Failure to Maintain Safe Air Temperatures
Penalty
Summary
The Nursing Home Administrator failed to effectively manage the facility's heating system, resulting in unsafe and uncomfortable air temperatures for 19 cognitively impaired residents. The heating units in rooms 310, 311, 312, 313, 314, 315, 316, and 317 were not functioning properly, with temperatures recorded as low as 56 degrees Fahrenheit in some areas. This issue persisted despite being reported through the facility's maintenance communication system, indicating a lack of timely response and resolution. Interviews with residents and staff revealed that the heating problems had been ongoing since November 2024. Residents expressed discomfort and concern for their well-being, with some residents requiring multiple layers of clothing and blankets to stay warm. Observations confirmed that the heating units were either not operational or not providing adequate warmth, contributing to the residents' discomfort and potential health risks. The facility's failure to maintain appropriate temperature levels in resident rooms and common areas led to an Immediate Jeopardy situation. The Nursing Home Administrator did not fulfill their responsibilities to ensure the facility was maintained in a safe and comfortable manner, as evidenced by the lack of action taken to address the heating issues reported by staff.
Plan Of Correction
1. The heating units in rooms 310, 311, 312, 313, 314, 315, 316, and 317 were repaired and residents were returned to their original rooms on 1/23/25. No adverse effect to any resident was noted. Reported event to DOH on 1/22/25. 2. An audit was completed on all units, in all residents' rooms to assure room temps were maintained within desired temperature range. 3. The Nursing Home Administrator was re-educated about maintaining air temperatures ranging from 71 degrees Fahrenheit and 81 degrees Fahrenheit in all resident areas and overseeing preventive maintenance of HVAC units to assure temperatures are sustained in the required range. Weekly walking rounds are conducted with the Administrator and Maintenance director to ensure the facility is maintained in good condition to assure the comfort of the residents. 4. The Administrator/designee will audit resident room temperatures of rooms 310, 311, 312, 313, 314, 315, 316, and 317 QSHIFT, weekly x4, monthly x2; to assure the temperatures are maintained between 71-81 degrees Fahrenheit. Results of the audit to reported at monthly QA x3 months. 5. The Regional Administrator will conduct monthly audit x3 to assure effectiveness of QA program.