Failure to Monitor and Hydrate Resident During Heat Event Resulting in Harm
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for a resident at risk for dehydration during a period of elevated indoor temperatures. When the cooling system servicing the resident's unit was taken out of service for maintenance, indoor temperatures rose above 81 degrees for an extended period, with some readings exceeding 90 degrees. Despite the facility enacting a 'Code Purple' for severe hot weather, there was a lack of consistent temperature monitoring and documentation, and the facility could not provide temperature logs for a significant portion of the affected period. The resident involved had diagnoses including Parkinson's Disease, dementia, and dysphagia, and was assessed as being dependent on staff for most activities of daily living. The care plan identified the resident as being at risk for dehydration, with interventions to observe for signs and symptoms of dehydration and to encourage thickened fluid intake. However, during the period of elevated temperatures, the resident's fluid intake was inadequately documented, with only minimal amounts recorded and no fluids documented on the day the resident was found nonresponsive. There were also no nursing progress notes entered during the critical period, and staff interviews confirmed that routine charting of hydration was not completed during the Code Purple. On the morning following the period of high temperatures, the resident was found nonresponsive with an elevated temperature and was sent to the hospital, where they were treated for heat exhaustion and dehydration. Medical staff confirmed that the resident was at increased risk for dehydration due to their medical conditions and thickened liquid requirement, and that the lack of hydration and monitoring contributed to the resident's significant change in condition. The facility's failure to ensure sufficient hydration and monitoring during the heat event resulted in actual harm to the resident.