Resident Left Unattended Outside Resulting in Hospitalization for Heat-Related Illness
Penalty
Summary
A dependent resident with multiple medical conditions, including rheumatoid arthritis, major depressive disorder, encephalopathy, acute kidney failure, and peripheral vascular disease, was left outside in her reclining wheelchair for two hours without water or a means to call for help. The resident was entirely dependent on staff for all activities of daily living and mobility, as documented in her care plan. On the day of the incident, she was placed directly in the sun after lunch, and staff failed to provide the required supervision and monitoring. Staff interviews revealed that the usual practice was to set a timer for 10-20 minutes when the resident was taken outside, with checks at those intervals due to her inability to signal for assistance or return inside independently. However, on this occasion, there was confusion and lack of communication among staff regarding who was responsible for monitoring the resident and whether a timer had been set. Multiple CNAs stated that the resident did not have water with her and could not hold a drink, and there was no call light or device for her to request help. The resident was not in direct view of the door, and staff were unaware of her presence outside until she was found unresponsive by another CNA. Upon discovery, the resident was unresponsive, with her eyes rolled back and twitching, and was noted to be red, hot, and very thirsty. Immediate interventions included providing water, applying cold compresses, and administering oxygen. She was subsequently transferred to an acute care hospital, where she was treated for heat exhaustion, sunburn, hypoxia, altered mental status, and dehydration. Hospital records confirmed sunburn to her face, neck, and chest, hypoxia, and improvement after IV fluids. The facility's policy required 15-minute checks for residents outside, but this was not followed, resulting in the resident's prolonged exposure and subsequent hospitalization.
Removal Plan
- An assessment form was created and implemented to assess the residents' ability to safely be outside unattended. All residents have a completed assessment for going outside unattended. Newly admitted residents will have a completed assessment for going outside unattended. This assessment will be reviewed if there is any change in condition. Audits will be completed by DON or designee.
- Current policy reviewed. Input from Certified Nursing Assistants (CNAs) was collected via Survey Monkey. Policy updated with feedback from managers and CNAs. The policy includes identifying safety measures and resident assessment, timely checks on the resident and documentation on a log. A timer is placed at the door entry (Door 4) where residents go outside. The log book is stationed at Team B nurses' station, next to Door 4. The log includes documenting time going outside, checks, notes regarding resident, hydration offered, time coming in, and staff signature.
- All managers were educated on the new policy/procedure. Managers then educated their staff. This ensured that staff were educated on the policy and procedure prior to their next shift worked. Agency: New policy & Procedure has been sent to agency organizations who will in turn disseminate to their staff. Agency staff will be educated on arrival by DON or designee.
- Policy states that whoever takes the resident outside is the one responsible to ensure check is conducted. A timer is set to alert for checking on the resident outside. If the CNA is unable to check on resident, CNA must find another CNA to check on the resident. CNA must confirm with other CNA that the check is being conducted, either verbally or over the walkie/talkie. If the CNA is unable to find another individual to do the check, the resident is brought back in to the facility.
- Audits will be conducted by DON or designee.