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

We reviewed an allegation regarding the quality of care a veteran received in a community living center (CLC) at the Palo Alto Health Care System, Palo Alto, CA. We partially substantiated the allegation. We substantiated that the veteran was left unattended on a patio, but we did not substantiate that he was sunburned. An occupational therapy student left him on the patio without informing nursing staff. The veteran was in the sun for approximately 2 hours and experienced a heat reaction before staff discovered him. Clinical staff responded appropriately, and he sustained no long-term effects. After the incident occurred, the CLC Manager took appropriate actions, initiated additional safety measures, and educated staff on heat exposure. We also identified an issue that needed improvement. Although nursing students at the CLC received safety training, students of other disciplines did not receive the same training. We recommended that all students who interact with CLC residents receive safety training.