|The Executive Director stated in an interview on 07/09/18 that staff are expected to check memory care residents every hour. This is a part of staff’s initial training and includes staff documenting checks on the daily log. Caregivers also confirmed in interviews that they must find coverage when taking breaks or going to lunch so monitoring is continued and to ensure there are two caregivers at all times in the memory care unit.|
Daily logs show R1 was checked at every hour while he was on the memory care patio. The Executive Director stated staff checked on the resident who was outside from 9:45-11:30 AM and he was given water at 10:30 AM. Time cards shows S2 was responsible for monitoring R1 on 6/30/18. She stated in an interview that she (S2) gave R1 water to avoid dehydration several times. However, interviews of other staff on duty that day (S3, S4, S5) could not confirm that S2 found a replacement caregiver to cover her lunch break from 10:35 to 11:10AM which included the time that R1 was outside. When S2 went to lunch at 10:35 am – 11:10 am, there was only one staff on duty. An interview with the Med-Tech/LVN (S4) confirmed that she did not cover the time when one staff went to lunch. The Med Tech stated in an interview on 9/28/18 that she did not think there was coverage when S2 went to lunch.
Based on the Incident Report dated 6/30/18 and interviews, S2 and S3 went outside to bring R1 back into the building for lunch at 11:30 AM and found him unresponsive. Ambulance records, however, revealed that 911 was called at 12:04PM. R1 had been sitting outside for 1 hours, 45 minutes or longer when temperatures were increasing and reached 93 degrees by 12PM when emergency services were called. The temperatures were verified by a local city weather graph. When R1 arrived at the hospital, his body temperature was 103.4 (F), he was dehydrated, and had multiple areas of sunburn (basic blister burns)/redness on body. R1 was diagnosed with a heat stroke on 6/30/18 and admitted to intensive care. R1 expired on 7/14/18. The immediate cause of death noted on the Death Certificate was heat stroke due to prolonged exposure to sun and heat.
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