“I am burning alive, I am burning alive,” Chapman kept saying, according to an investigative report from the Missouri Department of Health and Senior Services.

Chapman had dementia, and because of her paralysis, limited use of her legs and left arm. She was a longtime smoker. The nursing home performed eight “smoking assessments” for her between 2012 and March 17, 2017, the suit says. All of the assessments determined she could smoke without supervision, despite concern expressed by staff in October 2016 and the discovery of burn marks on her clothing in February, the suit adds.

In March, the nursing home did tell Chapman she had to wear a special smoking apron to protect her from hot ashes and dropped cigarettes. Despite concerns that her dementia was worsening and that burn marks continued to be found on her clothes, she was put on the back porch alone on May 13 without a smoking apron, the suit says.

“At some point, an employee decided to check on Donna and found her still sitting in her wheelchair with flames on her body and wheelchair,” the suit alleges.