The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Facility staff brought the resident outside to smoke in subzero weather dressed only in sweatpants and a long-sleeved shirt. It was unable to be determined how long the resident was outside but when he came back in, his hands appeared red. The resident’s fingers had various blisters and turned blue shortly after. The resident was later diagnosed with frostbite. The facility lacked a process or system to ensure residents who smoked would remain safe when going outside during extreme temperatures.

The report stated that the investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the primary care provider. The investigation included review of the resident record, hospital records, facility incident reports, staff schedules, and facility policy and procedures. Also, the investigator observed the area where the resident smoked and the resident’s frostbite.

The resident resided in an assisted living facility. The resident’s diagnoses included traumatic brain injury and left sided weakness. The resident’s service plan included assistance with behavior management and smoking assistance. The resident’s assessment indicated staff were to assist the resident outside to smoke as he desired, and the resident could smoke independently once outside. The resident had left sided weakness and was only able to use his right hand. The assessment failed to identify how the resident would be kept safe while outside
smoking during temperature extremes.

Weather data for the date the frostbite occurred indicated high temperatures were forecasted to be negative 7 degrees Fahrenheit and a low temperature of negative 13 degrees Fahrenheit, with windchills nearing negative 47 degrees Fahrenheit.