To Summer RALLY Families,
Here is some updated information and details related to the incident that occurred on June 14th, and some of the corrective action that has already been taken.
First, we again apologize for the stress and disruption the incident involving floor sealant caused our RALLY families.
Here are a few key pieces of information that may be helpful to you; some are repetitive, and some may be new information:
1. There were 13 children who ingested some floor sealant.
2. In the initial calls to families, it seems that it was shared that it was “paint thinner.” This was inaccurate, and we aren’t sure why that was misstated.
3. The actual item was floor sealant, and all 13 families were sent the fact sheet related to this chemical's health and safety impacts.
4. We know that the chemical (in a large pouch inside a cardboard box with a nozzle) was stored in the wrong warehouse for over a year. The pallet holding these boxes was near milk sources that were appropriately stored at the warehouse. The chemicals were contained on a separate pallet, not mixed on the same pallet with any milk products.
5. On the morning of June 14th, NANA employees picked up the sealant from the warehouse, mistaking it for milk. (the substance is white and “milky”) Once delivered to the school, the NANA staff served it without verifying what substance it was.
6. The sealant was poured into cups because it appeared to be a multi-serving pouch, not individual servings.
7. Poison Control was called immediately, and directions for monitoring the students were followed. Poison Control connects callers to a poison specialist who is a registered nurse or pharmacist. After a year of training, poison specialists sit for a national certifying exam to become CSPIs (Certified Specialists in Poison Information).
8. The NANA delivery driver and server are no longer employed by NANA.
9. Investigation of the incident has been done by a variety of agencies: Juneau Police Department, Department of Education and Early Development, Department of Health and Social Services Childcare Licensing, Department of Environmental Conservation, and OSHA. The NANA/NMS safety team conducted an incident review, including a product/event timeline, findings, and corrective action. JSD has reviewed communications and emergency preparedness protocols. DEC, DEED/CNP, OSHA, JPD conducted inspections/investigations.
10. The JSD School Board has authorized the district to seek out another investigation entity to overlook each of these third-party reports and report back with additional information and/or recommendations for improvement of the corrective action plan.
11. The JPD report is complete.
12. There are no criminal charges being brought forward.
13. Full June tuition was reimbursed to all families who had a child in the cafeteria when the sealant was served.
14. The Safety Data Sheet for the specific chemical was shared with those families who had a child ingest some of the chemical. #4 on this data sheet specifically addresses ingestion.
Several Corrective Action Steps have already been activated, and others are in process. This is not a complete list but a sample of changes and responses.
In place now:
· Inventory: changed delivery, storage, rotation, and pick-up protocols, labeling of pallets and individual cases, and short-term and long-term inventory practice.
· NANA retrained and is complying with their “taste/sip” protocol, where all food and drink (if not an individually sealed container) is tasted before serving.
· All meals this summer are now being served in a “Grab and Go” style, ensuring all drinks will be in individually sealed containers.
· New NMS training took place in June, and NMS/JSD food service training is scheduled in August for all school year staff.
Some future Steps:
· Secure a communication platform to be used by RALLY to increase the efficiency of parent communications. This will allow staff to send mass notifications to families, like the phone/text/email system that is in place during the school year. This will improve communications for all purposes, but especially in the case of an emergency.
· All summer program facilitators (including RALLY) will be trained on emergency preparedness and response before the school year. This will be in addition to our safety training during the school year.
We are sincerely sorry that this incident occurred, specifically for our communications not being what they should have been. The Juneau School District has responded to this incident with focus and diligence. I have spoken to each family multiple times who had a child who ingested the chemical. However, if you are one of those families or anyone with a child at RALLY and have additional questions, please do not hesitate to reach out.
JSD is doing this restorative work alongside NANA Management Services (NMS) and Yakobi Fisheries in coordination with all of the investigative departments since notification of the chemical ingestion incident on 6/14/22. Since the incident, NMS has provided additional oversight for NANA staff in Juneau with a rotation of safety officers, the president, vice president, area manager, general managers, and an additional assistant manager. JSD, NMS, and Yakobi have worked in coordination with the State of Alaska Department of Environmental Conservation Food Safety & Sanitation and Department of Education Child Nutrition Program to review protocols and procedures in regard to food and operational safety, warehouse delivery/receiving procedures, and additional procedures, monitoring, and reporting have been implemented as a result.
We are continuing to analyze our response and develop/implement corrective action steps to provide assurance that the chemical ingestion incident was an isolated event and that the gaps in procedures found during the investigation no longer exist. As we learn anything new, whether from our analysis or that of other investigations, we will continue to adapt our practices and those of NANA/NMS.
Again–do not hesitate to reach out if you have any follow-up questions. JSD is working with CBJ to cover costs associated with this incident, and those families directly involved will continue to get additional information.
