Failure to Maintain Resident Room Temperatures Within Regulatory Limits
Penalty
Summary
Administration failed to ensure that the facility was operated in a manner that enabled effective and efficient use of resources to maintain the highest practicable well-being of residents. This deficiency was evident as all 55 sampled resident rooms across four floors were found to have temperatures exceeding federal and state requirements, with recorded temperatures ranging from 83°F to 105°F. On one occasion, specific rooms were measured at 105°F, 102°F, and 96°F. Three complaints were submitted to the State Agency regarding high temperatures throughout the facility, indicating that all residents were affected. The facility did not have an effective system in place to monitor and maintain room temperatures within the acceptable range of 71°F to 81°F. The facility's Quality Management Program policy outlined a comprehensive, data-driven approach to performance management, including the safety and security of the environment. However, temperature logs documented that on two consecutive days, resident room temperatures remained above the acceptable range, with several rooms exceeding 100°F. Despite the policy, the facility leadership did not ensure that the system for monitoring and controlling room temperatures was effective, resulting in widespread exposure of residents to excessive heat. Interviews revealed that staff received multiple complaints from newly admitted residents about extreme heat, particularly on one floor. Maintenance and nursing staff were notified, and some actions were taken, such as calling maintenance and attempting to move residents. However, communication gaps were evident, as some staff did not escalate concerns to the DON or Administrator, and the DON only became aware of the issue after being informed by a State Surveyor. The facility's leadership, including the Administrator and Medical Director, acknowledged awareness of the elevated temperatures but did not have an effective system in place to prevent or promptly address the issue.