Failure to Maintain Safe and Comfortable Temperatures During Planned Cooling System Outage
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents on two of its care wings during a planned maintenance outage of the cooling system. The cooling tower servicing the A and B wings was taken offline for scheduled maintenance, and although portable cooling units were rented and placed in the affected areas, they were insufficient to keep temperatures below 81 degrees Fahrenheit. Temperatures in the building exceeded 81 degrees for more than four hours, triggering a Code Purple, and remained consistently above this threshold for approximately 48 hours, with some areas reaching over 90 degrees. Temperature monitoring was not consistently documented, as logs were unavailable for the initial period of the outage, and temperature checks were only conducted in hallways, not in resident rooms, which were reported to be even hotter. The facility's emergency procedure for severe hot weather, Code Purple, required specific actions such as moving residents to cooler areas, monitoring for heat-related illnesses, and notifying emergency management agencies. However, the County Emergency Management Agency (EMA) was not notified until the day after the Code Purple was enacted, despite the event being a planned outage. Staff were educated to monitor residents for signs of heat exhaustion and dehydration and to provide additional hydration, but there were no specific assignments for monitoring hydration, and fluid intake documentation was inconsistent. The facility also did not ensure that different consistencies of fluids were readily available for residents with special needs during the event. Interviews with facility staff and management revealed that the response to the heat event was reactive rather than proactive. The Director of Maintenance and Safety and Security Director acknowledged that temperature monitoring was not systematically logged at first and that the portable cooling units and fans were not sufficient to maintain comfortable conditions. The decision to move residents to a vacant, cooler unit was delayed and ultimately not carried out because the cooling system was restored. The facility identified several shortcomings in their response, including the need for better preparation of vacant units for potential relocation and improved documentation and provision of fluids, but these were only recognized after the event.