A Maplewood residence for mental health patients lost track of a 25-year-old client for more than seven hours on a subzero night last March and he turned up the next morning caked with ice, disoriented and suffering from frostbite so severe that his socks were frozen to his feet, according to authorities.
The man eventually required treatment at the Regions Hospital hospital burn unit in St. Paul, where he was treated for frostbite on his hands and feet and for an injured forehead.
Investigators for the Minnesota Department of Health cited “system breakdowns” that led to lax overnight supervision and faulted the nonprofit agency that operates the Community Foundations facility in the 1000 block of Gervais Avenue.
In a separate report, a police officer described arriving at the facility and seeing the man in the front office, bundled in blankets and wearing a winter coat, a sweater and sweatpants.
“I saw a large amount of ice on [his] right hand surrounding all his fingers,” the officer wrote. “The ice was approximately a half-inch thick. [His] left hand was … extremely cold to the touch.”
As medics helped the man remove his shoes, “his socks were frozen to his feet,” the officer continued.
The residence is one of more than a dozen operated in the Twin Cities area by St. Paul-based South Metro Human Services. Terry Schneider, South Metro’s director of clinical services, said, “It’s a very unfortunate situation that happened.”
Schneider said the facility “has made the corrections” requested by the Health Department, including staff training and creating a written policy for bed checks. He also said no staff members merited discipline for the incident.
According to the Health Department investigation:
As the temperature headed toward 15 degrees below zero, the man left the residence about 10:40 p.m. without the staff’s knowledge. A new shift came on at midnight and those workers were unaware that the man had left. A bed check at 3 a.m. found the light on in the man’s room and his bed unoccupied.
“Staff assumed the resident was in the bathroom,” the report read. The staffer called out for the man and thought there was a response of “hey” or “OK.”
The man returned about 6 a.m. through the front door, and 911 was called. Staff members said the resident’s fingers were red and “ice-covered,” and his pants were wet as if he had been sitting in the snow. He was unable to say where he had been or long he had been outside.
Facility administrators said they require staff to conduct one bed check a night and it must be visual, but they acknowledged not having a written policy on how staffers should carry it out.