Failure to Maintain Safe Water Temperatures and Provide Adequate Supervision for Transfers
Penalty
Summary
The facility failed to maintain safe hot water temperatures at point-of-use for all residents on the 200 hallway and the specialty care unit. Observations and temperature measurements revealed that hot water temperatures in resident rooms and common areas reached as high as 134 degrees Fahrenheit, significantly exceeding the recommended safe upper limit of 120 degrees Fahrenheit. Residents and staff reported that the water became very hot after running for a few minutes, and maintenance staff confirmed the malfunction of the blender valve responsible for regulating water temperature. Monthly water temperature logs showed repeated instances of temperatures above 120 degrees Fahrenheit, but these were not consistently identified or addressed by facility leadership. Additionally, the facility did not provide adequate supervision or follow care plans for residents requiring assistance with transfers and activities of daily living. Multiple residents with documented fall risks and care plans specifying the need for staff assistance and use of gait belts were observed or reported to be transferring themselves without staff help. Interviews with residents and staff indicated that some residents regularly performed transfers and dressing independently, despite care plans requiring assistance. Staff were not consistently aware of or following the prescribed level of assistance for these residents, and there was a lack of clear communication and adherence to care plans during shift handoffs. Furthermore, direct observations showed that staff did not always use required safety equipment, such as gait belts, during resident transfers. In one instance, a nursing assistant assisted a resident with a pivot transfer without using a gait belt, contrary to the resident's care plan and facility policy. Interviews with therapy and nursing staff confirmed that these residents were not approved for independent transfers and required at least standby or one-person assistance. Facility policies required regular assessment of fall risk and updating of care plans, but these were not consistently implemented in practice.