**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident record review, hospital record review, and review of the facility's policies and procedures, the facility failed to ensure residents were free from medical neglect when the facility staff failed to provide adequate supervision when Resident #1 was left outside, inadequately supervised on the facility patio during weather conditions with outside temperatures of 93 degrees Fahrenheit for 3 hours and 31 minutes. The facility's failure to provide supervision for Resident #1 resulted in Resident #1 being found by another resident and brought inside the facility. Resident #1 was found unresponsive, CPR (Cardiac Pulmonary Resuscitation) was initiated, and the resident was transported to the hospital. Resident #1 suffered from cardiac arrest, hyperthermia, 2nd degree burns and had a body temperature of 108.5 Fahrenheit. Resident #1 did not survive. Hyperthermia is defined as dangerously overheated body, usually in response to prolonged, hot, humid weather. Hyperthermia occurs when the body's heat-regulating mechanisms don't work effectively. Older age, certain illnesses, and medications increase the risk of developing hyperthermia. A temperature of 40 °C (104 °F) or higher is life-threatening. Confusion, nausea or vomiting, and rapid breathing are some symptoms. The very young and elderly: Seniors (over 65) and children (especially those under the age of 4) are often more at increased risk of heat-related illness, as they typically tend to be less aware of temperature changes and their bodies generally don't regulate as well. Findings include: Review of the admission record for Resident #1 documented diagnoses to include cerebral infarction due to embolism of unspecified cerebral artery (stroke), type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis following cerebral infarction affecting right non-dominant side, essential (primary) hypertension (high blood pressure), hypothyroidism, polyneuropathy (nerve damage), atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), presence of cardiac pacemaker, osteoarthritis, presence of artificial hip joint unilateral, unspecified dementia, acquired absence of right leg above knee, and other seizures. Review of the nursing progress note for Resident #1 dated [DATE] at 6:30 PM authored by Staff C, Licensed Practical Nurse (LPN), read, Pt [Patient] was assisted OOB [out of bed] at 1530 [3:30 PM] into W/C [wheelchair]. Once in W/C pt self propelled himself into courtyard outside of the dining room where he sat with other residents. At 17:50 (5:50 PM), CNA [Certified Nursing Assistant] alerted nursing staff that pt was in the dining room and did not look well. Nursing staff immediately went to pt and he was found with no heart rate, no respirations. Staff immediately lowered pt to the floor and RN [Registered Nurse] and other nursing staff on duty started CPR. I called 911. Paramedics arrived and took over CPR. Pt left via stretcher with paramedics and emts [Sic. Emergency Medical Technicians] at 18:20 [6:20 PM]. I notified pt's daughter [Resident #1's Daughter's name]. I notified pt's friend [Resident #1's Friend's name] as well. Provider notified. Review of the nursing progress note for Resident #1 dated [DATE] at 4:21 PM authored by Staff C, LPN, read, Late entry for [DATE] @ [at] 1830 (6:30 PM]; Resident was assisted out of bed at approximately 1400 [2:00 PM]. Review of Code Blue Form for Resident #1 dated [DATE] at 6:30 PM read, A. Chain of Events: Date/Time of Respiratory/Cardiac Arrest: [DATE] 17:50 [5:50 PM] . 2a. Code Blue Called: [DATE] 17:51 [5:51 PM], 2b. Code Status Verified: [DATE] 17:51 [5:51 PM], 2c. 911 Called: [DATE] 17:51 [5:51 PM], 2d. CPR Initiated: [DATE] 17:53 [5:53 PM], 2e. EMS [Emergency Medical Service] arrival: 0000 [Sic.], 3. Resident Transferred To: HCA [Hospital Corporation of America] [NAME]. Review of the facility's video footage on [DATE] at 1:00 PM with the Administrator and Regional Nurse Consultant showed on [DATE] at 2:19:43 PM, Resident #1 entered the patio in shorts and sleeveless shirt in his wheelchair with shoe on his left foot and sat in the sunshine. Staff A, CNA, was present on the patio during smoking time when the resident went outside. On [DATE] at 2:27:07 PM, Staff A, CNA, left the outside patio and returned to the building with the smoking cart. On [DATE] at 2:31:05 PM, Staff A, CNA, entered the patio and handed a drink to a resident. Staff A had no interaction with Resident #1 and left the patio again at 2:31:35 PM. On [DATE] at 2:32 PM, Resident #1 wheeled himself under the covered gazebo with 2-3 other residents and sat in the shaded area. On [DATE] at 2:48:28 PM, an unknown staff member entered the area and exited within 20 seconds. There was no interaction with any resident on the video. On [DATE], Resident #1 remains on the patio until 3:40 PM under the shaded gazebo. On [DATE] at 3:40:25 PM, Resident #1 moved out to the sunny area nearer to the automatic doorway entrance to the facility. On [DATE] at 4:08:31 PM, Staff A entered the smoking area with the smoking cart, handed cigarettes to the residents who were smokers. Staff A did not interact with Resident #1. On [DATE] at 4:40 PM, Staff A left the smoking area with cart and did not interact with Resident #1. On [DATE] between 4:40 PM and 5:50 PM, there were no facility staff present in the smoking area. On [DATE] at 5:49:14 PM, a resident entered the patio, walked past Resident #1, immediately returned to Resident #1, and began to wheel Resident #1 inside the door of the facility. On [DATE] at 5:50 PM, Resident #1 was wheeled completely into the facility and out of the video view. Review of the local hospital's Emergency Provider Report for Resident #1 dated [DATE] at 7:16 PM read, HPI [History of Present Illness]-Cardiac Arrest . Presentation: Chief Complaint: Cardiac arrest, Found dwn [down], Found unresponsive. Measures Prior to Arrival: Patient found unresponsive in cardiac arrest by another resident of the nursing home, patient was on asystole for unknown period of time. Down Time Prior to EMS: Unknown. Total Time Arrest to Arrival: Unknown. Arrest Circumstances: Unwitnessed arrest, Asystole in field, Asystole in ED, Ongoing CPR on arrival, No resp (response) to EMS interven [intervention]. Context: Resuscitation. Initial rhythm asystole, Orotracheal inubation [Sic. intubation], Epinephrine IV [Intravenously] x 3, bicarbonate 1 amp [ampule]. Reason for ED Visit: cardiac arrest. Hx [History] Obtained From: EMS. Onset Occurred: Sudden. Symptom Duration: Since onset, Brief, Constant. Progression since Onset: Unchanged, Constant. Context of Onset: Exposure, Environmental, Hyperthermia. Location: Back, Chest R [Right], Chest L [Left]. Quality. Unable to verbalize . Focused PE [Physical Examination]: General/Const [Constitutional]: Arrived to emergency room via EMS ground [NAME] County from the nursing home, CPR in progress, patient was oral intubated and bagging by a paramedic, cardiac monitor show systole on arrival. No pulse was palpable, the patient temperature rectal was 108.5 [degree Fahrenheit]. MS Head: Head: Atraumatic, Normocephalic. Eyes: Pupil dilated bilateral no reactive to light stimuli and fixed. Resp [Respiratory]/Chest: Oral intubation. Cardiovascular: Cardiovascular Asystole. Skin: Skin Back blisters on the superior aspect of his back most likely secondary to 2 degree [Sic.] burns, the skin was easy peel with the fingers. Also, on his lateral neck. Neurologic: Neurologic No reflex . Free Text MDM [Medical Decision Making] Notes: [AGE] years old male came to the emergency department via EMS ground [NAME] County part of the information was obtained from the paramedics and nursing home history. According to the paramedics the patient was outside for unknown period of time. Patient was found by another resident and push inside at that time. The patient was already on cardiac arrest. Nobody knows for how long the patient was down. Nursing home personnel started CPR and called EMS. They started CPR around 17:50 [5:50 PM] and transfer the patient to the ER where we stop the CPR and pronounced the patient at 18:31 [6:31 PM] after more than 41 minutes of asystole. The patient never had a palpable pulse during the 41 minutes of CPR. We noticed during the resuscitation that the patient was very hot and we checked a rectal temperature that was 108.5, and we also noted that the patient had blisters and some evidence of skin damage secondary to the heat