Health inspection·March 2, 2023

F689 Free of Accidents Hazards/Supervision/devices Section 483.25(d)(1) The resident environment remains as free of accident hazards as is possible Section 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 6/3/2021, an unannounced visit was conducted at the facility to investigate a complaint regarding a Resident who was left outdoors and received burns to his skin. The Department determined the facility failed to protect Resident 1 from an excessive duration of exposure to sunlight and heat when Resident 1 was outdoors on the facility patio. This failure resulted in Resident 1 sustaining heat injury (a serious medical condition resulting from the body's inability to cope with a particular heat load) and sun exposure burns to his left foot and right lower extremity. Findings: A review of Resident 1's face sheet indicated he was admitted to the facility in March 2021 with diagnoses including diabetes (a disease causing too much sugar in the blood) and neuropathy (nerve damage or dysfunction causing numbness, tingling, muscle weakness and pain). According to Brief Interview for Mental Status (BIMS- a screening tool for mental capacity), dated 4/1/21, Resident 1 was cognitively intact. The Hospital Transfer Form, dated 5/27/21, indicated Resident 1 was a smoker. During interviews on 6/3/21, at 11:47 a.m. and 1:00 p.m., with the Nurse Assistant (NA), the NA stated she was the person who found Resident 1 in the smoking area on 5/27/21. She stated that she works as the receptionist as well as the smoking monitor. When she monitors the smoking area, she stated that "there are no monitoring intervals that I follow." NA also stated that she was not aware of any [smoking monitor] schedule. During an interview on 6/3/21, at 12:16 p.m., with Certified Nursing Assistant (CNA) 1, the CNA 1 stated, we have smoking monitors, there should be a monitor [in the smoking area] right now." CNA 1 further stated, "Certain residents require [one on one supervision] for smoking, these people are on a list and the smoking monitor knows they need to be monitored." During an interview on 6/3/21, at 12:25 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that the smoking area should have a smoking monitor present all day. LVN 1 stated the smoking monitor should be able to provide instruction to residents about sun exposure and hydration and the monitor should be able to provide hydration. During an interview and observation on 6/3/21, at 12:35 p.m., with Smoking Monitor (SM) in the smoking area, SM stated, "I try to advise [residents] to come in from hot sun. I don't have water to give to them. If they need water, they get it from inside. If they feel hot they come to shade." SM stated during the daytime and afternoon, someone is in the smoking area, at night-time it is closed. SM stated he does not have training about heat illness or the need for hydration. No thermometer or water was observed in the smoking area. The absence of water and a thermometer was verified by the SM. During an interview and observation on 6/3/21, at 12:45 p.m., with Resident 2, in the smoking area, Resident 2 stated, "Sometimes there are people out here to monitor us. I don't know where she is. She must be on a break." Resident 2 stated there was no monitor half of the time. No staff was observed in the smoking area. During an interview on 7/22/21, at 2:15 p.m., with CNA 2, CNA 2 stated, "I was the CNA that day [5/27/21] for [Resident 1]. I transferred him from bed to wheelchair around 10:00 a.m. He said he was going outside to smoke." CNA 2 stated she later heard a call for help over the loudspeaker, around lunch time, 12:00 p.m. CNA 2 stated, "I went to station 2. I saw Resident 1, he was red. He looked passed out. They were cooling him down with a fan and wet wash cloth. He was wearing shorts and a long sleeve sweater...He looked fine when I transferred him earlier, not red and he was talking..." During an interview on 7/22/21, at 2:25 p.m., with Nurse Practitioner (NP) 1, NP 1 stated Resident 1 was on 1-hour checks before the incident. It was not a formalized order. He is now on 10-minute checks. He is independent and a smoker ..." During an interview on 7/22/21, at 2:42 p.m., with CNA 3, CNA 3 stated she was working that day, 5/27/21, "NA brought him to station 2. He seemed like he had taken some sort of drug. That was my first impression. He was wearing shorts. The top of his legs were like blisters, more on the right side. It was like I could push it and it was full of water. [I] don't remember if he was wearing shoes. He looked red. His eyes were not all there. He felt really hot. His head was hot...he had pockets of water above his knees that were a different color than the skin around them ..." During an interview on 7/22/21, at 3:00 p.m., with RN 1, RN 1 stated he knows Resident 1, he was a smoker. RN 1 stated, "The smoking area should have a monitor." RN 1 stated he does not know if the monitoring is logged or documented. During a concurrent interview and observation, on 7/22/21, at 3:35 p.m., with Resident 1 in the smoking area, Resident 1 stated he likes to sit in the sun when he can. No thermometer or water was present in the smoking area. During an interview on 7/22/21, at 4:00 p.m., with LVN 2, LVN 2 stated she was working at nursing station 2 and was the first nurse to see Resident 1 when he was brought from the smoking area, which had no smoking monitor that day (5/27/21). LVN 2 stated Resident 1 was wearing a black hoodie, he had a low blood pressure and a fast heart rate. She stated, "His first temperature we took was 102 degrees orally after removing his jacket and after he drank some water ...He was responsive to pain but was very lethargic [sluggish]...The [NP 2] was there, she did the initial assessment. His [lower legs] had gauze wraps around the entire lower legs and were completely wet as if he urinated on himself...He had red skin. His top right knee had a blister about one and a half inches in diameter. It was fluid filled...He felt hot to the touch. I don't remember seeing any sweat. His arms were dry." During a concurrent interview and record review on 7/22/21, at 4:25 p.m., with the Director of Nursing (DON), the DON confirmed that there was no care plan for Resident 1 related to sitting in the sun for prolonged periods. No charting of 1-hour checks were