According to the MDH report, during an interview, a registered nurse (RN) stated staff assisted the resident to go outside to smoke, and all smoking supplies were stored with the staff. The RN stated the resident would take off his oxygen, staff gave him his supplies, and the resident would light his own cigarette then called staff when he was ready to come back inside. The RN stated he had heard the resident had some previous noncompliance with the facility smoking policy, but he had not witnessed it himself. The RN stated the resident was not considered an independent smoker due to the assistance that he did need to smoke. The RN stated he believed the resident obtained cigarettes and other smoking materials from visitors he had.

During an interview, the ULP stated on the day of the fire, she was in resident 2’s room assisting him when she heard the smoke detector sounding. The ULP stated when she looked to see what was going on, she saw a large fire coming out of the resident’s room and could not enter the room due to the size of the fire. The ULP stated she shut the door of resident 2’s room while on the phone with 911 and ran to the basement to notify an ambulatory resident downstairs of the fire. The ULP stated she exited the facility with the ambulatory resident and the fire department would not let her re-enter the facility. The ULP stated she had no idea how the fire started, and she saw no smoking materials on the resident or in his room when she had assisted him to bed just prior to the fire. During an interview, the resident’s case manager (CM) stated she attended a care meeting with the resident, herself and the AP, where they discussed with the resident the dangers of smoking in his room. The CM stated she discussed with the resident during the meeting that smoking in his room was not safe for him or others, and it put everyone at risk for a fire, especially since he used oxygen. The CM stated the resident at first stated nothing would happen and did not see anything wrong with what he did, but the resident did eventually state that he understood and would follow the facility smoking policy. The CM stated when she checked in with the resident a month after the meeting, the AP notified her the resident had not attempted to smoke in his room since the meeting the month prior.

The resident was not interviewed due to being deceased. Family did not return the investigators request for interview. The resident’s death record and fire report were not available at the time of the investigation. In conclusion, the Minnesota Department of Health determined neglect was substantiated.