over the superior back area. The Coroner 's Office was notify [Sic.] about the findings on this patient. MDM-Complexity: Differential Diagnosis: Cardiac arrest, electrolyte abnormality, hypertension, hyperthermia, respiratory arrest, cardiac arrhythmia, PE [Pulmonary Embolism]. Patient Discharge & Departure. Vital Signs/ Condition. Vital Signs: First Documented: Temp [Temperature] Result: 42.5 [degree Celsius, equal to 108.5 Fahrenheit], Date: 07/19, Time 1830 [6:30 PM] . Condition: deceased . Clinical Impression: Primary Impression: Cardiac arrest. Secondary Impression: Hyperthermia. Time of Impression: 1831 [6:31 PM]. Disposition Decision. Time: 1831, Date: [DATE], deceased : Yes. During an interview on [DATE] at 9:15 AM, the Administrator stated, We have 2 areas, which residents can go outside. Although he [Resident #1] was not a smoker, he would go out to the smokers' side and socialize. We did review the video from that day and developed a timeline of the events that day. Staff were assigned to that area, but they did not really have the responsibility to monitor everyone in the area. Staff are assigned to the smoking times; they weren't responsible to make sure residents came inside at any given time. There is always a water cooler available for drinks out there, a covered area and fans out in that area. It was not unusual for him to nap frequently, and he was observed wheeling himself out of the covered area to the sun and fell asleep and the staff did not wake him. No one took the initiative to ask or wake him up because it was common for him to take naps. The staff were concerned with resident rights and didn't think about telling residents to come in. The high temperature that day was 93 and the resident was out in the area from almost 2 to almost 6 PM when another resident found him unresponsive. We should have evaluated any environmental concerns before this occurred. During a telephone interview on [DATE] at 11:00 AM, Staff F, LPN, stated, I did respond to the code. I was at the nurse's station when another resident came up to me and said, I don't think he's breathing. I began walking towards the resident and into the dining room and saw [Resident #1's name] and didn't find a pulse. We wheeled him to the hallway and immediately someone started CPR after he was on the floor. He was very warm when I checked his pulse. I did not see anything except his right arm was red and maybe I think had an abrasion. We are supposed to check on all residents and round in the patios every hour to make sure the residents don't need anything. During an interview on [DATE] at 12:00 PM, Staff A, CNA, stated, I'm not assigned to residents, and I deal with smoking breaks until about 4:30 PM. [Resident #1's name] was not a smoker, but was outside frequently to talk to the other residents. I am supposed to hand out and light cigarettes and make sure they are awake, and safe while smoking, that they don't bring any cigarettes or lighters in with them. [Resident #1's name] was usually talking with other residents when he went out there. He would fall asleep sometimes. I wouldn't necessarily wake someone up. Before I leave to go back inside, I will ask if everyone is okay or do they need anything. He had a drink with him. He always had a drink with him. He appeared to be asleep the last time I went by him. I did not wake him up. It was very hot that day in the mid-nineties. He was sitting in the sun. I really just didn't think about it. I didn't see anything unusual. I didn't really know how long he was out there for I am only out there for a half hour with the smokers. I didn't know he had never gone inside that day. During an interview on [DATE] at 12:20 PM, Staff D, RN, stated, I was working on 200 hall and was getting ready to give meds when I heard my name and that they needed help in the dining room. When I got to the dining room, he [Resident #1] was unresponsive. I confirmed he didn't have a pulse and initiated CPR, while another nurse called 911. I did CPR until the paramedics arrived. He was very warm to touch. I really didn't notice anything else. I can't tell you if he was sunburned. I have worked with him in the past. He would get up later in the day, get a Starbucks coffee, spent time watching TV and went outside to socialize. He would take cat naps in his chair. There was no system really in place to make sure that when residents are outside they go inside frequently. We should have been offering residents drinks and water when they go outside. Most of us are aware that the elderly can dehydrate more quickly. There was not a system of anyone responsible to round on the residents when they were on the patio. But we all should make sure our residents have been evaluated at least every 2 hours if not more. There are assigned smoking times and that's the only time that staff are assigned to see the residents. During a telephone interview on [DATE] at 1:20 PM, Staff B, CNA, stated, He [Resident #1] was a quiet resident. I understood what he was saying. He was easy to work with. That day, he was okay. It was a busy day. He had been sleepy that morning and wanted to get up later in the morning. I got him up in his chair, and he went about on his way. He liked being outside and so I noticed he was outside and, in his chair. Hours later, there was a Code Blue and they were doing CPR. We are supposed to check on patients as frequently as we can. He really liked being outside. I went out every 2 hours and checked on him. He was fine. I think the last time I checked him was around 4 o'clock. During an interview on [DATE] at 8:25 AM, the Director of Nursing (DON) stated, All smoking is supervised smoking, and we have staff go monitor the area during smoking times. The area is not staffed outside of designated smoking times. The activities CNA [Staff A] should have been offering residents drinks, the assigned CNA [Staff B] should have rounded on him even if he was outside. He was alert and oriented. We just didn't think that this would happen. His routine was to go in and out. But we did not have constant supervision and we should have. We just didn't think about something like this happening. During an interview on [DATE] at 8:40 AM, the Medical Director stated, I have been the Medical Director here for the last 5-6 years. I think we should have assessed any weather readiness and should have recognized the implications of heat for the elderly with multiple disease states and medications that have adverse effects related to heat. Reminders should have been done with staff related to the high temperatures we have been having. Any elderly resident with lung disease, vascular disorders, diabetes should be monitored and assessed for dehydration. We absolutely should have evaluated our facility and done an assessment to determine what we should do in extreme weather. During a telephone interview on [DATE] at 2:00 PM, Staff C, LPN, stated, I was his nurse that day, when about 6 o'clock, one of the CNAs ran to get nurses and said that [Resident #1's name] had no respirations or heart rate. I ran to the dining room. We moved him to the hall and got him out of the chair onto the floor and [Staff D's name] started CPR. We should be seeing our residents every 2 hours, at least every 2 hours. Normally he liked to be outside. He was behaving normally that day. He normally was a late riser, but he was a little later than normal. I did not round on him, and I can't really say how long he was outside for. He was warm to touch when I brought him inside. I don't remember if he had a sunburn. Everything happened so fast once we realized he didn't have a pulse. During an interview on [DATE] at 8:05 AM, the Administrator stated, I was unaware of any weather advisories that were issued for that day. It is normal for temperatures to be in the low to mid 90's in July. We did not have a process in place to notify staff of safety procedures for heat prior to this event. During an interview on [DATE] at 8:30 AM, the DON stated, I was not aware of the predicted high temperatures or any weather advisories. None came over my telephone. Prior to this, we would notify staff of severe weather such as thunderstorms, if severe heat advisories were issued, tornados, upcoming hurricanes. But we did not have a system in place for notifying of daily temperatures. During an interview on [DATE] at 1:45 PM, Staff A, CNA, stated, I was not aware of the temperatures forecasted for that day. We did not have any daily announcement of temperatures. We did not have any real policy that we needed to ask residents to drink or get them water before this happened. Review of the policy and procedure titled Standard and Guidelines: SG Accidents and Supervision with implementation and revision dates of [DATE] read, Standard: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which result in injury or illness to a resident. Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas . Risk refers to any external factor, facility characteristic (e.g. staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. The facility shall make a reasonable effort to identify the hazards and risk factors for each resident. b. Various sources provide information about hazards and risks in the resident environment. c. These sources may include, but are not limited to: i. quality assessment and assurance (QAA) activities, ii. environmental rounds, iii. MDS/CAA [Minimum Data Set/ Care Area Assessment] data, iv. medical history, v. physical exam, vi. facility assessment, vii. individual observation. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relative staff, b. Providing training as needed, c. Documenting interventions (e.g. plans of action developed by the Quality Assurance Committee or care plans for the individual resident), d. Ensuring that the interventions are put into action, e. Facility-based interventions may include but are not limited to: i. educating staff, ii. repairing the device/equipment, iii. developing or revising policies and procedures. F. Resident-directed approaches may include: i. implementing specific interventions as part of the care plan, ii. supervising staff and residents, etc., iii. facility records document the implementation of these interventions . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency, b. Based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the policy and procedures titled Standards and Guidelines: ANE [Abuse, Neglect, Exploitation] and Investigations with an implementation date of [DATE] and last revision date of [DATE] read, Standards: It will be the standard of this facility honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal law. It will be the standard of this facility to ensure that all alleged violations of Federal or State laws, which involve mistreatment, neglect, abuse (verbal, mental, physical or sexual), injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use or [Sic.] physical or chemical restraint not in accordance with regulation to treat resident's symptoms be reported immediately to the administrator/DNS [Director of Nursing Services]/designee. Appropriate agencies will be notified in accordance with existing laws. Definitions . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Immediate Jeopardy was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of immediacy to prevent the likelihood of harm and/or death as evidenced by the following: On [DATE], the facility conducted a facility-wide audit of all residents to identify possible injury or harm from heat related concerns with skin and dehydration assessments. On [DATE], the facility conducted an Ad Hoc [When necessary or needed] QAPI [Quality Assurance and Performance Improvement] meeting to discuss and review the allegation of neglect, and inadequate supervision and conducted a root cause analysis. On [DATE], the Administrator completed an inspection of the patio and courtyard areas to ensure that adequate shaded areas, hydration stations and fans are available and the residents were adequately supervised while on the patio. On [DATE], the Chief Clinical Officer (COO) provided education and training to the Administrator, the DON, and the IDT [Interdisciplinary Team]/management team related to supervision of staff and residents, prevention of neglect, and systemic changes to be implemented. On [DATE], the facility completed a quality lookback audit for all residents who were transferred to hospital or who expired in the facility for the previous 45 days. On [DATE], the facility initiated posting of signage of expected temperatures and weather conditions at the exit doors of the patio, front exit door and on the activities calendars. On [DATE], overhead announcements were initiated three times daily for weather conditions including expected high temperatures. On [DATE] and [DATE], the facility provided training on neglect, accidents, adequate supervision, hyperthermia, dehydration, and heat-related illnesses for 82 out of 83 nursing and activities staff. The survey team observed the posted signage, heard the overhead weather announcement twice daily, reviewed the facility-wide audit of residents, root cause analysis, and staff and administrative staff training records, and interviewed 21 CNAs, 8 LPNs, 2 RNS, and Activities Director for the knowledge to prevent future reoccurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident record review, hospital record review, and review of the facility's policies and procedures, the facility failed to ensure residents were provided adequate supervision when Resident #1 was left outside, inadequately supervised on the facility patio during weather conditions with outside temperatures of 93 degrees Fahrenheit for 3 hours and 31 minutes. The facility's failure to provide supervision for Resident #1 resulted in Resident #1 being found by another resident and brought inside the facility. Resident #1 was found unresponsive, CPR (Cardiac Pulmonary Resuscitation) was initiated, and the resident was transported to the hospital. Resident #1 suffered from cardiac arrest, hyperthermia, 2nd degree burns and had a body temperature of 108.5 Fahrenheit. Resident #1 did not survive. Hyperthermia is defined as dangerously overheated body, usually in response to prolonged, hot, humid weather. Hyperthermia occurs when the body's heat-regulating mechanisms don't work effectively. Older age, certain illnesses, and medications increase the risk of developing hyperthermia. A temperature of 40 °C (104 °F) or higher is life-threatening. Confusion, nausea or vomiting, and rapid breathing are some symptoms. The very young and elderly: Seniors (over 65) and children (especially those under the age of 4) are often more at increased risk of heat-related illness, as they typically tend to be less aware of temperature changes and their bodies generally don't regulate as well. Findings include: Review of the admission record for Resident #1 documented diagnoses to include cerebral infarction due to embolism of unspecified cerebral artery (stroke), type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis following cerebral infarction affecting right non-dominant side, essential (primary) hypertension (high blood pressure), hypothyroidism, polyneuropathy (nerve damage), atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), presence of cardiac pacemaker, osteoarthritis, presence of artificial hip joint unilateral, unspecified dementia, acquired absence of right leg above knee, and other seizures. Review of the nursing progress note for Resident #1 dated [DATE] at 6:30 PM authored by Staff C, Licensed Practical Nurse (LPN), read, Pt [Patient] was assisted OOB [out of bed] at 1530 [3:30 PM] into W/C [wheelchair]. Once in W/C pt self propelled himself into courtyard outside of the dining room where he sat with other residents. At 17:50 (5:50 PM), CNA [Certified Nursing Assistant] alerted nursing staff that pt was in the dining room and did not look well. Nursing staff immediately went to pt and he was found with no heart rate, no respirations. Staff immediately lowered pt to the floor and RN [Registered Nurse] and other nursing staff on duty started CPR. I called 911. Paramedics arrived and took over CPR. Pt left via stretcher with paramedics and emts [Sic. Emergency Medical Technicians] at 18:20 [6:20 PM]. I notified pt's daughter [Resident #1's Daughter's name]. I notified pt's friend [Resident #1's Friend's name] as well. Provider notified. Review of the nursing progress note for Resident #1 dated [DATE] at 4:21 PM authored by Staff C, LPN, read, Late entry for [DATE] @ [at] 1830 (6:30 PM]; Resident was assisted out of bed at approximately 1400 [2:00 PM]. Review of Code Blue Form for Resident #1 dated [DATE] at 6:30 PM read, A. Chain of Events: Date/Time of Respiratory/Cardiac Arrest: [DATE] 17:50 [5:50 PM] . 