Failure to Maintain Safe Resident Room Temperatures
Penalty
Summary
The facility failed to maintain resident room air temperatures within the required range of 71 to 81 degrees Fahrenheit for at least 23 residents, resulting in multiple rooms reaching temperatures as high as 88 degrees Fahrenheit. Several residents reported that their rooms were uncomfortably hot for multiple days, with some air conditioning (AC) units leaking water and failing to provide adequate cooling. Residents with significant medical histories, including diabetes, chronic obstructive pulmonary disease (COPD), heart disease, and other chronic conditions, were affected. Some residents requested to be moved to cooler rooms, while others endured the heat until the fire department intervened. Staff interviews revealed that multiple staff members, including LPNs, CNAs, and housekeeping, were aware of the elevated temperatures and malfunctioning AC units but did not consistently report these issues to supervisors or take further action. Some staff believed there was nothing they could do about the AC problems, especially on weekends, and did not escalate the concerns to the Administrator or Director of Nursing (DON). The facility's maintenance director was on vacation during the incident, and housekeeping staff, who were responsible for monitoring room temperatures, did not always communicate elevated readings or resident complaints to the appropriate personnel. Facility policies required staff to monitor and report high temperatures and to relocate residents if necessary, but these procedures were not consistently followed. Documentation showed that several rooms exceeded the 81-degree threshold, and the facility's own logs confirmed elevated temperatures during the period in question. The deficiency was only addressed after a resident called 911, prompting the fire department to intervene and direct the relocation of residents from overheated rooms.