Failure to Maintain Comfortable Room Temperatures and Homelike Room Conditions
Penalty
Summary
Facility staff failed to ensure a safe, comfortable, and homelike environment for two residents by not adequately addressing room temperature concerns and room condition issues. One cognitively intact resident with chronic kidney disease and neuralgia reported ongoing problems with her room being cold, stating during a resident meeting that maintenance had been informed but the issue was not fixed. Resident council notes documented a prior grievance from this resident about temperature, but it referenced common areas rather than her specific room. On multiple occasions, the resident reported her room felt cold, including one instance where she stated she thought she was going to freeze because she had not had heat in her room since the previous day, despite the maintenance engineer later measuring the room temperature in the low 70s Fahrenheit and acknowledging that the PTAC unit had been incorrectly switched from cold to heat. Another resident with atrial fibrillation and chronic venous insufficiency, who had severely impaired cognitive abilities per a recent MDS assessment, was observed in bed stating she did not feel well, though she could not specify what was wrong. Her room was observed to be cluttered, with personal belongings scattered on the bedside table, chair, and overbed table, and the wall behind her bed had torn wallpaper. When asked, the resident expressed a preference for having her belongings stored and for the wall beside her bed to be repaired. The DON later stated that nursing was responsible for ensuring residents' personal belongings were stored appropriately. Interviews with staff further described the circumstances contributing to these deficiencies. A CNA reported that the resident with temperature concerns had complained of being cold at night and was given two blankets. The maintenance engineer explained that the PTAC unit required switching between heat and cold modes and admitted he had switched it incorrectly, contributing to the resident’s perception of inadequate heat. The assistant engineer reported that many rooms had accent walls needing repair and attributed wall damage to direct care staff tearing walls when moving beds, noting that repairs had not been completed because residents would need to be moved out of rooms for the work. These actions and inactions resulted in residents not consistently experiencing a comfortable temperature or a homelike, well-maintained room environment.
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