| 5612 |
WOODRUFF MANOR |
425179 |
1114 EAST GEORGIA ROAD |
WOODRUFF |
SC |
29388 |
2015-06-04 |
323 |
L |
0 |
1 |
02VR11 |
Based on observations, record reviews and interviews the facility failed to assure safe water temperatures for 13 of 13 resident bathrooms on Unit 2 (Hall 200). The Maintenance Director failed to have adequate knowledge for checking temperatures and calibrating thermometers and there was no scheduled monitoring of water temperatures. The findings include: On 6/2/15 at approximately 9:00 AM during initial tour of the facility water temperatures were checked by hand in thirteen resident bathrooms on Unit 2 and observed to be too hot. On 6/2/15 at approximately 9:30 AM Surveyor Team thermometers were used to check all facility bathrooms. Thirteen resident bathrooms on Unit 2 were found to have hot water temperatures of approximately 121-124 degrees F (Fahrenheit). On 6/2/15 at approximately 9:55 AM the Maintenance Director was asked to provide a water temperature log and to take water temperatures for the Unit 2 resident bathrooms. He/she stated that no log was kept and obtained a(NAME)stick thermometer from the kitchen. When asked about calibration he/she stated that the thermometer had been calibrated yesterday. The Surveyor asked for the thermometer to be calibrated again and the Maintenance Director took the thermometer to the kitchen and asked the Dietary Manager to calibrate. On 6/2/15 at approximately 10:10 AM the Maintenance Director used the kitchen thermometer calibrated by the Dietary Manager to check bathroom water temperatures on Unit 2. Water temperatures were check in bathrooms for room 201/203, 204/206, 209, 211/213, 216 and 215/217. The results obtained by the Maintenance Director were between approximately 100-110 degrees F. The Maintenance Director demonstrated considerable variability in technique when taking temperatures and stated several times that the water sure feels a lot hotter than this. The thermometer was held under the hot water stream at varying angles and the entire temperature sensitive portion of the thermometer was not exposed to the water. The Surveyor temperature reading taken at the same time were between approximately 122-124 degrees F. On 6/2/15 at approximately 10:57 AM the Maintenance Director stated during an interview that he/she did not keep a water temperature log. On 6/2/15 at approximately 11:50 AM the Maintenance Director stated in an interview that he/she had not checked water temperatures in 3-4 months. On 6/2/15 at approximately 11:55 AM inspection of the two hot water heaters for Unit 2 located in an outside room next to room 206 revealed a Honeywell digital controller reading 110 degrees F and an analog thermometer located past the controller reading 117 degrees F. The Maintenance Director was unable to explain the difference, speculated that the thermometer could be old and needed to be replaced and stated there were no logs kept for the two hot water heaters. On 6/2/15 at approximately 2:50 PM prior to rechecking water temperatures the Maintenance Director stated that he/she did not know how to calibrate a thermometer. The kitchen thermometer being used by the Maintenance Director and the Surveyor thermometer were then calibrated in the same ice bath, at the same time by the Dietary Manager and the Surveyor. Once calibrated, the maintenance Director and Surveyor checked water temperatures in bathrooms for rooms 201/203, 204/206, 209, 211/213, 206 and 215/217. Temperature readings for both the Facility thermometer and the Surveyor thermometer ranged from 121 degrees to 123 degrees F. On 6/2/15 at approximately 4:35 PM the Administrator verified that no water temperature logs were being kept by the Maintenance Director. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (A[NAME]) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the A[NAME] included the following: I. Corrective Action taken to remove the Immediate Jeopardy: On 6/2/2015 at approximately 5:00pm (sic), the survey team notified the facility that an Immediate Jeopardy situation was present in regards to Hot Water Temperatures on the 200 Unit. The survey team stated that resident room temperatures on the 200 Unit were in excess of 120 degrees (highest temperature reported was 124 degrees). It was stated by the survey team leader that excessive temperatures were limited to the 200 Unit and that the other Unit's temperatures (100 Unit) were in compliance. The Administrator informed the nursing staff on the 200 Unit to cease using hot water on 6/2/15 at approximately 5:20pm (sic) until the situation was resolved. On 6/2/15 The DON, in coordination with the Licensed Nursing Staff completed 100% body audits on all residents on both units to ensure that there was no evidence of any resident injury or bums due to hot water. The findings of