Failure to Thoroughly Investigate Resident Heat Stroke Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who suffered heat stroke after being left outside on the patio, resulting in a life-threatening situation. The resident, who had multiple complex medical diagnoses including multiple sclerosis, encephalopathy, dementia, and severe cognitive impairment, required staff assistance for mobility and activities of daily living. On the day of the incident, the resident was found unresponsive on the patio with a temperature of 103.8°F and was subsequently transferred to the emergency room for evaluation and treatment. The investigation conducted by the facility was incomplete, as it did not include a statement from the resident's companion who was present at the time of the incident. Interviews with staff revealed inconsistencies regarding supervision in the dayroom and on the patio, with some staff unaware of how the resident ended up outside. The companion later reported that upon arrival, they found the resident alone on the patio, unresponsive and exposed to direct sunlight, and had to seek help from nursing staff. Documentation showed that the resident was outside for approximately 30-40 minutes before being discovered in distress. Facility records indicated that CNAs were assigned to supervise the dayroom in 30-minute rotations, but there was confusion about who was responsible for the resident at the time. The facility's investigation relied only on statements from the nurse and CNA involved, omitting the companion's account until later interviews by the surveyor. The facility's policy required thorough investigation of all possible incidents of neglect, but the lack of a complete investigation and failure to obtain all relevant statements constituted a deficiency in responding to and investigating alleged violations.