Failure to Maintain Comfortable Room Temperature for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for two residents with cognitive impairments when it did not ensure an appropriate room temperature. One resident, with severe dementia and Alzheimer's disease, was found sleeping under a thick fleece blanket with the blanket pulled over her head, and only responded to a loud voice. The room felt drafty, with a cool breeze coming from a vent directly above her head, and the thermostat was set at 74°F per the resident's daughter's instructions. The second resident, with moderate cognitive impairment, malnutrition, and major depressive disorder, was observed sitting in bed wearing a jacket and reported feeling cold due to a wind from the vent, expressing a preference for a warmer room. Staff interviews confirmed that both residents often appeared cold in their room, with one typically staying under a blanket and the other wearing a coat in bed. The maintenance supervisor measured the air coming from the vent at 60°F and the bed surfaces at 72°F, acknowledging that the draft could be uncomfortable. Both the maintenance supervisor and licensed nurse agreed that the room was not homelike or comfortable for the residents at the time. Facility policy requires maintaining comfortable temperatures between 71°F and 81°F, and the Director of Nursing confirmed that the room temperature was not homelike and could have negatively affected the residents' mood and health.