§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Based on observation, record review, and staff interview the licensee failed to maintain hot water mechanical equipment in safe operating condition. According to CMS guidelines exposure at water temperature of 133 degrees Fahrenheit can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees Fahrenheit water. Resident #19 sustained second degree burns to his feet, legs, thigh, and hand. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees Fahrenheit (F) since January 2023. This caused an immediate jeopardy situation that began on 01/03/23 and ended on 01/07/24. This practice had the potential to affect all facility residents. Resident identifier: #19. Facility census 44.
Findings included:
a) Facility Reported Incident
A facility reported incident was received at the state agency on 01/05/24. The report stated Nurse Aide #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, the ombudsman, the local sheriff's department, and the nurse aide registry.
A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs.
A third facility reported incident dated 01/05/24 was sent to the state agency. This incident stated Maintenance Supervisor (MS) #76 had been monitoring water temperatures for over six (6) months that did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request.
The five (5) day follow up report obtained on 01/09/24 revealed the following:
"After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment."
This report was completed by the social service supervisor.
A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed:
"After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision." This report was completed by the social service supervisor.
b) Facility Entrance
During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. They said had been transferred to a local hospital and then transferred to an out of state burn unit.
b) Record Review
Record review on 01/09/24 2:18 PM, revealed no documentation was provided during the survey to show the corrective action or adjustments to the resident hot water system when water temperatures were routinely recorded above 110 degrees (F) monthly from August 2023 through December 2023 by the Maintenance Department Staff for resident corridors A1, B1, and resident areas Shower Room (Gore) and Dining Room (Gore). Interview on 01/09/24 at approximately 2:20 p.m. with the Assistant Administrator verified this finding.
c) Maintenance Supervisor (MS) #76
A phone interview on 01/10/24 at approximately 9:43 a.m., with MS #76 noted he had been the Maintenance Supervisor for approximately 5 years. Interview revealed he recorded the temperatures of the hot water system as noted on the gauges and seemed to be aware that the temperatures were supposed to be maintained at 110 degrees Fahrenheit. He also noted that he tried to keep temperatures warm enough on the floors as Nursing would let him know if the temperatures seemed too cold. Interview noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them by any of the reporting committees, such as the Safety Committee or the Quality and Performance Improvement (QAPI) Committee.
d) Preventative Maintenance and Casualty Prevention Plan Notes
Record review on 01/10/24 at 12:37 p.m., revealed Preventative Maintenance and Casualty Prevention Plan notes state that Safety Surveillance is conducted hospital wide monthly by members of the Safety Committee. Reports of inspection are given to the Safety Officer who will then assign the deficiency correction to the proper department for action. Per the Preventative Maintenance and Casualty Prevention Plan these reports and corrective action documents are then also attached to the master copy of the Quality Committee minutes. Record review revealed no documentation provided during the survey to show that Safety Surveillance was reported to the Quality and Performance Improvement (QAPI) Committee from July 2023 through December 2023, as outlined in the Preventative Maintenance and Casualty Prevention Plan.
e) Administrator and Assistant Administrator Interview
On 01/10/24 at 1:10 PM during an interview the assistant administrator and the administrator agreed they had not looked at the hot water temperatures being recorded by the maintenance employee, nor had they checked to see if any preventative maintenance was being done to the hot water equipment.
f) Resident #19
Record review revealed Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting.
