Deficiencies in Water Temperature Control and Resident Transfers
Penalty
Summary
The facility was cited for failing to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. During a tour, it was observed that the hot water in the back 100 spa room reached 128°F, despite the presence of a point-of-use mixing valve intended to temper the water to a safe level. Interviews with maintenance staff revealed that the facility did not regularly monitor hot water temperatures to ensure they remained within safe limits, increasing the risk of injury to residents. Additionally, the facility failed to ensure safe chair-to-bed transfers for two residents. One resident, who required substantial assistance for transfers, was observed being transferred by a CNA without the use of a gait belt or assistance from a second staff member, contrary to the resident's care plan. The resident attempted to bear weight on a foot with a pressure wound during the transfer. Another resident, who required a mechanical lift for transfers, was observed being transferred with the hoyer sling improperly attached, risking the resident's safety. Interviews with staff confirmed the improper transfer techniques and the residents' need for specific assistance during transfers.
Plan Of Correction
DPS A Element #1 No residents were mentioned in the citation. Element #2 No residents have been identified at risk. 100 spa rooms are not currently utilized by facility residents. Element #3 Mixing valve in spa room 100 was removed and delimited. Spa room 100 hot water temperature post deliming was under 120 degrees. Facility Maintenance technician has been re-educated on appropriate safe water temperatures in patient care areas. Element #4 Facility Maintenance tech/Designee will complete 5 random weekly temperature checks in resident care areas. Any variances will be addressed at time of observation. Audits to be forwarded to facility QAPI for review and further recommendations. Element #5 The Facility Administrator is responsible for compliance. DPS B Element #1 Resident #98 and #65 have been re-evaluated to determine the amount of assistance needed to transfer safely. Resident care summaries have been updated to reflect current care needs. Element #2 All residents who require assistance with transfers have the potential to be affected by the same deficient practice. Element #3 Licensed nurses and certified nursing assistants have been re-educated on resident care plan/resident care summary regarding the amount of assistance required for a safe transfer and mechanical lift operation. Element #4 Under the direction of the Quality Assurance and Performance Improvement Committee, the Director of Nursing or designee(s) will conduct weekly observation audits of resident transfers including those that use mechanical lifts to assure the correct transfer technique followed. Audits will be forwarded to the Facility QAPI Committee for review and further recommendations. Element #5 The Director of Nursing is responsible for sustained compliance.