Healthcare Inspection: Alleged Community Living Center Quality of Care Issues VA Palo Alto Health Care System, Palo Alto, California

摘要

The purpose of this review was to determine the validity of an allegation that a resident of the community living center (CLC) at the VA Palo Alto Health Care System, Palo Alto, CA was left unattended on the patio of his living unit and as a result was sunburned on over 36 percent of his body. We partially substantiated the allegation. We substantiated that the resident was left unattended on the patio, but we did not substantiate that he was sunburned as a result. An occupational therapy student left the resident unattended on an un-shaded patio without alerting nursing staff. When staff discovered him approximately 2 hours later, he was experiencing a heat reaction. Clinical staff responded appropriately and the resident sustained no long-term effects. The resident, fully clothed and wearing a hat, was not sunburned during this event. Prior to our review, CLC managers implemented appropriate actions to address supervision and heat related needs of residents on the patio.