Complaint Investigation Report

The investigator initiated interviews with clients, staff, and other witnesses on 10/26/21; 12/27/21, and 01/10/22. Hospital medical records were subpoenaed on October 4, 2021, received 10/08/2021 and reviewed on 10/19/2021. Client and personnel records review were conducted on 3/30/22.

The investigation revealed that on August 29, 2021, C1 was sitting outside in the backyard for approximately 45 minutes in 105 degree weather without constant supervision. Eventually when staff checked on C1, C1 was observed to be sweaty, and less responsive. The client could not move from the seat therefore, was lowered to the grass. The paramedics were contacted and C1 was taken to the hospital for care. C1 was diagnosed with dehydration, heat exposure and received wound care treatment for significant right and left foot burns that were described as “acute Full thickness Burns” which resulted in debridement on a total of 5 wounds. Home health skilled nursing services were initiated to tend to the wounds.

Per records review of C1’s Individual Program Plan (IPP), C1 needs constant daily supervision in all settings to prevent harm or injury. In addition, the Administrator did not provide staff appropriate training related to heat exhaustion.

Therefore, after review of the information gathered the allegation, “Client sustained severe sunburns while in care,” is substantiated. A civil penalty shall be issued for a violation that resulted in an injury to a client in care.

Exit interview conducted. Civil Penalties issued, report and appeal rights delivered to the Administrator.