Heating System Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain its heating system in proper working condition, resulting in temperatures in resident rooms, shower rooms, and common areas falling below the required range. Observations revealed that the hot water coil heating system in several resident rooms and a shower room was not delivering heat, and portable heating units were in use in some resident rooms. Additionally, three out of four resident shower rooms lacked any type of heating system, and residents' room windows were not properly maintained to prevent air drafts. The Director of Maintenance (DOM) was unaware of the temperature issues and stated that they did not receive any complaints from residents or staff. The DOM admitted that air temperatures were not taken daily, and there was no regular maintenance schedule in place. Environmental rounds were conducted once per month without documentation, and the facility did not have a temperature policy. The heating system had not been changed since 2013, and residents could control the heating coil units and open windows themselves. The facility's policy named Cold Weather Emergency was updated, but it did not specify how temperatures should be taken and documented. The DOM stated that repairs would be done in-house, and a plumbing company was scheduled to check the heating system. However, no maintenance records were provided to indicate regular inspection and maintenance of the facility's heating system for all three nursing units. The lack of a systematic approach to maintaining the heating system and addressing air drafts contributed to the deficiency.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 i. Residents rooms that were below 70 were immediately offered a room change. i.a The Administrator and Director of Maintenance in consultation with plumber/boiler vendor did a complete assessment of the heating system and identified multiple issues. 1. Hallway thermostat schedule wasn't set properly. 2. Visitor Bathroom heater was defective. 3. One boiler would go into standby mode. 4. Some windows needed to be resealed. 5. Some rooms were missing insulation above the windows. 6. Some of the vents on the room units were in the open position. 7. Some units fan blower motors need to be replaced. 8. East Shower room, one West shower room didn't have heating units. 9. One west shower room, North shower room heating unit weren't working. i.b 1. Hallway thermostat was reprogrammed, a lock box was replaced with access restricted to maintenance. 2. Visitor Bathroom heater was replaced, staff bathroom repaired. 3. Computer control board on the boiler was replaced. 4. Windows were resealed. 5. Insulation above the windows was replaced. 6. All vents were checked and closed. 7. All blower motors were checked and those that were broken were replaced. 8. A ductless unit was installed in the East Shower room, A ductless unit was installed in the West shower room. 9. West shower room heating unit was repaired, A ductless unit was installed in the North shower room. ii. This deficiency has the potential to affect all residents in the facility. iii. Policy & Procedure for Heating system was created and maintenance staff inserviced on new policy. iv. An audit tool will be developed to ensure that the heating system is functioning properly and a daily room temperature log will be added to the daily room check log. Any negative findings during monitoring will be addressed by the Maintenance Director or designee and referred to the QAPI committee for further review. Audits will be conducted weekly x 4 weeks, then monthly x 3 months. v. Director of Maintenance/designee will be responsible for F908 tag.