g) Water Temperature Log Review of temperatures taken at the mixing valve are as follows:
January 2023
01/03/23 122 degrees (F), 01/04/23 120 degrees (F), 01/05/23 118 degrees (F), 01/06/23 124 degrees (F), 01/09/23 120 degrees (F), 01/10/23 126 degrees (F), 01/11/23 122 degrees (F), 01/12/23 120 degrees (F), 01/15/23 120 degrees 126 degrees (F), 01/18/23 124 degrees (F), 01/19/23 122 degrees (F), 01/20/23 120 degrees (F), , 01/24/23 126 degrees (F), 01/25/23 122 degrees (F), 01/26/23 126 degrees (F), 01/27/23 124 degrees (F), 01/30/23 126 degrees (F), 01/31/23 126 degrees (F),
February 2023
02/02/23 124 degrees (F), 02/03/23 124 degrees (F), 02/06/23 126 degrees (F), 02/07/23 124 degrees (F), 02/08/23 130 degrees (F),02/13/23 126 degrees (F), 02/14/23 124 degrees (F), 02/15/23 128 degrees (F), 02/16/23 126 degrees (F), 02/17/23 128 degrees (F), 02/21/23 124 degrees (F), 02/22/23 128 degrees (F), 02/23/23 126 degrees (F), 02/24/23 128 degrees (F), 02/27/23 120 degrees (F)
March 2023
03/01/23 126 degrees (F), 03/02/23 120 degrees (F), 03/03/23 124 degrees (F), 03/06/23 130 degrees (F), 03/07/23 124 degrees (F), 03/08/23 126 degrees (F), 03/09/23 126 degrees (F), 03/10/23 130 degrees (F), 03/16/23 120 degrees (F), 03/20/23 130 degrees (F), 03/21/23 130 degrees (F), 03/22/23 119 degrees (F), 03/23/23 124 degrees (F) 03/27/23 124 degrees (F), 03/28/23 128 degrees (F)
April 2023
04/03/23 120 degrees (F), 04/04/23 126 degrees (F), 04/05/23 124 degrees (F), 04/06/23 119 degrees (F), 04/07/23 121 degrees (F), 04/10/23 120 degrees (F), 04/11/23 124 degrees (F), 04/12/23 123 degrees (F), 04/13/23 121 degrees (F), 04/14/23 115 degrees (F), 04/17/23 125 degrees (F), 04/18/23 120 degrees (F), 04/19/23 119 degrees (F), 04/20/23 121 degrees (F), 04/21/21 122 degrees (F),
04/24/23 130 degrees (F), 04/25/23 128 degrees (F), 04/26/23 115 degrees (F), 04/28/23 120 degrees (F)
May 2023
05/01/23 120 degrees (F), 05/02/23 124 degrees (F), 05/03/23 122 degrees (F), 05/04/23 122 degrees (F), 05/05/23 118 degrees (F), 05/10/23 116 degrees (F), 05/11/23 124 degrees (F), 05/15/23 120 degrees (F), 05/16/23 126 degrees (F), 05/17/23 130 degrees (F), 05/18/23 120 degrees (F), 05/19/23 118 degrees (F), 05/22/23 122 degrees (F), 05/23/23 120 degrees (F), 05/24/23 116 degrees (F)< 05/26/23 130 degrees (F), 05/29/23 130 degrees (F), 05/30/23 120 degrees (F), 05/31/23 124 degrees (F)
June 2023
06/01/23 120 degrees (F), 06/02/23 112 degrees (F), 06/05/23 120 degrees (F), 06/06/23 116 degrees (F), 06/07/23 120 degrees (F), 06/08/23 130 degrees (F), 06/09/23 130 degrees (F), 06/12/23 118 degrees (F), 06/13/23 126 degrees (F), 06/14/23 122 degrees (F), 06/15/23 124 degrees (F), 06/16/23 118 degrees (F), 06/19/23 121 degrees (F), 06/20/23 114 degrees (F), 06/21/23 120 degrees (F), 06/22/23 122 degrees (F), 06/23/24 116 degrees (F), 06/26/23 131 degrees (F), 06/27/23 122 degrees (F), 06/28/23 124 degrees (F), 06/29/23 120 degrees (F), 06/30/23 124 degrees (F)
July 2023
07/05/23 121 degrees (F), 07/06/23 120 degrees (F), 07/07/23 120 degrees (F), 07/10/23 121 degrees (F), 07/11/23 116 degrees (F), 07/14/23 120 degrees (F), 07/17/23 122 degrees (F), 07/18/23 132 degrees (F), 07/19/23 124 degrees (F), 07/20/23 114 degrees (F), 07/21/23 128 degrees (F),07/26/23 120 degrees (F), 07/27/23 118 degrees (F), 07/28/23 122 degrees (F), 07/31/23 120 degrees (F)
August 2023
08/01/23 120 degrees (F), 08/02/23 118 degrees (F), 08/03/23 120 degrees (F), 08/04/23 124 degrees (F), 08/07/23 120 degrees (F), 08/08/23 121 degrees (F), 08/09/23 118 degrees (F), 08/10/23 122 degrees (F), 08/11/23 130 degrees (F), 08/14/23 121 degrees (F), 08/15/23 129 degrees (F), 08/16/23 118 degrees (F), 08/18/23 136 degrees (F), 08/21/23 120 degrees (F), 08/22/23 124 degrees (F), 08/23/23 133 degrees (F), 08/24/23 114 degrees (F), 08/25/23 126 degrees (F), 08/28/23 130 degrees (F), 08/29/23 140 degrees (F), 08/30/23 128 degrees (F),
September 2023
09/01/23 125 degrees (F), 09/05/23 128 degrees (F), 09/06/23 130 degrees (F), 09/07/23 126 degrees (F), 09/08/23 130 degrees (F), 09/11/23 126 degrees (F), 09/12/23 124 degrees (F), 09/13/23 121 degrees (F) , 09/18/23 130 degrees (F), 09/19/23 126 degrees (F), 09/20/23 124 degrees (F), 09/21/23 120 degrees (F), 09/29/23 130 degrees (F)
October 2023
