Failure to Maintain Safe Temperatures During Air Conditioning Outage
Penalty
Summary
Facility administration failed to utilize its resources effectively and efficiently to maintain a safe and comfortable temperature for residents when multiple central air conditioning units broke down in several halls and common areas. Despite being aware of ongoing issues with the air conditioning units, as documented in resident council meeting minutes from January through April, administration did not implement immediate and effective measures to address the excessive heat. Residents repeatedly raised concerns about uncomfortable temperatures, and the administration acknowledged the problems but only noted that the concerns were being addressed, without evidence of timely or sufficient action. On multiple occasions, temperatures in residents' rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended comfort range. Several residents reported ongoing discomfort, difficulty sleeping, and feeling overheated for weeks, with some stating that the issue had persisted for months. The facility's temperature monitoring logs did not include resident rooms and were only conducted twice a month in common areas, failing to capture the actual conditions experienced by residents. The Director of Nursing confirmed that interventions to mitigate heat exposure, such as providing ice, water, and monitoring vital signs, were not implemented until after temperatures had already reached excessive levels. Interviews with residents and staff further revealed that the excessive heat was a persistent problem, with residents expressing that their complaints were not adequately addressed. The administration's approach relied on hallway temperature checks to trigger room checks, which proved insufficient. The lack of timely and comprehensive action to ensure a safe and comfortable environment for all residents created a likelihood of serious harm or death due to prolonged exposure to excessive heat, resulting in the determination of Immediate Jeopardy.
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 at multiple times and verified they were within the range of 71 to 81 degrees.
- Facility will continue to maintain hourly temperature logs until all air conditioner units are repaired.
- Completed education with the Administrator and Director of Nursing (DON) by the President of Clinical Operations regarding their responsibility to implement the facility excessive heat emergency plan related to broken air conditioning units.
- Education included the monitoring process and notification procedure to the Chief Executive Officer/Chief Nursing Officer and to ensure residents are provided with a clean, comfortable environment.
- Chief Nursing Officer educated the Administrator and DON on their job descriptions, emphasizing responsibility to ensure proper temperatures and a safe, comfortable environment.
- Reviewed the agenda and staff sign-in page for the Quality Assurance and Performance Improvement (QAPI) meeting, which included a review of the affected regulations and implementation of the facility's Excessive Heat Emergency Plan.