Failure to Maintain Safe Water Temperatures and Complete Post-Fall Assessment
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment in two key areas: water temperature control in resident-accessible areas and post-fall assessment for a resident. During observations and interviews, it was found that water temperatures in several resident bathrooms exceeded the facility's policy limit of 120°F, with some readings as high as 130°F and 135°F. Staff, including the Maintenance Director, Director of Staff Development, Infection Preventionist, and DON, all acknowledged that water temperatures above 120°F could cause burns or skin damage to residents. A resident also reported that the water would get too hot in the bathroom, but did not report it to staff and simply stopped using it. The facility's policy required water heaters servicing resident areas to be set no higher than 120°F, but this was not consistently followed. In addition, the facility failed to complete a post-fall mobility assessment for a resident who had a fall in the bathroom. The resident, who had dementia and diabetes, was found on the bathroom floor in pain and was subsequently sent to the emergency room. Although the facility's policy required a joint mobility screen after a fall, the DON confirmed that this assessment was not completed after the incident. The last mobility screen for the resident had been done prior to the fall. The DON acknowledged that not completing the assessment meant staff would not have updated information on the resident's mobility status. Facility policies reviewed indicated that water temperatures and fall risk assessments were to be closely monitored and managed to prevent harm. However, the observed failures in both maintaining safe water temperatures and completing required post-fall assessments demonstrated lapses in following these policies, potentially exposing residents to physical harm.