” on the inside of his/her right cheek. P4 removed the capsule from the AV’s mouth. The capsule was “little, dark green” on one half and “teal” on the other half. There were numbers on the capsule. · P4 picked up the AV and carried him/her and the capsule to P1’s office and told P1 what had happened. P4 then went back to the infant classroom.
· P1 stated that at approximately 11:45 a.m., P4 “rushed” the AV and the capsule into his/her office. P1 “immediately” went into the infant classroom and P1, P2, P3, and P4 began looking for “other capsules.” One additional capsule was found on the floor near a shelf. P1, P2, P3, and P4 checked the other infants to make sure they were not chewing on any capsules. P2, P3, and P4 each told P1 that the capsules were not theirs. · P1 went to his/her office and called Poison Control. P1 explained that the capsule in the AV’s mouth had not started to break down and was told that because the capsule had not yet started to break down in the AV’s mouth, the AV was “completely fine.” The AV would have had to ingest “two to three” capsules for them to “do anything” to the AV. Poison Control told P1 that the capsules would have made the AV “sleepy,” and/or “irritable.” P1 returned the AV to the classroom. P1 then called the FM and told him/her that the AV had chewed on a capsule, but it was taken away. P1 explained that s/he did not know where the capsule originated from and would talk with staff persons and review camera footage. P1 talked with the SP when s/he returned from break. The SP confirmed that the capsules were his/hers and that the type of capsule P1 told Poison Control was correct. P1 continued to check in on the AV throughout the day, and the AV was fine and P1 did not notice any changes in the AV’s behavior. · P4 stated that after P1 returned the AV to the classroom, the AV was placed in a highchair, ate lunch and was “super smiley.” P4 left the classroom at 1:30 p.m., and the AV was “totally normal.” · P3 was in the infant classroom until the SP returned to the classroom and the AV was “fine.” P2 worked in the infant room until 3 p.m., and the AV was “100 percent fine” with no reaction to the capsule. · P1 stated that staff persons were trained not to have medications “on them,” and that medications should be locked up or kept in their vehicles. The SP was trained on the facility’s medication policy. P1 stated that s/he believed the training was adequate. · P2, P3, and P4, each stated they were trained not to bring personal medications into classrooms and felt their training was adequate. The SP provided the following information: · On October 9, 2025, s/he was in the infant classroom with P2, P3, and the AV. At approximately 10:50 a.m., s/he left the infant classroom and went to the facility break room to take his/her medication, Hydroxyzine. The SP forgot to bring his/her water bottle to the break room, so s/he put two, 25 milligram capsules into his/her hand and went back to the infant classroom. · When the SP returned to the infant classroom s/he needed to either change a diaper or feed an infant a bottle and did not take his/her medication and instead, put it in his/her pants pocket. Around 11 a.m., P4 entered the infant classroom to give the SP a break, and the SP left the classroom. · When the SP returned to the classroom, P1 asked him/her if s/he had a “green medication,” and showed the SP the capsule in a bowl. The SP told them that it was his/her medication. P1 and P2 then told him/her that the AV had one of the capsules in his/her mouth and that Poison Control and the AV’s parents had been called and notified. P1 told the SP that the capsule had not opened in the AV’s mouth and if it had, it would have made the AV sleepy. · The SP stated s/he was trained to keep his/her personal medication in his/her vehicle or locker in the break room and felt his/her training was adequate. Prior to October 9, 2025, the SP had not brought his/her personal medication into the classroom. The facility provided a photo of the two capsules in a disposable bowl. One end of the capsule was dark green, and the other end of the capsule was light green. One capsule was fully intact, and the other capsule was mostly intact with the light green end flattened and a yellow powdery substance coming out of both ends. P1 reviewed video footage from the infant classroom on October 9, 2025, and saw the AV “playing with something” in his/her hand but whatever s/he was playing with was so small that P1 could not see it. The AV then put his/her hand to his/her mouth and started to “gum something.” Less than a minute later, P4 noticed the AV chewing on something and dug in the AV’s mouth and took out what the AV was chewing on. P4 and the AV then left the classroom. P1 then reviewed video