10/02/23 125 degrees (F), 10/03/23 130 degrees (F), 10/04/23 132 degrees (F), 10/05/23 130 degrees (F) 10/09/23 140 degrees (F), 10/10/23 138 degrees (F), 10/11/23 10/13/23 130 degrees (F), 10/16/23 120 degrees (F), 10/17/23 130 degrees (F), 10/18/23 124 degrees (F), 10/19/23 124 degrees (F),10/20/23 128 degrees (F), 10/24/23 132 degrees (F), 10/25/23 128 degrees (F), 10/26/23 130 degrees (F), 10/27/23 142 degrees (F), 10/30/23 140 degrees (F), 10/31/23 132 degrees (F)
November 2023
11/01/23 128 degrees (F), 11/02/23 132 degrees (F), 11/03/23 141 degrees (F), 11/06/23 140 degrees (F), 11/07/23 128 degrees (F), 11/08/23 130 degrees (F), 11/09/23 134 degrees (F), 11/13/23 130 degrees (F), 11/14/23 126 degrees (F),
December 2023
12/01/23 130 degrees (F), 12/04/23 130 degrees (F), 12/05/23 132 degrees (F), 12/06/23 140 degrees (F), 12/07/23 128 degrees (F), 12/08/23 132 degrees (F), 12/11/23 130 degrees (F), 12/12/23 126 degrees (F), 12/13/23 140 degrees (F), 12/14/23 140 degrees (F), 12/15/23 138 degrees (F), 12/20/23 130 degrees (F), 12/21/23 126 degrees (F), 12/22/23 140 degrees (F), 12/26/23 128 degrees (F), 12/28/23 132 degrees (F), 12/29/23 130 degrees (F)
January 2024
Record review revealed water temperatures continued to be above 110 degrees (F) on 01/05/24, 01/06/24, and on 01/07/24. These temperatures logs revealed temperateurs were taken at four (4) sinks, and in the shower room.
h) Education of staff
During the night of 01/04/24 into 01/05/24 the ADON educated the night shift staff that temperatures that exceed 110 degrees were not within regulation and should not be used on any resident. The staff included RN #100, Nurse Aid #99, # 41, #59, #63, #60 and #85.
i) Maintenance Director Inservice
On 01/06/24 at 12:20 PM the Maintenance Director and maintenance staff was in -serviced the Maintenance staff as follows:
"Anytime the water Temp is Above 110 you must notify the charge nurse that the hot water is not to be used in that specific area and make corrections. You must document when notification was made and to whom." Typed as written."
j) Nurse Educator (NE) #78
An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explains that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situaiton. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done. Record review revealed the nursing home administartor gave an order and the hot water was shut off at 6:54 PM on 01/07/24.
k) Quality Assurance and Performance Improvement (QAPI)
Evidence provided by the QA-QAPI RN on 01/09/24 stated that this was the first rough draft of events involving hot water that resulted in third degree burns to Resident #19.
Resident #19 was transferred to the emergency room and is currently not residing in (name of facility).
All residents have the potential to be affected. On 01/05/24, DON conducted a skin assessment of all residents which revealed no other residents to have evidence of burns.
On 01/04/24 the maintenance director placed the identified whirlpool (tub) out of service and investigated what may have caused the increased hot water temperature in the tub during the incident. The investigation revealed a malfunctioning hot water tank thermostat, which was immediately replaced by the maintenance director/maintenance staff on 01/04/24.
On 01/05/24, the QAPI team instituted a more frequent monitoring of hot water temperatures, every hour and to prevent resident use of hot water above 110 degrees. Additionally, on 01/05/24, the QAPI stopped all showers and tub baths until hot water could be restored to no higher than 110 degrees. The administrator on 01/07/24 directed maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system.
On 01/05/24, the QAPI team instituted temperature checks of hot water outlets on the resident units, to be completed each hour. Temperatures found to be greater than 110 degrees, were to be reported immediately to the administrator, residents were to be prevented from using the identified outlet(S), and mechanical adjustments made to the hot water system in order to bring temperatures below 110 Fahrenheit. On 01/08/24, due to residents no longer having access/exposure to hot water outlets, the QAPI team modified the monitoring of hot water temperatures to an as needed basis due to repairs actively being made to the hot water system, until further.
