Deficiency Due to Lack of Supervision Resulting in Resident's Sun/Heat Exposure
Penalty
Summary
A deficiency occurred when a resident was left unsupervised in the facility's courtyard for approximately one hour during the hottest part of the day, from 2:45 p.m. to 3:45 p.m. The resident, who had a history of physical limitations, difficulty walking, and required assistance with personal care, was found unresponsive and had to be transferred to a higher level of care for treatment related to sun and heat exposure. The resident subsequently developed skin damage, including redness and fluid-filled blisters on the arms and thighs, as documented in medical records and provider notes. Staff interviews revealed that the resident was last seen by the activities assistant around 2:30 p.m. in the activity room eating ice cream, after which the resident went outside. Multiple staff members, including the DON and activities staff, stated that residents who are alert and oriented are allowed to go outside, but are supposed to be checked on periodically and offered hydration and sunscreen. However, on the day of the incident, no staff were present in the courtyard to supervise or monitor the resident, and it was not clear how long the resident had been outside before being found unresponsive by another staff member who happened to be passing by. The facility's policy required periodic monitoring of residents in outdoor areas, especially in warmer weather, and specified that residents with moderate to severe impairments should be attended by staff or a visitor when outside. Despite these policies, the resident was left unattended, and staff were unable to account for the resident's whereabouts or provide documentation of supervision during the critical period. The lack of adequate supervision and failure to follow established procedures directly led to the resident's exposure to hazardous conditions and subsequent medical complications.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope of severity regarding any of these deficiencies cited are correctly applied. In order to ensure that the services provided at Life Care Center of Sarasota meet the professional standards of quality, the team had initiated the following plan of correction: Resident #1 was discharged from the facility. Residents who enjoy outdoor activities have the potential to be affected by not providing adequate supervision to prevent exposure to the sun/heat. The facility revised and implemented a new process for the courtyard that includes designated times in which the courtyards will be open and supervised pending inclement weather. The Executive Director and or designee will educate the facility staff on the courtyard process, courtyard hours, communication, supervision, and sign-out process for residents who enjoy outdoor activities. The Executive Director and or designee will complete 5 random audits per week on the facility courtyard process which will include communication and supervision. The results of the audits will be tracked, trended, and reported to the monthly Quality Assurance and Performance Improvement meeting for a period of three months or until sustained compliance is achieved. F 689 F 689 F 689 F 689 F 689 F 689 F 689
Removal Plan
- Courtyards were rounded on hourly, all who chose to go outside offered hydration, sunscreen and encouraged to wear sunblock.
- Courtyard re-opened with checks conducted by the Activities Director, Executive Director and/or designee.
- 100% of staff provided education as to inclement weather policy and facility procedures for facility courtyards.
- Current facility practice of communication ensures nursing is made aware of residents leaving unit to participate in an outdoor activity.
- Care plans updated as appropriate.
- Courtyard closed for renovations.
- At the recommendation of the Ad Hoc QAPI committee, education regarding upcoming courtyard process change, sign in and sign-out process for front desk.
- Education regarding new courtyard process sent to residents/families, front desk/receptionist staff.
- Met informally with resident council president to discuss courtyard process.
- Courtyard re-opened with distinct opportunities to utilize with 100% supervision. All dependent upon inclement weather policy.