Resident Left Unattended in Sun Resulting in Heat-Related Injury and Delayed Medical Response
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, glaucoma, vascular dementia, and anxiety disorder, who was noted to have impaired cognitive function and poor decision-making, was left unattended outside in the sun for several hours. The resident, who required substantial assistance for activities of daily living and was dependent on staff for toileting and transfers, was allowed outside after a social service assistant determined she could go out due to her high BIMS score. Staff were aware the resident had a habit of undressing in public and had previously refused to come inside from the courtyard. On the day of the incident, the resident was observed outside, undressed, and staff covered her with a gown. Despite being told by the administrator not to let the resident outside unsupervised after a similar incident the previous day, the resident remained outside for an extended period in temperatures ranging from 82 to 85 degrees Fahrenheit. The resident was found unresponsive in her wheelchair after several hours, with a body temperature of 107 degrees Fahrenheit and an oxygen saturation of 88 percent. She had developed second-degree burns and blisters on her arms and legs. Staff brought her inside, applied ice packs, and moved her to an air-conditioned area, but did not immediately notify a physician or call emergency services. Documentation of the incident was delayed, and there was no evidence of follow-up vital signs or timely physician notification. The resident was not transferred to the hospital for evaluation and treatment until approximately 24 hours after the incident, despite the severity of her condition. Interviews with staff revealed confusion about who authorized the resident to go outside and a lack of clarity regarding responsibility for monitoring her safety. The exit door keypad was broken, preventing the resident from re-entering the facility independently, and this issue had been ongoing for months. Staff did not consistently monitor the resident while she was outside, and there was a lack of immediate and appropriate intervention when her condition deteriorated. The failure to supervise the resident, monitor her condition, and provide timely medical intervention resulted in actual harm and was identified as a deficiency by surveyors.
Removal Plan
- Resident was sent to the ER for evaluation and treatment.
- Resident returned to facility with an order to follow up with the outpatient burn center.
- Resident has wound care orders in place to affected areas.
- Resident was reeducated on risks factors of prolonged heat and sun exposure.
- Policies and procedures were reviewed to ensure they were comprehensive and accurate: Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, Heat Related Illness, and Abuse Policy.
- Education was completed for all licensed staff on Examination and Assessment, Charting and Documentation, Routine Checks, Change in Condition, Heat Related Illness, and Abuse Policy.
- The forecast of weather conditions with high and low temperatures was posted at the Second Floor Courtyard door, First Floor Courtyard door, and Smoking Area door.
- Staff were educated to reference the high temperature to the heat-related illness guidance and to educate all residents on risks of outside temperatures that day if they request to go outside.
- For temperatures of 80 degrees (Fahrenheit) or higher, staff will increase resident safety checks.
- If residents choose to remain outside, staff will offer additional safety interventions from the facility Excessive Heat policy, including additional education, ice water, move to shaded areas, etc.
- Resident's care plan was reviewed and updated to reflect the current resident's condition and needs.
- A post-education test on Heat Illness Education was administered to all staff and all staff successfully completed the post test.
- Head-to-toe assessments on all residents were initiated to ensure there were no negative outcomes from heat-related illnesses.
- The facility QAPI Committee reviewed the deficiencies, the plan of action, the policies and procedures related to Heat Related Illness, Change in Condition and Notification, and completed a root cause analysis.
- Outside thermometers were hung by the Administrator with the forecast posting so staff can see the actual temperature compared to the forecasted highs and lows.
- Staff were educated that if resident(s) will not come inside, they will immediately contact the Director of Nursing, Administrator and/or the Director of Social Services to assist bringing in the resident(s) to ensure their safety.
- Facility began reviewing change of condition via 24hr and 72hr report by DON/Designee. Audit will include notification, interventions, assessments.
- Facility began posting outside temperature listing which will be audited by Administrator/Designee.
- Facility began resident interviews regarding neglect for residents with BIMS of 13 or higher. Random residents will be interviewed by Administrator/Designee.
- Facility began random resident assessments on residents with BIMS of 12 or lower for signs of neglect. Random residents will be assessed by DON/Designee.
- Facility began random staff interviews on heat illness via posttest and what current outside temperature is that day by Administrator/Designee.
- All findings will be reviewed in QAPI.
- The Administrator and the DON will be responsible for the oversight of the monitoring/audits.
- Before residents are taken outside, by activities or other staff, they will check with charge nurse to determine which residents are able to go outside.
- The External Courtyard Keypad was repaired by the facility maintenance director and determined to be in working order.
- The Keypad will be audited for functionality by Administrator/Designee.
- All residents that go outside will be supervised by facility staff.
- Prior to taking residents outside, for activity or other reasons, staff will verify with charge nurses that residents are safe to go outside supervised based upon resident's current medical condition.