Failure to Monitor and Provide Care During Elevated Temperatures Resulting in Resident Harm
Penalty
Summary
The facility failed to monitor and provide appropriate care and services to residents during a period of elevated temperatures in resident care areas, resulting in actual harm to a resident. When the rooftop HVAC system malfunctioned, the facility experienced high temperatures, particularly in certain units where temperatures reached up to 90°F in common areas and 87°F in resident rooms. Although portable air conditioning units were rented and some residents were moved or offered extra fluids, documentation shows that not all residents were adequately monitored for symptoms of heat-related illness. A resident with a history of Alzheimer's disease, traumatic brain injury, vascular dementia with behaviors, and epilepsy was affected during this period. Despite the facility's awareness of the elevated temperatures, there was no evidence of timely or thorough assessment for hyperthermia or documentation of vital signs, including temperature, pulse, respiratory rate, blood pressure, and oxygen saturation for this resident. Progress notes documenting the resident's status prior to the change in condition were entered as late entries after the resident had already been sent to the hospital, and did not reflect real-time monitoring or assessment during the period of risk. The resident was eventually found to be lethargic, with shortness of breath, a high temperature (103.3°F to 103.4°F), and altered mental status, leading to emergency transfer to the hospital. Upon arrival at the emergency department, the resident was critically ill, with a temperature of 107.1°F and acute respiratory distress, requiring intubation and ICU admission. The facility was unable to provide documentation of appropriate monitoring or interventions for hyperthermia prior to the resident's decline, resulting in significant harm as evidenced by hyperthermia and acute respiratory failure.