the body audits concluded that there had been no injuries or burns to residents. The Maintenance Director contacted the facility's contracted plumber and they dispatched a plumber to the facility immediately. The plumber, along with the Maintenance Director and Regional Director of Operations visibly inspected the two hot-water heaters that control resident room temperatures on the 200 Unit. The two hot water heaters each have their own thermostats but are then connected by an adjustable mixing valve. The plumber adjusted the left thermostat to the lowest allowable setting. In addition, the mixing valve was adjusted approximately a 1/4 inch colder temperature to ensure compliance. At 6:15, the plumber, Maintenance Director, and Regional Director of Operations conducted an initial test of a resident room where excessive temperatures had been noted by the survey team. At that time, the temperature at the resident sink was noted to be 117 degrees, indicating that the adjustments made to the thermostat had successfully removed the immediate jeopardy to the residents. At 6:30pm (sic) the plumber signed a Teachable Moment form, indicating that he had educated the Maintenance Director on adjusting the thermostats and mixing valves to achieve the desired temperatures, as well as proper calibration of thermometers. At the plumber's recommendation, new Digital Thermometers were purchased by the facility Administrator on 6/2/2015. At IOpm (sic), The Maintenance Director and Regional Director of Operations checked 100% (12 on each of 2 Units) of resident bathroom sinks and shower rooms on 6/2/2015. All temperatures were within regulatory limits (100 - 120 degrees). The facility has no recorded grievances by residents that the room water temperatures were too hot. The facility has had no incidents of residents being burned or scalded by hot water. 2. Measures put into place or systemic changes made to ensure that the immediate jeopardy will not recur: The Administrator and Regional Director of Operations inserviced the Maintenance Director on 6/2/2015 regarding the requirement to check resident room temperatures in accordance with facility policy. A log to record temperatures was provided and will be utilized to ensure ongoing compliance. The water temperature log will be completed daily for two weeks to ensure stability of temperature settings, and weekly thereafter. Any temperature readings in excess of 120 degrees will be corrected immediately and reported to the facility Administrator. The Staff Development Coordinator began inservicing all nursing staff on 6/2/2015 on the facility's Safety of Water Temperatures policy. No nursing staff will be allowed to work until having received this inservice. This inservice includes: o Any time water feels excessively hot to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to their immediate supervisor. o Risk factors for scalding/burns that are more common in the elderly, such as: Decreased skin thickness; Decreased skin sensitivity; Peripheral neuropathy; Reduced reaction time; Decreased cognition; Decreased mobility, and Decreased communication. o Other factors that influence temperature tolerance (length Of exposure, amount of skin exposed, and the resident's current condition). o Signs and symptoms of burns (first, second, and third degree) o If a resident is scalded or burned, nursing staff shall follow pertinent first aid and physician notification protocols and report the injury to his or her direct supervisor. As a precaution, the hot water heaters that control resident room water temperatures on the 100 Unit were reviewed by the plumber, Maintenance Director, and Regional Director of Operations. The findings of the review indicated the left hot water heater was set on 120 degrees, and the right was set on 110. The water from the two hot-water heaters is combined prior to entering the facility. The thermostat of the left hot water heater was reduced to 115 degrees. There has been no reported temperatures on the 100 Unit in excess of 120 degrees. All new nursing staff will be oriented regarding the Safety of Water Temperatures policy during orientation. Any new Maintenance personnel will also be oriented on this policy, and the log for tracking hot-water temperatures. Results of hot-water temperature monitoring will be brought to the Quality Assurance Committee monthly to ensure ongoing compliance. However, any noted temperatures above the allowable range of 100-120 degrees will be corrected immediately and reported to the facility Administrator. Observations, review of policy, education and signature sheets on 6/3/15 revealed the Allegation of Compliance submitted by the facility on 6/3/15 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 6/3/15 at 5:25 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F. |
2018-11-01 |