Community Foundations ‘at fault’ for resident’s frostbite injuries

Community Foundations in Maplewood was found “at fault” for an incident in which a resident wandered off in the middle of a cold March evening.

Health Department issues report on security issues

The Minnesota Department of Health has found a Maplewood residential care facility at fault for an incident involving a mentally ill client who wandered away from the building on a frigid March night.

Community Foundations, 1096 Gervais Ave., was found to be negligent for not alerting employees who arrived for the overnight shift that a vulnerable adult wasn’t present in the building.

The facility was also reprimanded for failing to follow through on a nightly bed check to ensure that the resident hadn’t strayed off.

According to the report, at 3 a.m., an employee went to check the male patient’s room. The worker entered and saw the light was on and the bed was unmade. Instead of locating the man, the employee assumed he was in the restroom and chose not to investigate further.

According to the report drawn up by the Health Department, the man, whose name and age were not disclosed, left the unlocked facility sometime after 10:30 p.m. and returned shortly around 6 a.m.

He had been diagnosed with mental illness and had chemical dependency issues. The report said he sustained serious injuries from the incident and had to be hospitalized.

According to the Health Department, the temperatures were below zero that night, and the man was outdoors for seven and a half hours. When he returned, his hands and feet were frostbitten and he had a cut on the forearm.

The report said the man was disoriented from being outdoors in the snow and could not say where he had been.

The man had been admitted to the facility just five days earlier.

The residential treatment center is owned by the nonprofit South Metro Human Services, which runs 16 centers, including the Maplewood facility. Terry Schneider, board chair, psychologist and director of clinical services, spoke to the Review about the incident.

“This was a horrible event, and the staff feel really badly about that,” he said. “That’s the first thing I want to get across.”

Employees indicated to the Department of Health that beyond the requirement that bed checks be made, they had differing interpretations on how to conduct them.

Some staff members said the policy was to visually see the patient, while others said it was acceptable to hear the resident snoring or hear a response from a bathroom.

Regarding the bed check on the missing man, a staff member called out and thought the resident responded “hey” or “OK” through the rest room door.

Describing the incident as very unfortunate, Schneider said the main issue he heard from health department officials was that “they didn’t feel our policy had enough detail”, and the bigger issue was how the checks were carried out. 

Ultimately, he said it was an isolated event, and nothing similar had happened since. When asked if he could comment on the internal reaction when the incident took place, he was frank in his answer.

“I can not,” he said.

You can reach Tim Faklis at 651-748-7814, at, or on Twitter @tfaklisnews.


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