Failure to Maintain Safe and Comfortable Room Temperature for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for a resident with chronic obstructive pulmonary disease and shortness of breath, who was on continuous oxygen therapy. The resident's room temperature was observed to be 81.6 degrees, exceeding the facility's stated acceptable range of 71 to 81 degrees. The resident reported feeling hot and experiencing some difficulty breathing, despite having two fans running in her room. She stated that she had reported the issue to CNAs, nursing staff, and the Maintenance Director, but no action had been taken to address the temperature. Multiple staff members, including CNAs, a charge nurse, and a guardian angel, noticed the elevated temperature and stuffiness in the resident's room over the previous two days. Some staff reported the concern to others, but the issue was not escalated or addressed. The Maintenance Director stated he only checked temperatures in the halls, not individual rooms, unless a concern was reported directly to him, and he had not received any such report. The facility's temperature logs only reflected hall temperatures, which were within the acceptable range, and did not include individual room checks. Interviews revealed a lack of clear communication and follow-up regarding the resident's discomfort and the elevated room temperature. The charge nurse did not recognize the concern as significant, and the Maintenance Director had not serviced the air conditioning unit in the resident's room for 12 months. The facility did not have a policy related to monitoring or maintaining individual room temperatures, and the administrator was unaware of the issue until it was brought to his attention during the survey.