complaint·December 23, 2024

9099C-1.. The fire department's report from 9/22/24 notes they were dispatched to the facility, at 1545 hours, for the reason "unknown problem/person down", arrived at 1551 hours and found (R1) "slouched in a wheelchair". The chief complaint noted on the report was "altered level of consciousness, possible heat stroke". Also documented is that facility staff reported there was a recent shift change and staff found (R1) who was left outside in the sun and with a blanket. Upon discovering (R1) outside, facility staff brought (R1) into the facility and called 9-1-1. Facility staff reported they believe (R1) may have been outside for a maximum of (3) hours and were not certain due to a recent shift change. Hospital medical records indicate that (R1's) initial temperature was elevated and cooling protocols were implemented. A Computed Tomography (CT) was determined to be negative for intracranial hemorrhage or large brain mass. Staff interviews indicated that (R1) was able to slowly ambulate themself in the wheelchair and would ask other residents for assistance, including to take them outside. One staff stated they believe (R1) asked another resident for assistance and that's how they got outside on the patio and staff didn't know where (R1) was. Shortly after shift change, (R1) was noticed outside on the patio but was not brought inside until about (40) minutes later, by the "pm" staff. A second staff confirmed residents are allowed to go outside on the patio but staff try to re-direct residents from going outside, if it's a hot day. If staff are not able to redirect the resident, staff are to check on the resident who is outside every 10-15 minutes, offer water and keep trying to redirect the resident inside. This staff stated another staff informed them around 1530-1600 hours that (R1) was outside and needed to be checked on. This staff stated they observed (R1) to be wearing layers of clothing, was not responsive, their eyes were flickering and their skin was hot to the touch. Neither the morning or afternoon staff assigned to care for (R1), or other staff, could confirm how long (R1) had been outside on the patio before being sent out for emergency services on 9/22/24, around 1530 hours, and being diagnosed with heat stroke. There is no camera coverage in the seating area where (R1) was. *cont on 9099C-2... 9099C-2.. Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview with Resident Care Coordinator and Administrator (by phone). Copy of report and appeal rights provided.