Missouri DHSS releases documentation concerning long-term care 'immediate jeopardy' tag

The Missouri Department of Health and Senior Services (DHSS) has made public the documentation of its visit and investigation in reference to an "Immediate Jeopardy" deficiency tag that occurred at Moore-Few Care Center on Aug. 1, 2023. Review at that time showed that the facility did not have a policy related to residents being out in heat or on the enclosed patio prior to Aug. 3, 2023. It was noted that the facility failed to provide protective oversight for residents when the facility did not have a policy and system in place to monitor residents who entered the enclosed courtyard during periods of increased temperature and humidity, resulting in one resident suffering non-responsiveness and sunburn from being outside for an extended period of time.

The facility has been required to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility will be required to review and update this assessment, as necessary, and at least annually. There was no fine imposed regarding the deficiency incident or as part of the plan of correction. The document stated that no plan of correction is required

According to the document, on Aug. 1, a resident of Moore-Few Care Center was outside on the patio and had refused to come in during lunch. The resident did take medication at 12:30 p.m. Then, at 2 p.m., the aides brought the resident up the hall. The resident was unable to operate their electric wheelchair and was not responding to verbal questions. It was noted that the resident also wouldn't open their eyes. Staff applied cold compresses to the resident and noted they had a temperature of 102.3 degrees F (normal is 98.6 degrees); pulse of 106 (normal is 60 to 100 for an adult); and blood pressure of 90/47 (normal is 120/80 for an adult). The resident's respirations and oxygen saturation were considered to be in the normal range. The resident was able to respond once in bed with cold compresses. After being given Tylenol to reduce fever and relieve minor pain, it was noted that the resident's skin was slightly sunburned with the resident stating that they, “had to have fallen asleep out there.”

Review of the resident's medical record showed that staff did not document regarding the resident being outside, any monitoring, any assessment, or any attempt to re-approach the resident about returning inside. Further, review showed that the facility did not provide an investigation or written statements regarding the resident being outside in the heat.

During an interview on Aug. 3, 2023, the resident said that an aide had helped them out through the patio doors and never told anyone that they were out there and did not come back. The resident stated that the Nurse Aide (NA) is the staff that opened the door for them. Additionally, the resident stated that their face and upper chest “were a little red” and that staff did not check on them. It was noted by the resident that they can not open the door to get back in since it requires a code and assistance to get back in the building. Also included in the resident's statement was the allegation that staff did not tell the resident's children that they had been out there too long and did not offer to send them to the hospital. The resident clarified in the interview that they had told their children themself on the telephone later that day.

The following is a timeline of the resident's time outdoors on the patio on Aug. 1, as gathered from interviews with a Registered Nurse (RN), Dietary Aides (DA), Licensed Practical Nurse (LPN), Certified Nurse Aides (CNA), and Director of Nursing (DON):

• Resident got up at approximately 10:15 a.m. and then went outside.

• At around 11:30 a.m., a DA asked the resident if they wanted to come inside for lunch. The resident said no. The resident did not come in at that time and they were in direct sunlight. It had been over an hour after the resident had initially went out into the heat. The resident normally goes outside every day, but usually comes in for lunch. The DA was not sure whether they had reported to anyone that the resident had declined lunch. The temperature outdoors at the time was estimated to be at 89.6 degrees with humidity of 55.65 percent.

• At around 12:30 p.m., an LPN went to the resident and provided medications and the resident did not want to come in at that time. It had been an hour since the last time the resident was checked on in the heat. The resident was in their wheelchair in the direct sun with their eyes closed. The resident opened their eyes when the LPN spoke to them. The LPN noted that the resident was “a little pink,” but did not want to come inside. The LPN also noted that the resident was alert and oriented. The LPN then gave the resident a cup of water and the resident drank only enough water to take their medication. The temperature outdoors at that time was estimated to be at 91.4 degrees with humidity of 52.61 percent.

• Another DA went to the patio after lunch was over and found the resident to be red and unresponsive. When the DA tried to get the resident back inside, their badge would not work and had to get other staff attention inside to get the doors opened. The DA noted that their shift started at 1 p.m. and they believe that it was at least 1:30 p.m. when they went outside to check on the resident. The temperature outdoors at that time was estimated to be at 93.2 degrees with humidity of 52.86 percent.

• At around 2 p.m., two aides brought the resident down the hall and, with the assistance of a nurse, transferred the resident to their bed. The resident received aloe to the sunburn and Tylenol for pain. According to the document, it is believed that an NA opened the door for the resident to go out to the courtyard, but the NA denied helping the resident outside.

It was noted in the interviews that it took about 30 minutes for the resident to become alert and that the nurse was going to send the resident to the emergency room, but then she became alert.

During an interview the state conducted on Aug. 3, 2023, with Moore-Few's Administrator Crystal Layman, she noted that there was not a policy related to residents being outside in the heat or on the patio prior to this incident, but all staff should always monitor all residents whether they were inside or outside the building.

The Long-Term Care Board (which oversees Moore-Few Care Center) will be in attendance at this evening's Nevada City Council meeting. The board will be giving a presentation in regards to a request for information from the City on matters of the City's desire to withdraw from competition in nursing home services. For further coverage, see Wednesday's edition of the Nevada Daily Mail.