2a. Code Blue Called: [DATE] 17:51 [5:51 PM], 2b. Code Status Verified: [DATE] 17:51 [5:51 PM], 2c. 911 Called: [DATE] 17:51 [5:51 PM], 2d. CPR Initiated: [DATE] 17:53 [5:53 PM], 2e. EMS [Emergency Medical Service] arrival: 0000 [Sic.], 3. Resident Transferred To: HCA [Hospital Corporation of America] [NAME]. Review of the facility's video footage on [DATE] at 1:00 PM with the Administrator and Regional Nurse Consultant showed on [DATE] at 2:19:43 PM, Resident #1 entered the patio in shorts and sleeveless shirt in his wheelchair with shoe on his left foot and sat in the sunshine. Staff A, CNA, was present on the patio during smoking time when the resident went outside. On [DATE] at 2:27:07 PM, Staff A, CNA, left the outside patio and returned to the building with the smoking cart. On [DATE] at 2:31:05 PM, Staff A, CNA, entered the patio and handed a drink to a resident. Staff A had no interaction with Resident #1 and left the patio again at 2:31:35 PM. On [DATE] at 2:32 PM, Resident #1 wheeled himself under the covered gazebo with 2-3 other residents and sat in the shaded area. On [DATE] at 2:48:28 PM, an unknown staff member entered the area and exited within 20 seconds. There was no interaction with any resident on the video. On [DATE], Resident #1 remains on the patio until 3:40 PM under the shaded gazebo. On [DATE] at 3:40:25 PM, Resident #1 moved out to the sunny area nearer to the automatic doorway entrance to the facility. On [DATE] at 4:08:31 PM, Staff A entered the smoking area with the smoking cart, handed cigarettes to the residents who were smokers. Staff A did not interact with Resident #1. On [DATE] at 4:40 PM, Staff A left the smoking area with cart and did not interact with Resident #1. On [DATE] between 4:40 PM and 5:50 PM, there were no facility staff present in the smoking area. On [DATE] at 5:49:14 PM, a resident entered the patio, walked past Resident #1, immediately returned to Resident #1, and began to wheel Resident #1 inside the door of the facility. On [DATE] at 5:50 PM, Resident #1 was wheeled completely into the facility and out of the video view. Review of the local hospital's Emergency Provider Report for Resident #1 dated [DATE] at 7:16 PM read, HPI [History of Present Illness]-Cardiac Arrest . Presentation: Chief Complaint: Cardiac arrest, Found dwn [down], Found unresponsive. Measures Prior to Arrival: Patient found unresponsive in cardiac arrest by another resident of the nursing home, patient was on asystole for unknown period of time. Down Time Prior to EMS: Unknown. Total Time Arrest to Arrival: Unknown. Arrest Circumstances: Unwitnessed arrest, Asystole in field, Asystole in ED, Ongoing CPR on arrival, No resp (response) to EMS interven [intervention]. Context: Resuscitation. Initial rhythm asystole, Orotracheal inubation [Sic. intubation], Epinephrine IV [Intravenously] x 3, bicarbonate 1 amp [ampule]. Reason for ED Visit: cardiac arrest. Hx [History] Obtained From: EMS. Onset Occurred: Sudden. Symptom Duration: Since onset, Brief, Constant. Progression since Onset: Unchanged, Constant. Context of Onset: Exposure, Environmental, Hyperthermia. Location: Back, Chest R [Right], Chest L [Left]. Quality. Unable to verbalize . Focused PE [Physical Examination]: General/Const [Constitutional]: Arrived to emergency room via EMS ground [NAME] County from the nursing home, CPR in progress, patient was oral intubated and bagging by a paramedic, cardiac monitor show systole on arrival. No pulse was palpable, the patient temperature rectal was 108.5 [degree Fahrenheit]. MS Head: Head: Atraumatic, Normocephalic. Eyes: Pupil dilated bilateral no reactive to light stimuli and fixed. Resp [Respiratory]/Chest: Oral intubation. Cardiovascular: Cardiovascular Asystole. Skin: Skin Back blisters on the superior aspect of his back most likely secondary to 2 degree [Sic.] burns, the skin was easy peel with the fingers. Also, on his lateral neck. Neurologic: Neurologic No reflex . Free Text MDM [Medical Decision Making] Notes: [AGE] years old male came to the emergency department via EMS ground [NAME] County part of the information was obtained from the paramedics and nursing home history. According to the paramedics the patient was outside for unknown period of time. Patient was found by another resident and push inside at that time. The patient was already on cardiac arrest. Nobody knows for how long the patient was down. Nursing home personnel started CPR and called EMS. They started CPR around 17:50 [5:50 PM] and transfer the patient to the ER where we stop the CPR and pronounced the patient at 18:31 [6:31 PM] after more than 41 minutes of asystole. The patient never had a palpable pulse during the 41 minutes of CPR. We noticed during the resuscitation that the patient was very hot and we checked a rectal temperature that was 108.5, and we also noted that the patient had blisters and some evidence of skin damage secondary to the heat over the superior back area. The Coroner 's Office was notify [Sic.] about the findings on this patient. MDM-Complexity: Differential Diagnosis: Cardiac arrest, electrolyte abnormality, hypertension, hyperthermia, respiratory arrest, cardiac arrhythmia, PE [Pulmonary Embolism]. Patient Discharge & Departure. Vital Signs/ Condition. Vital Signs: First Documented: Temp [Temperature] Result: 42.5 [degree Celsius, equal to 108.5 Fahrenheit], Date: 07/19, Time 1830 [6:30 PM] . Condition: deceased . Clinical Impression: Primary Impression: Cardiac arrest. Secondary Impression: Hyperthermia. Time of Impression: 1831 [6:31 PM]. Disposition Decision. Time: 1831, Date: [DATE], deceased : Yes. During an interview on [DATE] at 9:15 AM, the Administrator stated, We have 2 areas, which residents can go outside. Although he [Resident #1] was not a smoker, he would go out to the smokers' side and socialize. We did review the video from that day and developed a timeline of the events that day. Staff were assigned to that area, but they did not really have the responsibility to monitor everyone in the area. Staff are assigned to the smoking times; they weren't responsible to make sure residents came inside at any given time. There is always a water cooler available for drinks out there, a covered area and fans out in that area. It was not unusual for him to nap frequently, and he was observed wheeling himself out of the covered area to the sun and fell asleep and the staff did not wake him. No one took the initiative to ask or wake him up because it was common for him to take naps. The staff were concerned with resident rights and didn't think about telling residents to come in. The high temperature that day was 93 and the resident was out in the area from almost 2 to almost 6 PM when another resident found him unresponsive. We should have evaluated any environmental concerns before this occurred. During a telephone interview on [DATE] at 11:00 AM, Staff F, LPN, stated, I did respond to the code. I was at the nurse's station when another resident came up to me and said, I don't think he's breathing. I began walking towards the resident and into the dining room and saw [Resident #1's name] and didn't find a pulse. We wheeled him to the hallway and immediately someone started CPR after he was on the floor. He was very warm when I checked his pulse. I did not see anything except his right arm was red and maybe I think had an abrasion. We are supposed to check on all residents and round in the patios every hour to make sure the residents don't need anything. During an interview on [DATE] at 12:00 PM, Staff A, CNA, stated, I'm not assigned to residents, and I deal with smoking breaks until about 4:30 PM. [Resident #1's name] was not a smoker, but was outside frequently to talk to the other residents. I am supposed to hand out and light cigarettes and make sure they are awake, and safe while smoking, that they don't bring any cigarettes or lighters in with them. [Resident #1's name] was usually talking with other residents when he went out there. He would fall asleep sometimes. I wouldn't necessarily wake someone up. Before I leave to go back inside, I will ask if everyone is okay or do they need anything. He had a drink with him. He always had a drink with him. He appeared to be asleep the last time I went by him. I did not wake him up. It was very hot that day in the mid-nineties. He was sitting in the sun. I really just didn't think about it. I didn't see anything unusual. I didn't really know how long he was out there for I am only out there for a half hour with the smokers. I didn't know he had never gone inside that day. During an interview on [DATE] at 12:20 PM, Staff