Resident Left Unattended Outdoors Resulting in Heatstroke and Burns
Penalty
Summary
A cognitively impaired, aphasic resident with multiple serious medical conditions, including Alzheimer's disease, brain and colon cancer, and a history of traumatic brain injury, was left unattended on an outdoor patio for approximately two hours and forty minutes during a period of heat and sun exposure. The resident required maximal staff assistance for mobility and activities of daily living and was unable to communicate effectively. After being transported to the patio in a wheelchair by a CNA following lunch, the resident was not monitored or checked on by any staff, and the CNA failed to inform other staff members of the resident's location. During this period, the assigned CNA did not check on the resident or account for their whereabouts, and no other staff intervened. The resident was eventually discovered by another resident and a visitor, slumped over in the wheelchair, with hot, dry skin and an elevated temperature. Emergency services were called, and the resident was transferred to the hospital, where they were diagnosed with heatstroke, dehydration, acute kidney injury, elevated troponin, and second-degree burns (sunburns with blisters) on multiple body areas. Hospital records documented the resident's acute distress, altered mental status, and multiple metabolic complications resulting from the prolonged heat exposure and lack of monitoring. Facility records and staff interviews confirmed that there was no policy in place at the time regarding resident supervision outdoors, and staff failed to follow basic protocols for communication and resident safety. The assigned CNA was unaware of the resident's location for an extended period, did not perform required rounds, and failed to provide necessary care such as hydration, toileting, and skin protection. The lack of monitoring and communication directly resulted in the resident's serious medical deterioration and hospital admission.
Removal Plan
- Checks were implemented on all outdoor areas (patio, courtyard, entrance), checks recorded on log sheets
- Notifications to NJDOH, Ombudsman Office and facility administrative staff were sent
- Patio keypad was changed to locked
- All employees at the facility were educated on Resident Safety/Heat Advisory
- CNA #1 received inservice/education on Resident Safety
- CNA #2 received inservice/education on Resident Safety, knowing your assigned resident's whereabouts, making rounds on assigned residents and received a suspension
- A facility wide inservice on the new Outdoor Resident Policy was initiated with Resident Safety/Updated Log Sheets
- Camera installation on the patio was completed
- Checks remain on all outdoor areas recorded on log sheets