Failure to Maintain Safe Water Temperatures in Resident Care Areas
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to maintain safe water temperatures in resident care areas across all three units. During an observation, a surveyor experienced excessively hot water in a staff and visitor bathroom, resulting in visible redness on their hands after brief exposure. Subsequent temperature checks throughout the facility revealed multiple locations with water temperatures significantly exceeding safe limits, with some readings as high as 132.9 degrees Fahrenheit. The Maintenance Director was unaware of these high temperatures and could not provide documentation or logs verifying regular monitoring of water temperatures. Further investigation revealed that maintenance staff only monitored the temperature at the mixing valve daily and performed random room checks weekly, but there was no documentation to support these practices. Nursing staff reported using their wrists to test water temperature before resident use, and there were no working thermometers or temperature logs in the shower rooms. Interviews with the Nursing Home Administrator confirmed the absence of policies and procedures for monitoring water temperatures or ensuring safe water temperatures prior to resident care. Additional observations showed inconsistent practices among staff, with some using hot water for bed baths despite instructions to use disposable washcloths due to the ongoing water issue. Agency staff were not informed about the situation, and key administrative personnel were not present in the facility during follow-up visits. There was no evidence of ongoing temperature monitoring or staff education during the period when the water system remained uncorrected.
Removal Plan
- Maintenance responded onsite.
- Hot water was turned off.
- All resident-accessible sinks and shower rooms with hot water temperatures were audited. Any exceeding 110 F were immediately addressed.
- Nursing staff provided direct supervision and assistance with all bathing and hygiene needs as needed.
- Education was initiated to all staff regarding water temperatures and safety requirements.
- Skin assessments on all residents were initiated.
- Hot water temperatures are in the process of being re-tested using a calibrated thermometer at all resident accessible sinks and shower rooms on all nursing floors.
- Any affected outlets will be returned to resident use only after verification and documentation of compliant temperatures.
- All bathing and showering occurred only at outlets verified to be within the acceptable temperature range, with staff supervision provided as indicated.
- The facility implemented a hot water temperature monitoring process requiring: daily random water temperature checks in resident rooms, shower rooms, and common areas for 7 days; then weekly water temperature checks in resident rooms and shower rooms and common areas for 4 weeks; then ongoing monthly water temperature checks in resident rooms and shower rooms and common areas.
- Use of a thermometer, not hand tested.
- Documentation on a Water Temperature Monitoring Log.
- The facility clearly defined the requirement to include: maximum allowable temperature of 110 F, monitoring frequency, immediate corrective action for out-of-range temperatures.
- Facility staff education was initiated and to be provided to staff prior to start of their shift: acceptable hot water temperature ranges, with maximum water temperature not to exceed 110 F; proper use of thermometers to accurately measure water temperature (thermometers will be located at each nursing station, every shower room, and the receptionist desk); prohibition of hand-testing water temperature due to risk of injury and inaccuracy; immediate reporting of any water temperatures found to be outside the acceptable range to administrative staff and/or Maintenance Director for prompt corrective action.