The Quality Assurance and Performance Improvement Committee (QAPI) met on 01/09/24 at 10:00 AM to discuss the current situation of water temps for resident care. Documentation revealed that water temps were being checked every hour since 01/05/24 at the four (4) main sinks on Resident corridors of A1 and B1 and the resident showers on the corridors of A1 and Gore 1, with this documentation forwarded to Administration for review. The showers have not been used since 01/04/24. Repairs were initiated on the hot water system on 01/08/24 to isolate the hot water distributed to the resident care areas and residents currently have no access to hot water until the final repairs are made. Prior to the time of survey, potential mechanical issues with an isolation valve, hot water tank thermostat, and a water system distribution mixing valve and gauge were discovered. The isolation valve, thermostat, and mixing valve gauge had been replaced prior to the survey. The water system distribution mixing valve was being investigated further with parts being ordered for repair during the survey. Nursing staff were notified that they would be using wipes and no rinse shampoo and body wash until further notice.
Per the QAPI meeting minutes, reeducation was provided to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system.
l) Phone interview on 01/09/24 at 11:36 AM., with the Director of Facilities and Plant Operations #97 revealed that the perceived issue with the hot water system was a faulty thermostat on the hot water tank serving resident corridors A1 and B1 of the Nursing Building. The issue with the thermostat was believed to have failed in the close position and was discovered mid-morning on Friday, January 5th. The hot water system was drained and refilled with 55-degree city water. An isolation valve was added on Monday, January 8th. Employee #97 also noted that hot water temperatures were not supposed to be above 110 degrees.
m) An observation on 01/09/24 at 12:14 PM, revealed that the only hot water being provided to the resident areas was to the Dining Area. The temperature of the hot water as recorded at a hand sink in the Dining area was noted as 109.1. Hot water to the other resident areas such as Corridor A1, B1, and Gore 1 was isolated off in the basement and handles removed from faucets and fixtures to prevent residents from accidentally turning on the hot water while repairs and adjustments were made to the system.
n) Building Maintenance Mechanic (BMM)#95
An interview on 01/09/24 at 1:03 PM, with BMM #95 revealed that an issue with a thermostat on a hot water tank in the basement (Potato Room) was discovered and replaced. A ball valve was also replaced as a suspected back-feed elimination. A gauge for the mixing valve for the water leaving this area to the resident areas was also replaced. Employee #95 noted that a daily log of the water temperatures was maintained in each mechanical room. In addition, Employee #95 stated that he was not aware that temperatures above 110 degrees needed to be reported and only recorded what the gauges read and was not previously aware of what the water temperatures were supposed to be maintained at.
o) Building Maintenance Mechanic (BMM) #14An interview on 01/09/24 at 1:15 PM, with Building Maintenance Mechanic #14 revealed that he was off work during the time of noted issues with the water system and had just returned to work on the morning of Monday, January 8th. Employee #14 noted that he was not aware that any issues with the noted water temperatures needed to be reported to anyone.
p) Maintenance Supervisor (MS) #76
During a phone interview on 01/10/24 at 9:43 AM, the Maintenance Supervisor (MA) #76 noted that he had been the Maintenance Supervisor for approximately five (5) years.MS #76 noted that he recorded the temperatures of the hot water system as noted on the gauges and seemed to be aware that the temperatures were supposed to be maintained at 110 degrees. He also noted that he tried to keep temperatures warm enough on the floors as Nursing would let him know if the temperatures s#76 noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them.
q) Preventive Maintenance and Caualty Prevention Plan
The Office of Health Facilities Policy (Policy OHF.LS.0002) for Preventive Maintenance and Casualty Prevention Plan has been updated to include an effective date based upon the date of approval on the signature page. This policy outlines the testing and preventative maintenance procedures and documentation requirements for the Plant Operations, Maintenance, and Engineering Staff. Documentation from the Preventative Maintenance and Casualty Prevention Plan is monitored through safety surveillance, which is conducted hospital wide monthly by members of the Safety Committee. These inspection reports are to be given to the Safety Officer, who will then assign corrective action from the appropriate department. This policy outlines that all boiler room equipment gauges are to be visually monitored daily and that patient hot water is not to exceed 110 degrees (F) with any deviations reported to the Maintenance Department immediately.