Failure to Maintain Safe Room Temperatures and Notify Authorities During HVAC Outage
Penalty
Summary
The facility failed to maintain resident room temperatures within the acceptable range of 71 to 81 degrees Fahrenheit during periods of outdoor temperature extremes, specifically during a heating system failure. Documentation showed that several resident rooms had temperatures as low as 60.7 F, 62.1 F, and 63.6 F over multiple days, with temperature logs often lacking signatures, dates, or clear identification of responsible staff. The deficiency was further compounded by the lack of a comprehensive, facility-specific policy and procedure for climate control system outages, and the absence of clear guidance on when to notify state agencies or the Department of Health and Senior Services (DHSS) disaster line in the event of such failures. Interviews with staff and residents revealed that the heating issues began when a resident reported a malfunctioning unit via a QR code maintenance request. The Maintenance Director responded by contacting a heating company, but repairs were delayed due to unavailable parts. Additional rooms were later found to have similar heating issues, and staff began taking hourly temperature logs. Residents reported feeling cold, with one resident stating they had to cover up and dress warmly, and another's guardian expressing concern that staff did not offer to move the resident or provide additional blankets and warm clothing. The facility's emergency disaster manual referenced maintaining interior temperatures above 71 F and outlined steps for offering blankets or room moves in emergencies, but did not specify when to notify state authorities or provide a clear process for handling HVAC outages. The Administrator acknowledged the lack of a policy for contacting the disaster line and was unaware that multiple individual unit failures required state notification. These deficiencies had the potential to affect all residents, staff, and visitors in the facility.