Failure to Maintain Safe and Comfortable Temperatures Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect by not taking immediate and appropriate actions to maintain safe and comfortable temperature levels when multiple central air conditioning units broke down in several halls and common areas. Despite the breakdown of the central air conditioning units in the 400, 500, and 700 halls, the facility did not implement its Emergency Preparedness Plan in a timely manner to ensure residents' comfort and minimize the risk of hyperthermia. Window air conditioning units were installed in some resident rooms, but there was no consistent monitoring of room temperatures to ensure they remained within a safe range. Residents repeatedly reported discomfort due to excessive heat, with room temperatures documented between 81.3°F and 84.3°F. Multiple residents complained of being excessively hot and uncomfortable for several days, with some describing difficulty sleeping and feeling as if they were overheating. Resident Council meeting minutes over several months also documented ongoing concerns about temperature regulation, indicating that the issue was persistent and not adequately addressed by facility leadership. Temperature monitoring logs provided by the facility only included common areas and did not document temperatures in individual resident rooms. The logs showed that temperatures were only checked twice a month, rather than more frequently, and did not reflect the elevated temperatures experienced by residents. The facility's own policies defined neglect as the failure to provide necessary goods and services to avoid physical harm or distress, yet there was no evidence that the facility consistently monitored or responded to unsafe room temperatures until after the deficiency was identified by surveyors.
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.
- Took temperatures throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
- Will continue to maintain hourly temperature logs until all air conditioner units are repaired.
- Provided facility-wide staff abuse/neglect education, verified through staff interview and record review of post-test results.
- Ensured no staff will be permitted to work until they are reeducated on Abuse and Neglect policies.
- Education included a written competency test to include who and when to notify when a resident room is at or above 81 degrees.
- Education included information on where the cool zones are located, and that failure to report is considered neglect.