Failure to Maintain Safe Room Temperature and Supervision When Window Left Open in Freezing Weather
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe room temperature and provide adequate supervision to prevent accidents for two residents who were cognitively impaired and physically dependent for mobility. One resident had unspecified dementia with a BIMS score of 01, was dependent for lying to sitting, sit to stand, and bed-to-chair transfers, and did not ambulate due to medical/safety concerns. The other resident had a diagnosis of lack of coordination, a BIMS score of 05 indicating severe cognitive impairment, was dependent for bed mobility and transfers, and also did not ambulate due to medical/safety concerns. Both residents lacked the physical ability to get out of bed or close a window independently. Surveyors observed both residents lying in their beds while the room window was open, with the curtain blowing inward, when the outside temperature was 32°F. One resident’s bed was directly beneath the open window, and both residents stated they wanted the window closed because they were freezing. A CNA reported that she had opened the window approximately five minutes earlier to air out the room, did not request permission from either resident, did not realize the outside temperature was 32°F, and left the room after opening the window, despite acknowledging that neither resident was strong enough to close it. An LPN confirmed that neither resident was physically strong enough to close the window. The DON stated her expectation that windows remain closed unless requested by the resident after being educated on the outside temperature, and the Administrator stated his expectation that all windows in resident rooms stay closed at all times.
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