Complaint·January 16, 2025

The administrator stated that R1 was checked every two hours but walked outside to the courtyard around 1:30 PM on 10/2/2024. Morning caregiver S1 checked on R1 twice, providing water, but did not complete a shift crossover with the afternoon staff due to a meeting. R1 was last seen conscious but was found unconscious by afternoon caregiver S3, who attempted to cool R1 down before calling 911. 2 of 3 staff interviews revealed concerns of staffing shortages. S1 later expressed regret, acknowledging the incident could have been prevented with better judgment and that they felt the facility was short staffed. S4 also mentioned that they felt the facility is short staffed and there have been past complaints by families regarding the facility being short staffed and not having staff available which negatively impacted the level of care residents received. According to S4, they noticed R1 outside but did not notify staff or complete a shift crossover due to the meeting. After the meeting, S4 found R1 unconscious and helped with cooling measures. S4 also felt that the facility was extremely short on staff that negatively impacted care. According to interview, S3 was assigned to R1 in the afternoon, found R1 unconscious and moved R1 to the shade. S3 felt unfairly blamed for the incident due to communication failures and under staffing. S3 also noted that front desk person could have seen R1 on the video surveillance. S3 added that other staff had seen R1 outside earlier that day but took no action to ensure R1 was safe. Interviews revealed that facility management conducted their internal investigation and has determined to terminate S3 for the incident. Administrator stated that R1’s was not purposely neglected and that the incident was a result of a huge oversight from care staff. Administrator also stated that facility has added intervention techniques to avoid future incidents from occurring. Review of the video surveillance footage obtained from the facility cameras dated 10/2/2024 showed R1 was sitting in a patio chair in the courtyard at approximately 1:26 PM, with their body exposed to sunlight. At 1:38 PM, staff member (S1) briefly interacted with R1 for 20 seconds. Another staff member (S2) passed by R1 at 1:46 PM but did not stop. At 1:53 PM, S1 gave R1 a cup of water and stayed with R1 for about 10 seconds. At 1:59 PM, R1 was still exposed to full sunlight. Over the next hour, several residents walked past R1, and at 2:57 PM, R1 slumped over completely and was no longer visible in the chair. Afternoon staff member (S3) checked on R1 at 3:20 PM, and with assistance from another staff member (S4) and other staff, they brought R1 inside at 3:25 PM. Emergency Medical Services (EMS) arrived at 3:31 PM, and by 3:44 PM, they departed with R1 for medical care. {2 of 3} Review of R1’s medical record obtained from the hospital on 10/29/2024 showed that on 10/2/2024, R1 arrived at the hospital with a core temperature of 105.3 degrees Fahrenheit with a chief complaint of altered consciousness. It was also noted that R1 had 23% to 25 % of first and second degree burns on the right forearm, foot, face, and abdomen. R1 was also diagnosed with heat stroke. On 10/3/2024, R1 had a seizure and was noted to remained comatose off sedation. It was also noted that R1’s burns began to blister. On 10/4/2024, R1 experienced fourth seizure and remained comatose. On 10/5/2024, R1 remained comatose and on comfort care. R1 later passed away on 10/62024. Review of R1’s death report confirmed heat stroke as one of the causes of R1’s death. It was also noted that R1’s injuries occurred due to direct sunlight and elevated environmental temperature exposure. Additionally, it was also confirmed from AccuWeahter.com that, on 10/2/2024, the outdoor temperature in Elk Grove, CA was approximately 102 degrees Fahrenheit. The lack of care and supervision resulted in R1’s prolonged exposure to extreme heat, causing severe injuries and subsequent death. Factors contributing to R1’s incident include procedural failures, such as the lack of a shift crossover and delayed resident checks. The preponderance of evidence standards has been met; therefore, the allegation is SUBSTANTIATED. The following deficiencies are being cited from the California Health and Safety Code (HSC) 1569.312(e). Failure to correct the deficiencies may also result in civil penalties. At the time of the complaint visit, an immediate civil penalty of $500 was issued, and AD was informed that an additional civil penalty was pending review and may be assessed according to Health and Safety Code § 1569.49(e). Once a civil penalty has been determined, the Department will return at a future date to assess civil penalty. Exit interview was conducted with AD and details of the deficiencies and plan of corrections were discussed. Per discussion with AD, they implemented plans to ensure residents’ overall health, safety, and well-being are properly monitored following the incident. A copy of this report and appeal rights were provided during this visit. {3 of 3}