footage before the AV found the capsule but could not “pinpoint” when the capsules came out of the SP’s pocket. The facility provided two video segments from the infant classroom on October 9, 2025, that were time stamped and contained unintelligible audio. At 11:47 a.m., P2 and P3 were in the kitchen area, and the AV was on the floor near a highchair looking at his/her hands. P4 walked into camera view with another infant and walked past P2, P3, and the AV. The AV continued to look at his/her hands and touch one hand with his/her other hand. P4 placed the other infant on the floor and then walked out of camera view. At 11:48 a.m., P4 walked back into camera view and stood in the kitchen area. At 11:48:22 a.m., the AV moved his/her right hand to his/her mouth and appeared to put something in his/her mouth. P3 and P4 moved around the classroom and the AV looked at his/her hands again and then moved his/her right-hand fingers into his/her mouth. At 11:48:55 a.m., P4 walked into camera view and stood in front of the AV. At 11:49:19 a.m., the AV moved his/her mouth and P4 squatted down in front of him/her. P4 placed his/her left hand on the AV’s head and put fingers from his/her right hand into the AV’s mouth and removed something. P4 stood up and turned toward P2 and P3. P4 walked out of camera view and the AV crawled under a highchair and the video ended. The facility Employee Handbook stated that personal belongings were stored in the “breakroom.” Staff persons were responsible to ensure that work areas were safe and free of hazardous conditions. All medications were stored out of the reach of children. When an accidental ingestion of a poisonous substance occurred, staff persons contacted Poison Control.
The Risk Reduction Plan stated that exposing children to medication could be dangerous or even deadly. Medications were kept in a locked medicine cabinet out of reach of children. The accessibility of hazardous items to children was prohibited at all times when children were present. Facility documentation showed that P1, P2, P3, P4, and the SP each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies including the Employee Handbook and the Risk Reduction Plan. Relevant Rules and/or Statutes Minnesota Statutes, section 142B.54, subdivision 2, paragraph (e) and Minnesota Rules, part 9503.0140, subpart 17, states that hazardous objects must be inaccessible to children. Conclusion: Information was consistent that on October 9, 2025, that the SP took two Hydroxyzine capsules from his/her locker and brought them into the infant classroom to take them. When s/he got into the infant classroom, s/he needed to tend to children’s needs and put the capsules in his/her pants pocket. The capsules fell out of his/her pocket and onto the floor, where the AV found one capsule and put it in his/her mouth. Less than one minute later, P4 noticed the AV chewing on something and removed the capsule from the AV’s mouth. P4 notified P1, P1 contacted Poison Control, and another capsule was found in the infant classroom. The AV was unharmed. Although the AV was unharmed, the SP brought the capsules into the classroom which was a violation of Minnesota Statutes, section 142B.54, subdivision 2, paragraph (e) and Minnesota Rules, part 9503.0140, subpart 17, and the AV was able to access and place potentially hazardous items in his/her mouth. The SP’s actions represented a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health or safety when reasonably able to do so. 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. Although the AV found and placed the Hydroxyzine capsule in his/her mouth, 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 any previous incident that resulted in a finding of maltreatment for at least seven years; 2) the SP had not been determined responsible for any previous nonmaltreament mistake under this paragraph for at least four years; 3) the AV was not injured and did not require medical care after the incident; 4) except for the period when the incident occurred, the facility and the SP were in compliance with all licensing requirements relevant to the incident; and 5) at the time of the incident, the SP was performing job-related duties. 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 Facility: The facility completed an internal review and determined that their policies and procedures were adequate but not followed. All staff persons were retrained on the facility’s Personal Belongings and Hazardous Materials policies. 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. On October 7, 2026, the facility was issued a Correction Order for the violation outlined in this report. 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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