Failure to Prevent Heat Stroke During Outdoor Activity
Penalty
Summary
The facility failed to provide adequate and proper interventions to prevent heat stroke during an outdoor activity, resulting in actual harm to residents. Thirteen residents were taken on a planned outing to the zoo on a day when the outside temperature reached 88 degrees Fahrenheit with a heat index of 90. Despite some residents expressing discomfort and complaints of being hot, the outing continued as scheduled, and residents remained outside and on a bus for extended periods. The bus used for transportation was not pre-cooled, and after leaving the zoo, residents stayed on the warm bus while meals were provided at a fast-food restaurant. The bus was described as being very hot inside, and residents were exposed to high temperatures for several hours. Two residents became unresponsive during the return trip, requiring emergency medical intervention. One resident was found to have a temperature of 105.7 degrees Fahrenheit and was transferred to the hospital, placed on a ventilator, and treated for heat stroke. Another resident was also unresponsive with a temperature of 104 degrees Fahrenheit and was admitted to the hospital for heat stroke. Both residents had significant medical histories, including cerebral infarction, hemiplegia, chronic obstructive pulmonary disorder, and other chronic conditions. Other residents on the outing also experienced symptoms of overheating, with some refusing assessment or treatment by EMS, and several being recommended for emergency room evaluation but declining. Staff interviews and documentation revealed that the decision to proceed with the outing was made despite prior discussions about the high temperature and concerns raised by staff. There was no evidence that the physician was consulted regarding the appropriateness of the outing for the residents given the weather conditions and their medical statuses. The facility did not ensure that outdoor activities were planned and provided to meet the safety and total care needs of the residents, and interventions such as increased fluids, sunblock, and access to shaded or air-conditioned areas were ineffective in preventing harm. The lack of adequate planning and response to residents' needs during the outing directly resulted in heat-related illnesses and hospitalizations.