Deficient Supervision Leads to Resident's Heat Exposure and Hospitalization
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 hospital for treatment related to sun and heat exposure. The resident's care plan included interventions to avoid exposure to extreme heat and to observe for symptoms such as sweating, tremor, and lack of coordination, but these interventions were not effectively implemented. Multiple staff interviews revealed that the resident was last seen in the activity room eating ice cream before going outside. Staff responsible for monitoring residents outside, including activities staff and CNAs, did not provide adequate supervision or hydration during the resident's time outdoors. The resident was discovered by another staff member who noticed he was unresponsive and not at his usual baseline. Upon assessment, the resident was found to be very warm to the touch and unable to respond appropriately, prompting emergency services to be called. Medical records and hospital documentation confirmed that the resident suffered from heat exposure and developed skin damage, including redness and fluid-filled blisters on areas exposed to the sun. The facility's policy required periodic monitoring, hydration, and appropriate supervision for residents outdoors, especially those with moderate to severe impairments. However, these procedures were not followed, resulting in the resident's adverse health event.
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 has 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.