F0584

K

Failure to Maintain Safe Temperature Levels in Resident Rooms

Philadelphia, Pennsylvania Survey Completed on 01-24-2025

Penalty

No penalty information released

Summary

The facility failed to maintain comfortable air temperature levels on the 300 nursing unit, placing residents at risk for developing hypothermia. Observations and temperature readings revealed that the air temperatures in several rooms and the hallway were significantly below the required range of 71 to 81 degrees Fahrenheit. Specifically, temperatures as low as 56 degrees Fahrenheit were recorded, affecting 19 residents, many of whom were cognitively impaired and required assistance with daily living activities.

Interviews with residents and staff highlighted the ongoing issue with the heating system, which had been reported as non-functional since November 2024. Despite multiple reports and work orders submitted by nursing staff to the maintenance department, there was no documentation indicating that the issues were addressed. Residents expressed discomfort due to the cold temperatures, and staff had to resort to using multiple blankets to keep residents warm.

The affected residents had various diagnoses, including dementia, Alzheimer's disease, schizophrenia, and cerebral vascular accident, which made them particularly vulnerable to the cold conditions. The facility's failure to provide necessary maintenance services to ensure safe and comfortable temperatures in resident rooms and common areas posed a significant safety risk, leading to the identification of an Immediate Jeopardy situation.

Plan Of Correction

1. HVAC system repaired 1/23/25 to assure a temperature range of 71-81 degrees Fahrenheit was maintained for resident room 310, 311, 312, 313, 314, 315, 316, and 317.

2. Audit was conducted on resident room temperatures to assure room temperatures were maintained between 71 degrees Fahrenheit - 81 degrees Fahrenheit. No other rooms were noted to be outside of the desired range.

3. Education was completed for the Maintenance Director on the requirements for maintaining resident room temperatures to range between 71 degrees Fahrenheit - 81 degrees Fahrenheit. Preventive maintenance has been scheduled to ensure all heating units function within the required temperature ranges on an ongoing basis.

4. The Administrator/designee is auditing temperatures of resident rooms 310, 311, 312, 313, 314, 315, 316, and 317 every shift, weekly x4, monthly x2; to assure the temperatures are maintained between 71-81 degrees Fahrenheit. Results of the audit to be discussed at monthly QA x3.

Removal Plan

• All affected residents were moved to other areas of the facility where the temperature was maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit.
• All residents were assessed for signs and symptoms of hypothermia.
• Vital signs were taken on all affected residents.
• All responsible parties and all residents' physicians were made aware.
• Room temperatures of other units were audited and all rooms were found to have temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit.
• Vital signs were taken on all unaffected residents.
• Education was provided to the facility staff that were working when the areas were found to be affected and education will continue for staff who will work until temperatures are maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit in the affected rooms.
• The education includes reporting any residents with concerns of being cold, offering blankets, acceptable temperature ranges, or having signs and symptoms of hypothermia.
• Hourly temperatures of resident rooms are being taken to assure that the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit.
• Staff has been added to the schedule for the immediate nursing shifts to assure resident safety.
• Staff will continue to be added to the schedule to assure resident safety until the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit in the affected area and residents are returned to their original rooms.
• Industrial heating units have been procured and will be placed in the affected area.
• Vital signs will be taken for all residents at the facility to assure that no resident will have any negative effects related to the signs and symptoms of hypothermia and vital signs will continue until heat is restored to the affected area.
• Repairs of heating units will continue until heat is restored to the affected area and the temperature is maintained between 71 degrees Fahrenheit and 81 degrees Fahrenheit.
• The Maintenance Director or designee will audit room temperatures to ensure that the room temperature is between 71 and 81 degrees Fahrenheit. Corrective action will be taken as necessary.
• The results of the audits will be reported at monthly QAPI meeting until substantial compliance is reached.