Resident Left Unsupervised Outdoors Resulting in Heat Exhaustion
Penalty
Summary
A deficiency occurred when a resident with mild neurocognitive disorder, impaired mobility, and a history of delusions and agitation was left unsupervised on an outdoor patio. The resident was dependent on staff for transfers, had impaired balance, and required supervision with all decision-making. According to the care plan, the resident was at risk for falls and required prompt response to requests for assistance, as well as supervision when outside. Despite these needs, the resident was brought outside by staff and left alone for an extended period in hot weather, without access to water or sun protection. Staff interviews and documentation revealed that the resident was placed on the patio around early afternoon and checked on intermittently. Multiple staff members noted that the resident refused to return inside when offered, but she was not provided with water or adequate sun protection, and there was no way for her to independently alert staff if she needed help. The patio door required a code to re-enter the building, which the resident could not operate due to her physical limitations. Staff were unclear about the frequency of required checks and did not consistently communicate the resident's location or status during shift changes. The resident was found unresponsive after being left outside for several hours in temperatures reaching 90 degrees Fahrenheit. She exhibited signs of heat exhaustion and dehydration, including confusion, elevated vital signs, and sunburn. Emergency services were called, and the resident was treated in the emergency department for heat exposure, dehydration, and hyperkalemia before being returned to the facility. The facility's policy required supervision based on individual assessment and environmental hazards, but staff failed to provide adequate supervision and did not follow established procedures for monitoring residents outside.