Failure to Maintain Safe Temperature Levels
Penalty
Summary
Wyndmoor Hills Rehabilitation and Nursing was found to be non-compliant with federal and state regulations regarding maintaining a safe and comfortable environment for residents. The facility failed to ensure that air temperatures were maintained within the required range of 71 to 81 degrees Fahrenheit on two nursing units, specifically the Second and Third Floors. Observations revealed that temperatures in various rooms and hallways ranged from 59 to 70 degrees Fahrenheit, which posed a risk of hypothermia to 16 residents. Interviews with residents and staff confirmed the discomfort and cold conditions within the facility. Residents were observed wearing additional clothing such as sweatshirts, coats, and hats to keep warm. Staff members, including nurse aides and the maintenance director, acknowledged the cold temperatures and reported issues with the heating system. The maintenance director noted that the facility had experienced problems with water pipes, which affected the heating system's functionality. Further investigation revealed that a commercial contractor had identified an issue with the air handler, which required shutting off the system to prevent further damage. Despite being aware of the malfunction, the facility instructed the contractor to turn the air handler back on. The lack of adequate warm blankets and the failure to maintain appropriate air temperatures led to an Immediate Jeopardy situation, as residents were at risk of developing hypothermia due to the cold environment.
Plan Of Correction
1. Residents that resided in affected rooms were immediately offered a room move. Superb Plumbing was on site on 2/7/2025 to address concerns related to the heating unit. Additional blankets were purchased and provided to residents. Warming liquid hydration stations were placed in resident common areas by culinary staff on 2/7/2025. All 16 residents identified were assessed by nursing staff to ensure that there have been no undesired outcomes related to hypothermia and that no signs and symptoms of hypothermia were present due to the central heating system being temporarily inoperable, including vital signs, skin assessments, and any other pertinent assessments. 2. All rooms in the facility have been temped and are back in compliance. Residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hypothermia are present. 3. Facility staff will be educated on ensuring residents remain warm and to ensure that residents are assessed frequently to ensure that no signs and symptoms of hypothermia are present. 4. An Ad Hoc QAPI Meeting was held on 2/7/2025 to discuss the events surrounding the facility's failure to ensure that the temperatures in the facility were maintained between 71 and 81 degrees Fahrenheit, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding ensuring that temperatures are appropriately maintained in the facility. The facility has a plan in place when temperatures are not maintained and to ensure that the central heating system has routine maintenance. The facility will continue to audit all rooms until there are no rooms being affected. The facility will do a temperature audit once a week for one month, twice a month for one month, and once a month for one month. 5. The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee monthly for six months.
Removal Plan
- The facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that facility air temperatures were maintained between 71- and 81-degrees Fahrenheit.
- Residents that resided in affected rooms were offered a room move and declined. They were informed that if they were uncomfortable and would like to move rooms at any time to inform facility staff.
- [Plumbing Company] on site to address concerns related to the heating unit. Additional blankets were purchased and provided to residents.
- Warming liquid hydration stations were placed in resident common areas by culinary staff.
- All 16 residents identified were assessed by nursing staff to ensure that there have been no undesired outcomes related to hypothermia and that no signs and symptoms of hypothermia were present to the central heating system being temporarily inoperable to include vital signs, skin assessment and any other pertinent assessments.
- All other rooms in the facility will have temperatures taken and residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hypothermia are present to include vital signs, skin assessments along with any other relevant assessment related to hypothermia.
- Facility staff will be educated on ensuring residents remain warm and to ensure that residents are assessed frequently to ensure that no signs of symptoms of hypothermia are present.
- Facility temperature will be checked every shift by the manager on duty and facility administration to ensure that they are within appropriate range along with resident interview to ensure that they are comfortable with the current temperatures.
- If the facility rooms affected does not meet and maintain the appropriate temperatures facility will initiate the emergency plan to include closure of the affected rooms and mandate movement of resident to functioning rooms.
- An Ad Hoc QAPI Meeting was held to discuss the events surrounding the facility's failure to ensure temperatures in the facility were maintained between 71- and 81- degrees Fahrenheit, to identify the root cause, and to initiate improvement to the facility's processes and procedures regarding ensuring temperature levels are appropriately maintained in the facility, the facility has a plan in place when temperatures are not maintained and to ensure that the central heating system has routine maintenance.
- The PA Healthcare Coalition was notified via phone with a voice message left.
- An interview was conducted with Heating and Air Contractor, Employee E11, reported that the heating issue had been resolved. Temperatures in the hallways and rooms were increasing.
- Observations revealed the Second-floor nursing unit-maintained temperatures between 71- and 81- degrees Fahrenheit. The third nursing unit continued to have rooms with 7 rooms were below 71 degrees Fahrenheit. Facility brought portable space heater (safe) to maintain air temperature levels between 71- and 81-degrees Fahrenheit.
- The facility provided education to all staff on assessing residents for signs and symptoms of hypothermia. Staff were instructed to ensure residents remained warm by providing blankets, conducting vital sign checks every shift, and offering warm beverages as needed.
- The vital signs auditing was reviewed and residents were not exhibiting signs and symptoms of hypothermia.