Failure to Maintain Safe and Comfortable Temperatures Leads to Resident Hospitalizations
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature environment for its residents, as evidenced by multiple rooms and hallways being recorded at temperatures ranging from 81.2 to 86 degrees Fahrenheit over several days of high outdoor heat. The air conditioning system had been non-functional for approximately a year, and the facility had not restored adequate cooling despite ongoing high temperatures. Staff and residents consistently reported discomfort, with several residents experiencing symptoms related to excessive heat, such as sweating, dizziness, weakness, and lethargy. Two residents were sent to the hospital with symptoms consistent with heat exhaustion. One resident, with a history of adult failure to thrive, encephalopathy, atrial fibrillation, COPD, major depressive disorder, and hypertension, was found lethargic with slurred speech and low oxygen saturation after being exposed to the hot environment. Another resident with multiple sclerosis, anxiety, hypertension, and protein calorie malnutrition was observed lethargic and dizzy after spending most of the day outside and was later treated for dehydration at the hospital. Both residents returned from the hospital without new orders. Interviews with staff, residents, and family members confirmed the facility was uncomfortably hot and humid, with staff using personal fans and providing water to residents in an attempt to mitigate the effects of the heat. The facility's emergency preparedness policy required action when temperatures exceeded 81 degrees Fahrenheit for more than four hours, but observations and interviews indicated that these measures were insufficient or not fully implemented, resulting in ongoing resident discomfort and hospitalizations due to heat-related symptoms.