Failure to Supervise Cognitively Impaired Resident Results in Heat Stroke
Penalty
Summary
A cognitively impaired resident with multiple complex medical conditions, including dementia, multiple sclerosis, encephalopathy, and a history of falls and strokes, was found unresponsive on an outdoor patio during a period of extreme heat. The resident had a severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required staff assistance for activities of daily living and mobility. Facility records and staff interviews confirmed that the resident could not ambulate independently and required one-person assistance for ambulation. On the day of the incident, the resident was last seen in the dayroom by assigned staff, but was later discovered outside on the patio by a companion, unresponsive and exposed to direct sunlight. The companion immediately alerted a nurse, who found the resident unconscious with a temperature of 103.8°F and a heart rate of 124 bpm. The resident was brought inside, treated for heat stroke, and subsequently transferred to the emergency room for further evaluation and care. Interviews with staff revealed inconsistencies regarding supervision in the dayroom and the process by which the resident accessed the patio, with staff unable to account for the resident's movement outside or provide clear oversight during the critical period. Facility policies required supervision of cognitively impaired residents and specific precautions during periods of extreme heat, including staff monitoring and prevention of heat-related illness. However, documentation and interviews indicated lapses in supervision and failure to ensure the resident's safety, as no staff observed or prevented the resident from being outside unsupervised during hazardous weather conditions. The lack of effective oversight and adherence to established protocols resulted in the resident suffering a life-threatening heat stroke, constituting neglect.
Removal Plan
- Resident was assessed and transferred to emergency room for evaluation.
- Resident returned to the facility and was placed on monitoring.
- The nurse and CNA who were assigned to Resident were in-serviced on resident safety and protection from neglect.
- Resident was placed on one-to-one supervision.
- All cognitively impaired residents were placed on monitoring.
- The LNHA, DON, and ADON reviewed the abuse and neglect policy, taking residents outside the facility, hot weather, enhanced supervision, and nursing round policies with no revisions made.
- The DON, ADON, LNHA provided the nurses and CNAs with training on the abuse and neglect policy, resident supervision, protection of resident from neglect, and resident safety.
- The DON, ADON, and LNHA provided non-clinical staff training on abuse and neglect and residents' rights to be free from neglect.