D, RN, stated, I was working on 200 hall and was getting ready to give meds when I heard my name and that they needed help in the dining room. When I got to the dining room, he [Resident #1] was unresponsive. I confirmed he didn't have a pulse and initiated CPR, while another nurse called 911. I did CPR until the paramedics arrived. He was very warm to touch. I really didn't notice anything else. I can't tell you if he was sunburned. I have worked with him in the past. He would get up later in the day, get a Starbucks coffee, spent time watching TV and went outside to socialize. He would take cat naps in his chair. There was no system really in place to make sure that when residents are outside they go inside frequently. We should have been offering residents drinks and water when they go outside. Most of us are aware that the elderly can dehydrate more quickly. There was not a system of anyone responsible to round on the residents when they were on the patio. But we all should make sure our residents have been evaluated at least every 2 hours if not more. There are assigned smoking times and that's the only time that staff are assigned to see the residents. During a telephone interview on [DATE] at 1:20 PM, Staff B, CNA, stated, He [Resident #1] was a quiet resident. I understood what he was saying. He was easy to work with. That day, he was okay. It was a busy day. He had been sleepy that morning and wanted to get up later in the morning. I got him up in his chair, and he went about on his way. He liked being outside and so I noticed he was outside and, in his chair. Hours later, there was a Code Blue and they were doing CPR. We are supposed to check on patients as frequently as we can. He really liked being outside. I went out every 2 hours and checked on him. He was fine. I think the last time I checked him was around 4 o'clock. During an interview on [DATE] at 8:25 AM, the Director of Nursing (DON) stated, All smoking is supervised smoking, and we have staff go monitor the area during smoking times. The area is not staffed outside of designated smoking times. The activities CNA [Staff A] should have been offering residents drinks, the assigned CNA [Staff B] should have rounded on him even if he was outside. He was alert and oriented. We just didn't think that this would happen. His routine was to go in and out. But we did not have constant supervision and we should have. We just didn't think about something like this happening. During an interview on [DATE] at 8:40 AM, the Medical Director stated, I have been the Medical Director here for the last 5-6 years. I think we should have assessed any weather readiness and should have recognized the implications of heat for the elderly with multiple disease states and medications that have adverse effects related to heat. Reminders should have been done with staff related to the high temperatures we have been having. Any elderly resident with lung disease, vascular disorders, diabetes should be monitored and assessed for dehydration. We absolutely should have evaluated our facility and done an assessment to determine what we should do in extreme weather. During a telephone interview on [DATE] at 2:00 PM, Staff C, LPN, stated, I was his nurse that day, when about 6 o'clock, one of the CNAs ran to get nurses and said that [Resident #1's name] had no respirations or heart rate. I ran to the dining room. We moved him to the hall and got him out of the chair onto the floor and [Staff D's name] started CPR. We should be seeing our residents every 2 hours, at least every 2 hours. Normally he liked to be outside. He was behaving normally that day. He normally was a late riser, but he was a little later than normal. I did not round on him, and I can't really say how long he was outside for. He was warm to touch when I brought him inside. I don't remember if he had a sunburn. Everything happened so fast once we realized he didn't have a pulse. During an interview on [DATE] at 8:05 AM, the Administrator stated, I was unaware of any weather advisories that were issued for that day. It is normal for temperatures to be in the low to mid 90's in July. We did not have a process in place to notify staff of safety procedures for heat prior to this event. During an interview on [DATE] at 8:30 AM, the DON stated, I was not aware of the predicted high temperatures or any weather advisories. None came over my telephone. Prior to this, we would notify staff of severe weather such as thunderstorms, if severe heat advisories were issued, tornados, upcoming hurricanes. But we did not have a system in place for notifying of daily temperatures. During an interview on [DATE] at 1:45 PM, Staff A, CNA, stated, I was not aware of the temperatures forecasted for that day. We did not have any daily announcement of temperatures. We did not have any real policy that we needed to ask residents to drink or get them water before this happened. Review of the policy and procedure titled Standard and Guidelines: SG Accidents and Supervision with implementation and revision dates of [DATE] read, Standard: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which result in injury or illness to a resident. Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas . Risk refers to any external factor, facility characteristic (e.g. staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. The facility shall make a reasonable effort to identify the hazards and risk factors for each resident. b. Various sources provide information about hazards and risks in the resident environment. c. These sources may include, but are not limited to: i. quality assessment and assurance (QAA) activities, ii. environmental rounds, iii. MDS/CAA [Minimum Data Set/ Care Area Assessment] data, iv. medical history, v. physical exam, vi. facility assessment, vii. individual observation. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relative staff, b. Providing training as needed, c. Documenting interventions (e.g. plans of action developed by the Quality Assurance Committee or care plans for the individual resident), d. Ensuring that the interventions are put into action, e. Facility-based interventions may include but are not limited to: i. educating staff, ii. repairing the device/equipment, iii. developing or revising policies and procedures. F. Resident-directed approaches may include: i. implementing specific interventions as part of the care plan, ii. supervising staff and residents, etc., iii. facility records document the implementation of these interventions . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency, b. Based on the individual resident's assessed needs and identified hazards in the resident environment. The Immediate Jeopardy was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of immediacy to prevent the likelihood of harm and/or death as evidenced by the following: On [DATE], the facility conducted a facility-wide audit of all residents to identify possible injury or harm from heat related concerns with skin and dehydration assessments. On [DATE], the facility conducted an Ad Hoc [When necessary or needed] QAPI [Quality Assurance and Performance Improvement] meeting to discuss and review the allegation of neglect, and inadequate supervision and conducted a root cause analysis. On [DATE], the Administrator completed an inspection of the patio and courtyard areas to ensure that adequate shaded areas, hydration stations and fans are available and the residents were adequately supervised while on the patio. On [DATE], the Chief Clinical Officer (COO) provided education and training to the Administrator, the DON, and the IDT [Interdisciplinary Team]/management team related to supervision of staff and residents, prevention of neglect, and systemic changes to be implemented. On [DATE], the facility completed a quality lookback audit for all residents who were transferred to hospital or who expired in the facility for the previous 45 days. On [DATE], the facility initiated posting of signage of expected temperatures and weather conditions at the exit doors of the patio, front exit door and on the activities calendars. On [DATE], overhead announcements were initiated three times daily for weather conditions including expected high temperatures. On [DATE] and [DATE], the facility provided training on neglect, accidents, adequate supervision, hyperthermia, dehydration, and heat-related illnesses for 82 out of 83 nursing and activities staff. The survey team