[S]tate investigators say an assisted living facility in Waterbury where a resident died during an early July heat wave was in violation of care and housing requirements.
The state Division of Licensing and Protection’s investigation found that Kirby House violated the requirements to have a written plan of care for each resident and to provide a “safe, functional, sanitary, homelike and comfortable environment” to its clients.
Early in the morning of July 3, a resident was found unconscious but breathing on the floor of their room by staff, who were conducting routine safety checks on residents in the facility. The resident was unresponsive and stopped breathing just before emergency responders arrived and could not be resuscitated. Neither the state nor Kirby House would identify the resident who died.
The investigation cited high temperatures inside the facility as an issue.
Temperatures soared across Vermont in early July, breaking records in some locations. The heat was linked to multiple deaths around the state.
Sharon Dalley, president of Kirby House, said the four-decade-old facility is limited by availability of resources. The home has exclusively served people with psychiatric illnesses since 1974.
“I would love to have a beautiful facility for my folks, that all had heaters and air conditioning units and new furniture. The problem is there is no funding to help to achieve that,” Dalley said. “So we do what we can do to keep this home open because, quite honestly, I don’t know where my folks would go — they are often declined at other homes.”
The state investigation said the resident had been diagnosed with a psychiatric illness and did not always agree with taking medication, regularly refusing nursing care. The investigation also noted that the resident regularly wore “excessive layers of clothing” and would only wear “button up shirts, a blazer and jeans, as well as only wearing cowboy boots.”
When state inspectors visited Kirby House on July 16, a staff member told the investigators the resident did not like physical contact with any “nursing care at the residence.”
The investigators also found that there was little information in the resident’s care plan to make staff aware of “risk factors of dehydration and heat stroke due to their prescribed antipsychotic medications and advancing age” and though staff did encourage the resident to dress appropriately for the heat, “there were no specific interventions in the care plan to consistently guide staff in their interaction” with the resident.
Based on this evidence, the investigators found that Kirby House failed to ensure a “plan of care based on identified resident needs.”
The investigators determined the facility violated a requirement to ensure the facility maintained a “safe, comfortable and homelike environment” because of the air temperature in the facility and the number of air conditioning units.
According to the report, Kim Russell-Peck, resident manager at Kirby House, told investigators that two new portable air conditioning units had been purchased and installed during the heat wave, but said that the electrical system of the building can get “overwhelmed” and has been overloaded in the past.
“We have asked residents to avoid using coffee pots and hair dryers while hallway air conditioners are in use. We have added checking on these items to housekeeping and shift duties to avoid any interruption in power,” Russell-Peck said in the report.
During the mid-July tour of the facility, investigators measured the air temperature on the third floor of the residence and found it was 80 degrees—with only one portable air conditioning unit running in the hallway.
A resident was reported saying that it “felt warm” and they “felt kind of stressed” about the temperature in the residence.
After receiving these complaints from residents, the Division of Licensing and Protection referred the review of the facility’s electrical system to the Division of Fire Safety.
Dalley, the president of Kirby House, said the inspection of the electrical system did not uncover any risk factors to residents.
“We did have the state of Vermont Fire Safety division in here. The inspector and fire marshall were very quick to see there were no safety issues and there was no overload of the system,” Dalley said.
Dalley also said she feels the state decided it was obligated to assess blame to the facility in this incident even though it had just completed an annual survey of the facility a few weeks before without finding requirement violations.
“We work very, very hard to supply care to a population that nobody else wants to serve and the state, I feel like they had to find something. We had an absolutely terrible accident here and they had to find something,” she said.
In response to the state investigation, Kirby House has updated its guidelines for resident care and will continue its policy to “push fluids when appropriate in hot weather” and to advise residents to dress appropriately.
