Unsafe Water Temperatures in TCU Nursing Unit
Penalty
Summary
The Nursing Home Administrator (NHA) failed to effectively manage the facility to ensure safe water temperatures in the TCU Nursing Unit, leading to an Immediate Jeopardy situation. Observations revealed that the hot water temperatures in the central shower room and resident bathroom sinks were excessively high, with readings of 121.2 to 123.8 degrees Fahrenheit. The thermostat on the hot water tank was initially set at 150 degrees Fahrenheit and later adjusted to 135 degrees Fahrenheit, but the water inside the tank was still at 160 degrees Fahrenheit. This oversight placed residents at risk for serious injury from burns. Interviews with staff, including maintenance and nurse aides, indicated a lack of awareness and training regarding safe water temperature ranges for bathing residents. Several nurse aides admitted to not using thermometers to check water temperatures before giving showers and were unable to state the safe temperature range. This deficiency highlights the NHA's failure to fulfill essential duties and responsibilities, contributing to the Immediate Jeopardy situation, as residents were exposed to potential safety hazards due to inadequate management and oversight.
Plan Of Correction
No residents were harmed. The NHA will have job descriptions reviewed with them by the Regional Director. The administrator will work with the new company and their regional environmental director to complete an assessment of needs for the facility. The facility is recruiting a new maintenance director to support the needs of the facility. Regional Maintenance is coming in 2x a week to oversee. NHA is in constant communication with Maintenance Assistants. The Regional Director will complete bi-monthly audits for 3 months on risk events to ensure facility procedures were followed including work orders and preventative maintenance tasks. 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.