observed the posted signage, heard the overhead weather announcement twice daily, reviewed the facility-wide audit of residents, root cause analysis, and staff and administrative staff training records, and interviewed 21 CNAs, 8 LPNs, 2 RNS, and Activities Director for the knowledge to prevent future reoccurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident record review, hospital record review, and review of the facility's policies and procedures, the facility administration failed to use its resources effectively and efficiently to attain and maintain the highest practicable wellbeing of each resident by failing to ensure residents were provided adequate supervision when Resident #1 was left outside, inadequately supervised on the facility patio during weather conditions with outside temperatures of 93 degrees Fahrenheit for 3 hours and 31 minutes. The facility's failure to implement systemic interventions to protect residents from extreme weather conditions resulted in Resident #1 being found by another resident and brought inside the facility. Resident #1 was found unresponsive, CPR (Cardiac Pulmonary Resuscitation) was initiated, and the resident was transported to the hospital. Resident #1 suffered from cardiac arrest, hyperthermia, 2nd degree burns and had a body temperature of 108.5 Fahrenheit. Resident #1 did not survive. Findings include: Review of the job description for the Administrator signed on [DATE] reads, Purpose of Your Job Position: The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . Duties and Responsibilities. Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the Facility's programs and activities in accordance with guidelines issued by the Governing Body. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility . Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the Facility. Committee Functions . Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies . Safety and Sanitation: Ensure that all Facility personnel, residents, visitors, etc., follow established safety regulations to include fire protection and prevention, smoking regulations, infection control, etc . Review accident and incident reports (e.g. falls, injuries of an unknown source, abuse, etc.) Monitor to determine the effectiveness of the Facility's risk management program. Review of the job description for the Director of Nursing signed on [DATE] reads, Purpose of Your Job Position: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times . Duties and Responsibilities. Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Develop, maintain, and periodically update written policies and procedures that govern the day-to-day functions of the nursing service department . Develop methods for coordination of nursing services with other resident services to ensure the continuity of residents' total regime of care. Develop, implement, and maintain an ongoing quality assurance program for the nursing service department . Assist in developing and implementing appropriate plans of action to correct identified deficiencies . Committee Functions: Serve on, participate in, and attend various committees of the Facility as appointed by the administrator. Evaluate and implement recommendations from established committees as they may pertain to nursing services . Nursing Care Functions . Provide the Administrator with information relative to the nursing needs of the resident and the nursing service department's ability to meet those needs . Ensure that direct nursing care be provided by LPNs [Licensed Practical Nurses], CNAs [Certified Nursing Assistants], and or a nurse's aide trainee qualified to perform the procedure. Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Ensure that residents who are unable to call for help are checked frequently . Safety and Sanitation: Assist in developing safety standards for the nursing service department. Ensure that the department 's policy and procedure manuals identify safety precautions and equipment to use when performing tasks that could result in bodily injury . Monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies. Review of the job description for the Risk Manager signed on [DATE] reads, Standard: The standard of this facility is to designate the Executive Director [the Administrator] as the Risk Manager who will enforce both Federal and State Guidelines regarding Quality Assurance and Risk Management Program. Guidelines . 13. Develop appropriate measures to minimize the risk of adverse events to residents, including but not limited to, education and training in risk management and risk prevention for all non-physician personnel. Review of the job description for the Abuse Coordinator signed on [DATE] reads, Standards: The standard of this facility is to designate the Director of Nursing Services as the Abuse Coordinator who will enforce both Federal and State Guidelines regarding Abuse, Neglect, and Exploitation to also include, Suspicion of a crime, sexual and involuntary seclusion. Guidelines . 7. The Abuse Coordinator will develop appropriate measures to minimize the risk of abuse, neglect and exploitation by ensuring education and training in identifying, preventing, and reporting abuse, neglect and exploitation to all facility staff. Review of the admission record for Resident #1 documented diagnoses to include cerebral infarction due to embolism of unspecified cerebral artery (stroke), type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis following cerebral infarction affecting right non-dominant side, essential (primary) hypertension (high blood pressure), hypothyroidism, polyneuropathy (nerve damage), atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), presence of cardiac pacemaker, osteoarthritis, presence of artificial hip joint unilateral, unspecified dementia, acquired absence of right leg above knee, and other seizures. Review of the nursing progress note for Resident #1 dated [DATE] at 6:30 PM authored by Staff C, LPN, read, Pt [Patient] was assisted OOB [out of bed] at 1530 [3:30 PM] into W/C [wheelchair]. Once in W/C pt self propelled himself into courtyard outside of the dining room where he sat with other residents. At 17:50 (5:50 PM), CNA alerted nursing staff that pt was in the dining room and did not look well. Nursing staff immediately went to pt and he was found with no heart rate, no respirations. Staff immediately lowered pt to the floor and RN [Registered Nurse] and other nursing staff on duty started CPR. I called 911. Paramedics arrived and took over CPR. Pt left via stretcher with paramedics and emts [Sic. Emergency Medical Technicians] at 18:20 [6:20 PM]. I notified pt's daughter [Resident #1's Daughter's name]. I notified pt's friend [Resident #1's Friend's name] as well. Provider notified. Review of the nursing progress note for Resident #1 dated [DATE] at 4:21 PM authored by Staff C, LPN, read, Late entry for [DATE] @ [at] 1830 (6:30 PM]; Resident was assisted out of bed at approximately 1400 [2:00 PM]. Review of Code Blue Form for Resident #1 dated [DATE] at 6:30 PM read, A. Chain of Events: Date/Time of Respiratory/Cardiac Arrest: [DATE] 17:50 [5:50 PM] . 2a. Code Blue Called: [DATE] 17:51 [5:51 PM], 2b. Code Status Verified: [DATE] 17:51 [5:51 PM], 2c. 911 Called: [DATE] 17:51 [5:51 PM], 2d. CPR Initiated: [DATE] 17:53 [5:53 PM], 2e. EMS [Emergency Medical Service] arrival: 0000 [Sic.], 3. Resident Transferred To: HCA [Hospital Corporation of America] [NAME]. Review of the facility's video footage on [DATE] at 1:00 PM with the Administrator and Regional Nurse Consultant showed on [DATE] at 2:19:43 PM, Resident #1 entered the patio in shorts and sleeveless shirt in his wheelchair with shoe on his left foot and sat in the sunshine. Staff A, CNA, was present on the patio during smoking time when the resident went outside. On [DATE] at 2:27:07 PM, Staff A, CNA, left the outside patio and returned to the building with the smoking cart. On [DATE] at 2:31:05 PM, Staff A, CNA, entered the patio and handed a drink to a resident. Staff A had no interaction with Resident #1 and left the patio again at 2:31:35 PM. On [DATE] at 2:32 PM, Resident #1 wheeled himself under the covered gazebo with 2-3 other residents and sat in the shaded area. On [DATE] at 2:48:28 PM, an unknown staff member entered the area and exited within 20 seconds. There was no interaction with any resident on the video. On [DATE], Resident #1 remains on the patio until 3:40 PM under the shaded gazebo. On [DATE] at 