Failure to Maintain Safe Water Temperatures During Resident Care
Penalty
Summary
The facility failed to maintain water temperatures within normal limits, resulting in a deficiency affecting a resident with severe cognitive impairment and multiple medical diagnoses, including disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident. During incontinence care, staff were unable to obtain warm water from the resident's bathroom and had to leave the room to find water that was only lukewarm. The resident displayed discomfort during care, pulling away from the washcloth as aides attempted to wash her, and staff acknowledged that the water was cold. Review of facility records showed that a mixing valve for hot water had been replaced, but the issue persisted, requiring another replacement shortly after. Water temperature logs indicated that temperatures were within normal limits at one point, but direct measurement during the observed care showed the water was 93.7°F, which was confirmed by the DON to be too cold. Staff interviews revealed ongoing problems with water temperature, and there was no policy available for review regarding water temperature management.