present in the medical record. DON confirmed there were no care plans for 1-hour checks. During a concurrent interview and record review on 7/22/21, at 4:30 p.m., with the Staffing Coordinator (SC), while reviewing the facility schedule and time punch records, the SC stated NA was scheduled as the smoking monitor on 5/27/21. SC confirmed that was NA's sole duty, she had no other duties. She was scheduled 6:30 a.m. to 2:30 p.m. The time punch log indicated NA punched in at 6:39 a.m. and punched out at 3:28 p.m., with a lunch from 10:04 a.m. to 10:35 a.m. During an interview on 7/22/21, at 4:40 p.m., with the Social Services Director (SSD), the SSD confirmed the smoking monitor has no other duties. During an interview on 7/22/21, at 4:40 p.m., with the Administrator (ADM), the ADM stated the goal of the smoking monitors is to keep the smokers safe. The ADM did not confirm or deny that Resident 1 was kept safe. During a phone interview on 7/27/21, at 8:55 a.m., with NP 2, NP 2 stated Resident 1 was brought from the smoking area unconscious on 5/27/21, he looked sun burned and he had bugs on him. NP 2 stated Resident 1 was hot and flush with a temperature of 100 or 101, he had dry skin, was warm to the touch and smelled like urine. A sternal rub (a painful stimulus applied to a person's middle chest with the knuckles of a closed fist, used when a person is not alert and does not respond to verbal commands) was performed and Resident 1 was barely responsive. NP 2 stated Resident 1 had marks on the knees that looked like blisters. NP 2 stated, "It looked like he was out in the sun too long." During a phone interview on 7/27/21, at 9:15 a.m., with CNA 4, CNA 4 stated he wheeled Resident 1 to the station 2 nursing station from the smoking area on 5/27/21. CNA 4 stated Resident 1 " ...looked out of it, his head was laying straight back, his eyes were closed..." CNA 4 stated he did not know how long Resident 1 was out there sitting in the sun. Review of the Cognition/Neurological Change of Condition -- Acute (sudden in onset) Change In Mental Status form, dated 5/27/21, indicated, " ...NOTES...Patient seen on station 2 after being found unresponsive outside in smoking area...Temp[urature] 101.1. Patient [?] s bilateral (both sides) thighs sunburned. Skin hot to touch. Bilateral leg dressing wet from urine...Constitutional (general description of the body): Unresponsive in wheelchair...Mouth...Dry mucus membranes..." Review of the Hospital Transfer Form, dated 5/27/21, indicated, "Plan: Send out to [hospital 1] for acute altered mental status (a change in mental function that stems from illnesses, disorders and injuries), possible heat stroke (a condition caused by the body overheating), dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally), stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts)." Review of the Progress Notes, dated 5/27/21, at 8:45 p.m., indicated, "[Resident 1] returned from [hospital 1]-[Emergency Room] today at [8:45 p.m.]...Seen and examined by [medical doctor] with [diagnoses] of heat stroke and sunstroke, initial encounter...[Resident 1] came back with skin tear and huge skin blister to Right knee. [Treatment nurse] notified immediately for assessment..." Review of the Progress Notes, dated 5/28/21, at 4:10 a.m., indicated, " ...[Patient] is rolling in bed, moaning. Complains of [10 out of 10] pain to [right lower abdomen] upon palpation (examination by pressing on the surface of the body to feel the organs or tissues underneath) ...Per on-call [Physician Assistant] [name of Physician Assistant], send to [Emergency Department] for further evaluation." A review of the [Hospital 1] Emergency Department Note, dated 5/28/21, indicated, "History: Review of records indicates this patient was just evaluated here yesterday. He apparently is a nursing home resident with underlying history of dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). It appears that his care staff at his facility had left the patient outside in the sun in his wheelchair and he was found later with extensive sunburn (second-degree) involving both lower extremities. He arrived here with report of burns and altered mental status...Physical Exam: Skin:...Obvious evidence of second-degree burns noted with blistering...Diagnosis and Disposition:...Disposition: Transfer to another facility." Review of the [Hospital 2] [Emergency Department] Provider Note, dated 5/28/21, indicated, "History of Present Illness: [Resident 1] presents to the Emergency Department for evaluation of abdominal pain and burn. [Patient] seen at [Hospital 1 Emergency Room two times] over the past 2 days. Seen first for burn to right lower extremity and left foot. Sustained after [patient] was left outside in the sun at care facility ...[Patient] with approximately 10% body surface burn ...Concern for secondary cellulitis (skin infection). No burn service at [Hospital 2] and [Hospital 2 Physician] unavailable for consultation. Case discussed with [Hospital 3] burn unit, [Hospital 3 Physician], and determined plan to transfer [patient] for continued evaluation and burn care ...Disposition: Transfer to Outside Facility: [Hospital 3] Burn ..." Review of the [Hospital 3] Department of Burn Surgery, Hospital Discharge Summary, dated 6/8/21, indicated, " ...Hospital Course: ...4% [Total Body Surface Area] partial and full thickness burns to bilateral lower extremities: ...Upon admission burns were cleaned with soap and water and devitalized (dead or dying) tissue was removed with wash cloths. Wound care was performed 1-2 [times] daily. Skin grafting was not performed due to severity of chronic conditions. Surgery deemed to be risky ..." A review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated 07/2017, indicated, "Facility-Oriented Approach to Safety...2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes...4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents...Individualized, Resident-Centered Approach to Safety...3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision...Systems Approach to Safety...2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment." Therefore, The Department determined the facility failed to protect Resident 1 from an excessive duration of exposure to sunlight and heat when Resident 1 was outdoors on the facility patio. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.