3:40:25 PM, Resident #1 moved out to the sunny area nearer to the automatic doorway entrance to the facility. On [DATE] at 4:08:31 PM, Staff A entered the smoking area with the smoking cart, handed cigarettes to the residents who were smokers. Staff A did not interact with Resident #1. On [DATE] at 4:40 PM, Staff A left the smoking area with cart and did not interact with Resident #1. On [DATE] between 4:40 PM and 5:50 PM, there were no facility staff present in the smoking area. On [DATE] at 5:49:14 PM, a resident entered the patio, walked past Resident #1, immediately returned to Resident #1, and began to wheel Resident #1 inside the door of the facility. On [DATE] at 5:50 PM, Resident #1 was wheeled completely into the facility and out of the video view. Review of the local hospital's Emergency Provider Report for Resident #1 dated [DATE] at 7:16 PM read, HPI [History of Present Illness]-Cardiac Arrest . Presentation: Chief Complaint: Cardiac arrest, Found dwn [down], Found unresponsive. Measures Prior to Arrival: Patient found unresponsive in cardiac arrest by another resident of the nursing home, patient was on asystole for unknown period of time. Down Time Prior to EMS: Unknown. Total Time Arrest to Arrival: Unknown. Arrest Circumstances: Unwitnessed arrest, Asystole in field, Asystole in ED, Ongoing CPR on arrival, No resp (response) to EMS interven [intervention]. Context: Resuscitation. Initial rhythm asystole, Orotracheal inubation [Sic. intubation], Epinephrine IV [Intravenously] x 3, bicarbonate 1 amp [ampule]. Reason for ED Visit: cardiac arrest. Hx [History] Obtained From: EMS. Onset Occurred: Sudden. Symptom Duration: Since onset, Brief, Constant. Progression since Onset: Unchanged, Constant. Context of Onset: Exposure, Environmental, Hyperthermia. Location: Back, Chest R [Right], Chest L [Left]. Quality. Unable to verbalize . Focused PE [Physical Examination]: General/Const [Constitutional]: Arrived to emergency room via EMS ground [NAME] County from the nursing home, CPR in progress, patient was oral intubated and bagging by a paramedic, cardiac monitor show systole on arrival. No pulse was palpable, the patient temperature rectal was 108.5 [degree Fahrenheit]. MS Head: Head: Atraumatic, Normocephalic. Eyes: Pupil dilated bilateral no reactive to light stimuli and fixed. Resp [Respiratory]/Chest: Oral intubation. Cardiovascular: Cardiovascular Asystole. Skin: Skin Back blisters on the superior aspect of his back most likely secondary to 2 degree [Sic.] burns, the skin was easy peel with the fingers. Also, on his lateral neck. Neurologic: Neurologic No reflex . Free Text MDM [Medical Decision Making] Notes: [AGE] years old male came to the emergency department via EMS ground [NAME] County part of the information was obtained from the paramedics and nursing home history. According to the paramedics the patient was outside for unknown period of time. Patient was found by another resident and push inside at that time. The patient was already on cardiac arrest. Nobody knows for how long the patient was down. Nursing home personnel started CPR and called EMS. They started CPR around 17:50 [5:50 PM] and transfer the patient to the ER where we stop the CPR and pronounced the patient at 18:31 [6:31 PM] after more than 41 minutes of asystole. The patient never had a palpable pulse during the 41 minutes of CPR. We noticed during the resuscitation that the patient was very hot and we checked a rectal temperature that was 108.5, and we also noted that the patient had blisters and some evidence of skin damage secondary to the heat over the superior back area. The Coroner 's Office was notify [Sic.] about the findings on this patient. MDM-Complexity: Differential Diagnosis: Cardiac arrest, electrolyte abnormality, hypertension, hyperthermia, respiratory arrest, cardiac arrhythmia, PE [Pulmonary Embolism]. Patient Discharge & Departure. Vital Signs/ Condition. Vital Signs: First Documented: Temp [Temperature] Result: 42.5 [degree Celsius, equal to 108.5 Fahrenheit], Date: 07/19, Time 1830 [6:30 PM] . Condition: deceased . Clinical Impression: Primary Impression: Cardiac arrest. Secondary Impression: Hyperthermia. Time of Impression: 1831 [6:31 PM]. Disposition Decision. Time: 1831, Date: [DATE], deceased : Yes. During an interview on [DATE] at 9:15 AM, the Administrator stated, We have 2 areas, which residents can go outside. Although he [Resident #1] was not a smoker, he would go out to the smokers' side and socialize. We did review the video from that day and developed a timeline of the events that day. Staff were assigned to that area, but they did not really have the responsibility to monitor everyone in the area. Staff are assigned to the smoking times; they weren't responsible to make sure residents came inside at any given time. There is always a water cooler available for drinks out there, a covered area and fans out in that area. It was not unusual for him to nap frequently, and he was observed wheeling himself out of the covered area to the sun and fell asleep and the staff did not wake him. No one took the initiative to ask or wake him up because it was common for him to take naps. The staff were concerned with resident rights and didn't think about telling residents to come in. The high temperature that day was 93 and the resident was out in the area from almost 2 to almost 6 PM when another resident found him unresponsive. We should have evaluated any environmental concerns before this occurred. During a telephone interview on [DATE] at 11:00 AM, Staff F, LPN, stated, I did respond to the code. I was at the nurse's station when another resident came up to me and said, I don't think he's breathing. I began walking towards the resident and into the dining room and saw [Resident #1's name] and didn't find a pulse. We wheeled him to the hallway and immediately someone started CPR after he was on the floor. He was very warm when I checked his pulse. I did not see anything except his right arm was red and maybe I think had an abrasion. We are supposed to check on all residents and round in the patios every hour to make sure the residents don't need anything. During an interview on [DATE] at 12:00 PM, Staff A, CNA, stated, I'm not assigned to residents, and I deal with smoking breaks until about 4:30 PM. [Resident #1's name] was not a smoker, but was outside frequently to talk to the other residents. I am supposed to hand out and light cigarettes and make sure they are awake, and safe while smoking, that they don't bring any cigarettes or lighters in with them. [Resident #1's name] was usually talking with other residents when he went out there. He would fall asleep sometimes. I wouldn't necessarily wake someone up. Before I leave to go back inside, I will ask if everyone is okay or do they need anything. He had a drink with him. He always had a drink with him. He appeared to be asleep the last time I went by him. I did not wake him up. It was very hot that day in the mid-nineties. He was sitting in the sun. I really just didn't think about it. I didn't see anything unusual. I didn't really know how long he was out there for I am only out there for a half hour with the smokers. I didn't know he had never gone inside that day. During an interview on [DATE] at 12:20 PM, Staff D, RN, stated, I was working on 200 hall and was getting ready to give meds when I heard my name and that they needed help in the dining room. When I got to the dining room, he [Resident #1] was unresponsive. I confirmed he didn't have a pulse and initiated CPR, while another nurse called 911. I did CPR until the paramedics arrived. He was very warm to touch. I really didn't notice anything else. I can't tell you if he was sunburned. I have worked with him in the past. He would get up later in the day, get a Starbucks coffee, spent time watching TV and went outside to socialize. He would take cat naps in his chair. There was no system really in place to make sure that when residents are outside they go inside frequently. We should have been offering residents drinks and water when they go outside. Most of us are aware that the elderly can dehydrate more quickly. There was not a system of anyone responsible to round on the residents when they were on the patio. But we all should make sure our residents have been evaluated at least every 2 hours if not more. There are assigned smoking times and that's the only time that staff are assigned to see the residents. During a telephone interview