Failure to Maintain Safe Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing hot water temperatures in resident bathrooms to exceed the recommended maximum of 120 degrees Fahrenheit. Water temperatures ranging from 120 to 138 degrees Fahrenheit were found in 23 out of 92 resident bathrooms. The facility's own policy, as well as documentation from their equipment management system, specified that domestic water temperatures should be kept below 120 degrees Fahrenheit to prevent burns. Despite this, multiple residents, including those who were physically and/or cognitively impaired, had access to water at unsafe temperatures in their rooms. Several residents affected by this deficiency were identified as being moderately to severely cognitively impaired, with some being dependent on staff for activities of daily living (ADLs) and others being independent with mobility. Observations and medical record reviews confirmed that these residents, including those with diagnoses such as Alzheimer's disease, dementia, and other chronic conditions, were exposed to elevated water temperatures. In some cases, residents or their family members reported that the water seemed excessively hot, and maintenance staff confirmed high readings during checks with calibrated thermometers. The maintenance supervisor acknowledged that water heaters had been set to higher temperatures in response to staff complaints about insufficiently warm water and after recent repairs by an outside vendor. The supervisor also confirmed that regular water temperature checks were only performed in one random resident room per hall each week, and there was a lack of documentation regarding when water heater settings were changed. The administrator was informed of the issue but was not provided with specific temperature readings. These actions and inactions resulted in the facility not ensuring a safe environment, as required by policy and regulatory standards.