Failure to Identify and Address Unsafe Water Temperatures and Resident Safety Concerns
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to resident safety and accident prevention. The QAPI committee did not identify or address issues with hot water temperatures exceeding safe ranges, which rose to the level of immediate jeopardy. The facility also failed to conduct and document a thorough assessment of a resident with a new skin condition and did not notify the resident's provider in a timely manner. These deficiencies were identified through record review and staff interviews. Interviews revealed that the maintenance director, who was new to the facility, was responsible for monitoring water temperatures but did not record them as required. The facility's process involved staff entering work orders into the TELS system for maintenance, and a paper audit tool was created to monitor water temperatures. However, the audit tool was not consistently used, and temperature monitoring records were not properly maintained or reviewed by the nursing home administrator. The QAPI committee met monthly, but water management issues were not consistently included in meeting minutes or reviewed as part of the QAPI process.