Staff at a assisted living facility in Waseca failed to provide adequate checks on a resident, who had left the premises and was found 10 hours later having fallen in nearby woods.
A complaint against Colony Court Senior Living Solutions was found to be substantiated by the Minnesota Department of Health, after the resident was found to have suffered a fall earlier this year.
The resident has "cognitive deficits," the complaint says, and he required checks every two hours overnight.
But a staff worker, despite checking other rooms, failed to check the man's room, and when the morning shift started, another care worker found it empty.
He was found some 40 feet away lying face down in tall grass in a wooded area near the facility.
The temperatures overnight had dipped below 30F, with the gentleman showing signs of hypothermia with a body temperature of 96 when medical staff assessed him.
He had to spend several days in a rehab facility after suffering from rhabdomyolysis, which can be caused by intense shivering.
When management found him, he said it was about time someone got there, and said he'd gone for a walk because his legs hurt.
When later asked why he ended up outside, the resident said: "I don't know what the hell I was doing."
The worker who was meant to check on him had noted the resident wasn't a fan of the wellness checks and had previously yelled and charged at them in the past, as well as other care workers.
They expressed genuine remorse for what happened, saying "they screwed up."
Management at Colony Court told MDH it had made improvements to its wellness check procedures since the incident, and has also installed alarms on its exterior doors that alerts them if a resident leaves the property between 11 p.m. and 6 a.m.
A family member told MDH that the resident couldn't make rational decisions by himself, hence why he needs nightly checks.