Nursing Homes Leaves Resident Unsupervised, Results in Heatstroke and Skin Blisters

Valencia Hills Health and Rehabilitation Center was cited by the Florida Agency for Healthcare Administration because “the facility allowed a resident who was at risk for dehydration related to diuretic use, hypertension, and diabetes and at risk for skin breakdown remain outside on a day with a temperature of 93 degrees Fahrenheit.” The lack of supervision resulted in the resident being transferred to the hospital for two days. This facility was also cited in a past blog post, which can be read here.

The resident was found slumped over in an area behind the back patio, exposed to direct sunlight and lacking supervision. He was unresponsive and had a body temperature of 104.8 degrees. Because of his fragile skin condition, he had developed blisters on his right arm and neck. Staff members checked his vitals and found his heart rate to be 138 bpm (beats per minute), and his blood pressure was 110/59.

After moving him inside, staff soaked towels in ice water and placed them on the resident after removing his clothing. They were able to get his temperature down to 101.7 degrees Fahrenheit, and the primary care physician was notified.

After IV therapy was started, staff members noted the resident’s urine “looked concentrated.” The Advanced Registered Nurse Practitioner (ARNP) stated that according to what she saw, the resident was suffering from heat exhaustion, dehydration, and a Urinary Tract Infection (UTI). He was transferred to the hospital for heatstroke and sunstroke treatment, according to the ARNP’s documentation.

The investigator of this citation began interviewing the facility’s staff members and the resident to determine how the resident was left unsupervised. The investigator learned that the resident was known for enjoying sitting outside every morning with his coffee and cigarette. Once in awhile, he would sit outside throughout the day. Certified Nursing Assistants and nurses are instructed to perform 2-hour rounds to check on residents sitting outside, but the resident “may have been behind a bush and not in direct supervision.”

In this particular incident, the resident took a different path outside than normal because “he wanted to know what it looked like back there and he didn’t normally go to that area to sit.” The resident stated that he saw several staff members inside while he was outside, but no one came to offer him water or other means of hydration. At some point, the resident stated his wheelchair wheel became stuck between the sidewalk and the grass. According to the resident, he “didn’t remember much after that.” During an interview, the resident did say he had suffered from heat stroke but was feeling “much better.” The investigator noted five intact, fluid-filled blisters on his right arm and another on his neck. The resident said it was from being out in the sun too long.

When families place their loved ones in the care of nursing homes, they expect them to be supervised and cared for in order to avoid future harm. Residents who are known to leave the facility, particularly on hot days, need to be monitored to ensure proper hydration. Nursing homes also must ensure they follow their procedures for supervision so that residents aren’t put in harm’s way.

An interview was conducted with a Licensed Practical Nurse (LPN), who was the resident’s assigned nursed from 7 AM – 3 PM the day the incident occurred. She indicated the resident was “fine” in the morning, and she saw him between 12:15 PM and 12:35 PM. She confirmed the resident was allowed to go outside by himself to smoke. The LPN was assigned to the dining room, called to another room, and then tasked with admitting a new resident during the time of the incident. This is why she did not notice his prolonged absence or check on him. When she was notified of his condition, she said she was “not sure” how long the resident was outside before he was discovered.

An interview was conducted with the LPN Unit Manager regarding the incident. She stated she wasn’t familiar with the resident but would often see him propelling himself around hallways and sitting outside. The Unit Manager stated that the outside patio area behind the 100- and 200-unit dining rooms were well monitored; staff were frequently in and out of the dining room area to monitor residents. She indicated that she saw the resident outside 12:50 PM and 1:00 PM and that the resident smiled and waved at her. She did not see the resident after that. According to the citation, there was “no system currently in place to keep track of residents who were outside… every nurse and CNA was accountable for their residents.”

If you suspect nursing home abuse, we will provide a free, confidential case evaluation with no obligation to hire us. We treat our clients with compassion and aggressively represent their rights, making nursing homes take responsibility for abuse. Distasio Law Firm has the expertise and ability to advocate for victims of nursing home abuse and neglect, even if a case goes to trial.


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