Failure to Maintain Safe Room Temperatures During Air Conditioning Outages
Penalty
Summary
The facility failed to maintain a safe and comfortable air temperature range for residents when the central air conditioning units in multiple halls broke down. Specifically, the central air conditioning unit for the 500 hall failed on 4/28/25, and although window air conditioning units were installed in residents' rooms, the facility did not monitor the room temperatures to ensure they remained within a safe and comfortable range. Subsequently, on 5/19/25, the central air conditioning unit for the 400 hall also broke, and the facility did not implement immediate or appropriate actions to maintain safe temperatures in residents' rooms and common areas. On 5/20/25, temperatures in various resident rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended range and creating a likelihood of serious harm or death from prolonged heat exposure. Temperature monitoring logs from January through May 2025 showed that temperatures were only documented twice a month in common areas and hallways, not in individual resident rooms. The logs indicated temperature ranges up to 80°F, but did not capture the elevated temperatures that occurred in resident rooms during the air conditioning failures. Resident interviews revealed ongoing discomfort due to excessive heat, with multiple residents reporting difficulty sleeping, sweating, and feeling unwell over several days. Resident Council minutes from January through April 2025 documented repeated concerns about temperature regulation, with residents consistently reporting that temperatures were either too hot or too cold and that the issue was not being resolved. Staff interviews confirmed that the facility attempted to repair the air conditioning units and installed window units as a temporary measure, but did not implement a comprehensive safety plan or monitor room temperatures until after the elevated temperatures were identified by surveyors. The DON acknowledged that interventions to address the heat were not implemented until 5/20/25 at 3:30 p.m., after the high temperatures had already been present. The failure to monitor and control room temperatures, despite ongoing resident complaints and known equipment failures, resulted in the determination of Immediate Jeopardy due to the risk of heat-related complications for residents.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
- Maintenance staff were educated on maintaining the facility temperatures between 71 degrees and 81 degrees.
- Air conditioners will be maintained in working condition.
- If an air conditioner unit fails, maintenance staff along with administration will activate the emergency plan to maintain facility temperatures between 71 and 81 degrees.
- Clinical staff education on abuse/neglect related to assessment and care of residents when the temperatures are above 81 degrees, verified by posttest results and interview.