on [DATE] at 1:20 PM, Staff B, CNA, stated, He [Resident #1] was a quiet resident. I understood what he was saying. He was easy to work with. That day, he was okay. It was a busy day. He had been sleepy that morning and wanted to get up later in the morning. I got him up in his chair, and he went about on his way. He liked being outside and so I noticed he was outside and, in his chair. Hours later, there was a Code Blue and they were doing CPR. We are supposed to check on patients as frequently as we can. He really liked being outside. I went out every 2 hours and checked on him. He was fine. I think the last time I checked him was around 4 o'clock. During an interview on [DATE] at 8:25 AM, the Director of Nursing (DON) stated, All smoking is supervised smoking, and we have staff go monitor the area during smoking times. The area is not staffed outside of designated smoking times. The activities CNA [Staff A] should have been offering residents drinks, the assigned CNA [Staff B] should have rounded on him even if he was outside. He was alert and oriented. We just didn't think that this would happen. His routine was to go in and out. But we did not have constant supervision and we should have. We just didn't think about something like this happening. During an interview on [DATE] at 8:40 AM, the Medical Director stated, I have been the Medical Director here for the last 5-6 years. I think we should have assessed any weather readiness and should have recognized the implications of heat for the elderly with multiple disease states and medications that have adverse effects related to heat. Reminders should have been done with staff related to the high temperatures we have been having. Any elderly resident with lung disease, vascular disorders, diabetes should be monitored and assessed for dehydration. We absolutely should have evaluated our facility and done an assessment to determine what we should do in extreme weather. During a telephone interview on [DATE] at 2:00 PM, Staff C, LPN, stated, I was his nurse that day, when about 6 o'clock, one of the CNAs ran to get nurses and said that [Resident #1's name] had no respirations or heart rate. I ran to the dining room. We moved him to the hall and got him out of the chair onto the floor and [Staff D's name] started CPR. We should be seeing our residents every 2 hours, at least every 2 hours. Normally he liked to be outside. He was behaving normally that day. He normally was a late riser, but he was a little later than normal. I did not round on him, and I can't really say how long he was outside for. He was warm to touch when I brought him inside. I don't remember if he had a sunburn. Everything happened so fast once we realized he didn't have a pulse. During an interview on [DATE] at 8:05 AM, the Administrator stated, I was unaware of any weather advisories that were issued for that day. It is normal for temperatures to be in the low to mid 90's in July. We did not have a process in place to notify staff of safety procedures for heat prior to this event. During an interview on [DATE] at 8:30 AM, the DON stated, I was not aware of the predicted high temperatures or any weather advisories. None came over my telephone. Prior to this, we would notify staff of severe weather such as thunderstorms, if severe heat advisories were issued, tornados, upcoming hurricanes. But we did not have a system in place for notifying of daily temperatures. During an interview on [DATE] at 1:45 PM, Staff A, CNA, stated, I was not aware of the temperatures forecasted for that day. We did not have any daily announcement of temperatures. We did not have any real policy that we needed to ask residents to drink or get them water before this happened. Review of the policy and procedure titled Standard and Guidelines: SG Accidents and Supervision with implementation and revision dates of [DATE] read, Standard: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which result in injury or illness to a resident. Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas . Risk refers to any external factor, facility characteristic (e.g. staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. The facility shall make a reasonable effort to identify the hazards and risk factors for each resident. b. Various sources provide information about hazards and risks in the resident environment. c. These sources may include, but are not limited to: i. quality assessment and assurance (QAA) activities, ii. environmental rounds, iii. MDS/CAA [Minimum Data Set/ Care Area Assessment] data, iv. medical history, v. physical exam, vi. facility assessment, vii. individual observation. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relative staff, b. Providing training as needed, c. Documenting interventions (e.g. plans of action developed by the Quality Assurance Committee or care plans for the individual resident), d. Ensuring that the interventions are put into action, e. Facility-based interventions may include but are not limited to: i. educating staff, ii. repairing the device/equipment, iii. developing or revising policies and procedures. F. Resident-directed approaches may include: i. implementing specific interventions as part of the care plan, ii. supervising staff and residents, etc., iii. facility records document the implementation of these interventions . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency, b. Based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the policy and procedures titled Standards and Guidelines: ANE [Abuse, Neglect, Exploitation] and Investigations with an implementation date of [DATE] and last revision date of [DATE] read, Standards: It will be the standard of this facility honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal law. It will be the standard of this facility to ensure that all alleged violations of Federal or State laws, which involve mistreatment, neglect, abuse (verbal, mental, physical or sexual), injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use or [Sic.] physical or chemical restraint not in accordance with regulation to treat resident's symptoms be reported immediately to the administrator/DNS [Director of Nursing Services]/designee. Appropriate agencies will be notified in accordance with existing laws. Definitions . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Immediate Jeopardy was removed on site on [DATE], after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's action for removal of immediacy to prevent the likelihood of harm and/or death as evidenced by the following: On [DATE], the facility conducted a facility-wide audit of all residents to identify possible injury or harm from heat related concerns with skin and dehydration assessments. On [DATE], the facility conducted an Ad Hoc [When necessary or needed] QAPI [Quality Assurance and Performance Improvement] meeting to discuss and review the allegation of neglect, and inadequate supervision and conducted a root cause analysis. On [DATE], the Administrator completed an inspection of the patio and courtyard areas to ensure that adequate shaded areas, hydration stations and fans are available and the residents were adequately supervised while on the patio. On [DATE], the Chief Clinical Officer (COO) provided education and training to the Administrator, the DON, and the IDT [Interdisciplinary Team]/management team related to supervision of staff and residents, prevention of neglect, and systemic changes to be implemented. On [DATE], the facility completed a quality lookback audit for all residents who were transferred to hospital or who expired in the facility for the previous 45 days. On [DATE], the facility initiated posting of signage of expected temperatures and weather conditions at the exit doors of the patio, front exit door and on the activities calendars. On [DATE], overhead announcements were initiated three times daily for weather conditions including expected high temperatures. On [DATE] and [DATE], the facility provided training on neglect, accidents, adequate supervision, hyperthermia, dehydration, and heat-related illnesses for 82 out of 83 nursing and activities staff. The survey team observed the posted signage, heard the overhead weather announcement twice daily, reviewed the facility-wide audit of residents, root cause analysis, and staff and administrative staff training records, and interviewed 21 CNAs, 8 LPNs, 2 RNS, and Activities Director for the knowledge to prevent future reoccurrence.