Failure to Maintain Consistent and Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure that hot water temperatures from faucets throughout the building were consistently maintained between 105°F and 120°F, as required by both facility policy and state regulations. Observations and measurements revealed that water temperatures in various resident rooms ranged from as low as 76.1°F to as high as 121.4°F. Some rooms on the southeast side had water temperatures between 94°F and 99°F, while rooms on the north side had temperatures exceeding the maximum limit, reaching up to 121.4°F. Other rooms had water temperatures below the minimum requirement, with several readings under 105°F. These inconsistencies were found after allowing the faucets to run for two minutes, as per regulatory guidance. Interviews with facility staff indicated a lack of awareness and understanding regarding the proper procedures for monitoring and measuring water temperatures. The Maintenance Assistant described the water delivery system, which includes a hot water heater, a holding tank, and a mixing valve, but could not explain the cause of the temperature fluctuations. The Maintenance Person admitted to not following the correct method for measuring water temperatures, typically allowing water to flow for only one minute instead of the required two minutes. Additionally, the Administrator was unaware of the extent of the temperature variations until an incident involving a resident in the shower was reported. Review of facility policies confirmed that staff are required to monitor water temperatures, report abnormal findings, and maintain documentation. However, the staff interviews and record reviews demonstrated that these procedures were not consistently followed. The facility had not previously contacted a plumber to address the inconsistent water temperatures, and leadership was only considering this action after the issue was identified. The failure to maintain appropriate water temperatures and to follow established monitoring protocols potentially affected all residents in the facility.