Unsafe Water Temperatures in TCU Nursing Unit
Penalty
Summary
The facility failed to maintain safe water temperatures in the central shower room and resident bathroom sinks on the TCU Nursing Unit, which posed a risk of serious injury from burns to the residents. Observations revealed that the hot water temperatures in the central shower room and resident bathroom sinks exceeded the facility's policy range of 100-110 degrees Fahrenheit, with temperatures recorded as high as 123.8 degrees Fahrenheit. The thermostat on the hot water tank was initially set to 150 degrees Fahrenheit, and the water inside the tank was 160 degrees Fahrenheit, which contributed to the excessively high water temperatures. Interviews with staff members, including nurse aides, revealed a lack of awareness and adherence to the facility's water temperature policy. Several nurse aides admitted to not using a thermometer to check the water temperature before bathing residents and were unable to state the safe water temperature range. This lack of knowledge and failure to follow protocol further contributed to the unsafe conditions, as residents were exposed to potentially harmful water temperatures during bathing. The Immediate Jeopardy situation was identified due to the facility's failure to ensure that water temperatures did not exceed 110 degrees Fahrenheit, as required by their policy. This deficiency was communicated to the Nursing Home Administrator, highlighting the urgent need for corrective action to protect the residents from the risk of burns.
Plan Of Correction
No residents were harmed. Plumber onsite immediately addressed temperatures. The plumber addressed during onsite visit. He was also scheduled for a follow-up visit the following day to ensure the adjustments that were made were effective. Audited resident sinks and shower rooms and found no additional findings. Facility reeducated on policy. Facility in house staff have been in serviced. NHA/DON and/or designee conducted daily audits for a week, weekly for 4 weeks, then monthly for 3 months to ensure compliance. The administrator or designee will conduct random employee interviews for three months to ensure their competency on methods of on the water temperature policy including acceptable water temperature ranges and appropriate methods to check water temps. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.
Removal Plan
- The facility turned off the hot water valve to TCU unit when they were alerted about the high temperatures on TCU.
- Adjustments were made after the system was flushed. Hot water maintained and did not exceed 110 degrees. The plumber was called to assess and make recommendations.
- The facility checked the sink temperature in every room on the TCU after the hot water valve was turned back on.
- There were no additional high temps identified.
- The facility water temperature policy will be reviewed to ensure that safe processes for monitoring water temperatures have been fully developed.
- 80% of employee list that were working on the day and evening shift were educated on the water temperature policy including acceptable water temperature ranges (100-110 degrees) and appropriate methods to check water temps.
- Water temperature will be checked using a thermometer reading prior to immersing a resident in water, using water from a shower, or using hot water for the purpose of bathing or soaking.
- Hot water temperatures exceeding 110 degrees Fahrenheit or less than 100 degrees Fahrenheit will be reported immediately to the Charge Nurse or designee.
- Regular maintenance checks to ensure the plumbing system is functioning properly and temperature limits are being adhered to.
- Staff for future shift will be educated at the beginning of shift. Additional 10% staff will be virtually educated to total of 100% staff education compliance.
- The plumber is scheduled for a follow-up visit proactively to ensure the adjustments that were made were effective.
- The Maintenance staff or designee will complete temp audits hourly for the next 24 hours. The team will continue to monitor water temps daily until further direction of QAPI Committee.
- A random sampling of employee interviews to ensure that they are knowledgeable on how to identify and respond to elevated water temperatures. Audits will occur daily until further direction of the QAPI Committee.
- The Medical Director was updated on this Correction and Removal-Abatement Plan as well as occurrences of which this plan pertains. Monitoring will be initiated and completed by the Administrator and/or designee as indicated above.
- Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary.
- Frequency of continued audits will be determined at that time. If issues are identified, re-education will be completed. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed, and revision will be made as deemed necessary.